Another article from Highlights of the American College of Allergy,
Asthma & Immunology 2003 Annual Meeting, November 7-12, 2003.

Rhinosinusitis: New Approaches to Medical Management

Mark T. O'Hollaren, MD  

Introduction

Acute and chronic rhinosinusitis are 2 of the more common diagnoses
seen by both primary care and specialty physicians who see patients
with respiratory diseases. In this session, experts discuss 3 of the
most important aspects of treating rhinosinusitis.

These summaries are compiled from notes taken during the lectures,
combined with material from the lecture slides and syllabus. Every
effort has been made to accurately summarize the lecture of the
individual speakers. In some instances, background or introductory
information has been provided by the author of this summary to better
place these lectures in context for the reader.

Rhinosinusitis: Current Concepts

Myron J. Zitt, MD,[1] Clinical Associate Professor of Medicine, State
University of New York at Stony Brook, Stony Brook, New York,
discussed the current state-of-the-art thinking regarding the
pathophysiology, diagnosis, and treatment of rhinosinusitis.
Rhinosinusitis is an extremely common illness, with nearly 32 million
cases per year, resulting in more than 21 million antibiotic
prescriptions annually in the United States.[2]

Sinusitis is defined as inflammation of 1 or more of the paranasal
sinuses, and is further subclassified according to frequency of
recurrence and duration of symptoms. It may actually be more accurate
to use the term rhinosinusitis, since it is nearly always preceded by,
or occurs concomitantly with, symptoms of rhinitis. Rhinosinusitis has
been shown to have a significant adverse effect on quality of life.[3]

Common nomenclature is needed in order to best discuss the diagnosis
and treatment of this disorder. The traditional classification of
rhinosinusitis is as follows:

Acute: 2 to 4 weeks of symptoms;

Recurrent acute: greater than or equal to 4 episodes per year lasting
from 7 to 10 days with complete resolution between attacks;

Unresolved acute (subacute): symptoms last more than 4 weeks, but less
than 12 weeks; and

Chronic: more than 12 weeks of symptoms.

Acute rhinosinusitis is characterized by persistent upper respiratory
infection (URI) lasting more than 7 to 10 days, and is accompanied by
nasal congestion and mucopurulent nasal or postnasal discharge. Other
supportive symptoms also may include postnasal drip, cough, fever,
headache, facial pain or pressure, dental pain, sinus area tenderness,
ear pain or pressure, halitosis, and fatigue.

Rhinosinusitis may occur in 0.5% to 2.5% of URIs. The percentage may
be greater in children, approaching 10% of all URIs.[4] Bacterial and
viral sinusitis may be difficult to differentiate. In most cases, if a
patient has a "cold" with ongoing symptoms (as noted above) lasting
more than 7 days, they probably have acute rhinosinusitis, which
frequently resolves without antibiotic treatment. Immediately
prescribing antibiotics at the first sign of any purulent drainage in
this situation is undoubtedly contributing to the increasing incidence
of antibiotic-resistant organisms.

The sinus computed tomography (CT) scan has been considered the "gold
standard" for diagnosis of acute and chronic sinusitis. However,
recent studies have shown that the sinus CT scan is frequently
abnormal in routine URIs, and that these abnormalities frequently
resolve without antibiotic treatment.[5] One study of 31 patients who
had a sinus CT performed within 48 to 96 hours of a self-diagnosed
"cold" showed that 77% had an occluded ethmoid infundibulum. They
noted frequent sinus abnormalities, including 87% in the maxillary
sinuses, 65% in the ethmoids, 32% in the frontals, and 39% in the
sphenoids. A total of 79% of these abnormalities cleared within 2
weeks without antibiotic therapy.[5]

In order to best prevent or slow the development of
antibiotic-resistant bacteria, it is important to avoid prescribing
antibiotics for trivial indications. In general, symptomatic treatment
and reassurance is the preferred initial management strategy for
patients with mild symptoms of acute rhinosinusitis. In those with
more severe symptoms or in those who are acutely ill, clinicians
should use the narrowest spectrum antibiotic possible, given the
bacterial antibiotic sensitivities in the surrounding community.

In contrast to acute rhinosinusitis, symptoms of chronic sinusitis may
be much more subtle and may seem to be more easily missed by the
treating physician. Patients may have a primary complaint of simply
chronic nasal congestion and postnasal drainage. They also frequently
complain of fatigue, lack of energy, and "foggy thinking." They may
have cough, hyposmia or anosmia, headache, facial pain, frequent
throat clearing, or ear discomfort. Symptoms may be present in the
absence of confirmatory sinus CT findings or may be absent in the
presence of abnormal CT findings, thus underscoring the importance of
correlating symptoms with CT findings to ensure accurate diagnosis, if
it is in question.

A Waters view sinus radiograph, when positive, may show a maxillary
sinus air-fluid level, opacification, or mucosal thickening; but it
does not show the ostiomeatal complex, the extent of mucosal
thickening, or the ethmoid sinuses. It is rarely used any longer,
having been nearly totally replaced by the sinus CT scan. A screening
sinus CT scan, employing fewer images, is the scan of choice, with a
full sinus CT scan usually only used if surgery is being considered or
if more complicated problems are being evaluated.[6]

When Should a Sinus CT Scan Be Used?

If the diagnosis of rhinosinusitis is strongly suspected clinically,
and the decision has been made to treat with antibiotics, a CT scan
would not likely change the decision regarding therapy and, therefore,
is probably not indicated. However, if the diagnosis is in question or
the patient has failed to respond to appropriate treatment,
particularly in recurrent or chronic sinusitis, the CT scan may be
very helpful. If there is suspected spread of infection outside of the
sinuses, or to evaluate for possible anatomic abnormalities, the CT is
also extremely useful.

Is Magnetic Resonance Imaging (MRI) Helpful in the Evaluation of Acute
or Chronic Sinusitis?

In most cases, MRI is not used in the imaging of the sinuses for
evaluation of either acute or chronic sinusitis. There are several
reasons for this. First, MRI does not distinguish air from bone.[7]
Second, it appears to be overly sensitive in showing transient mucosal
changes associated with the routine nasal cycle, in which mucosal
thickness temporarily varies in thickness from one side of the nose to
the other. It is therefore not used in the routine evaluation of
suspected sinusitis.[8] It is helpful when suspicion exists for fungal
sinusitis or neoplasm, and it may be helpful in differentiating
between inflammatory disease and malignant tumors.

What Is the Role of Fiberoptic Nasal Endoscopy?

Flexible or rigid nasal endoscopy may be a valuable tool, as it
permits more detailed examination of nasal and pharyngeal structures
compared with anterior rhinoscopy.[9] In experienced hands, it allows
visualization of the sinus ostia and assessment of purulent discharge
from the sinuses. It may also be used to help obtain a more directed
culture from the sinus ostia. In addition, it is helpful in assessing
nasal anatomy when patients do not respond adequately to treatment for
acute or chronic sinusitis. It provides a more complete view of
interior nasal anatomy if adequate examination is not possible by
anterior rhinoscopy due to anatomic abnormalities; and it is also used
for perioperative nasal inspection and cleaning as well as to
objectively monitor patients who are hospitalized for spread of
infection outside of the sinuses.[7]

Should We Be Obtaining Cultures to Guide Antibiotic Treatment of
Rhinosinusitis?

In general, treatment of acute (and often chronic) sinusitis is done
empirically without the guidance of cultures. Because of the intrinsic
bacterial flora that normally resides in the nasal cavity, nasal
cultures have not been particularly helpful in guiding antibiotic
selection. Antral puncture is considered the gold standard when
cultures are needed; however, it is also an invasive procedure with
some discomfort and risk.[7] Endoscopically guided microswab culture
of the hiatus semilunaris may yield an accuracy rate of 80% to 85% in
cases of bacterial rhinosinusitis.[7] Culture is typically indicated
for clarification of bacterial pathogens, to assess antimicrobial
sensitivities, and to confirm infection in sinusitis studies.[7]

What Factors Predispose an Individual to Sinusitis?

It is now felt that a crucial factor in the protection against
bacterial sinusitis is adequate sinus drainage via the sinus ostia. If
the sinus ostia is occluded due to swollen nasal mucosal (from a URI,
allergic rhinitis, anatomic obstruction, ciliary dysfunction, or
inflammation from other causes), then secretions are unable to drain
from the sinus cavity. These secretions may then stagnate in an
environment that can no longer ventilate with the outside air,
resulting in more acidic mucus in a sinus environment with a lower
concentration of oxygen and a higher concentration of carbon dioxide.
In this setting, sinus cilia and epithelium may be damaged, resulting
in additional retained secretions that can serve as a culture medium
for bacterial infection. This may lead to more mucosal inflammation,
further sinus ostial occlusion, and perpetuation of the process.

It should be noted, however, that factors other than just occlusion of
the sinus ostia appear to be important in some patients with chronic
rhinosinusitis, since some patients with this disorder do not have
occlusion of the ostiomeatal complex.[10]

Dr. Zitt noted that evidence continues to strengthen the concept of
"one airway," indicating that the upper and lower airways are
inextricably connected, and that pathophysiologic processes that occur
in one area of the airway may affect the other area. For example,
tests involving allergen challenge into the upper (nasal) airway
result in eosinophil migration into the lower airway.[11] Furthermore,
segmental lower airway bronchial challenge can result in eosinophil
migration into the upper airway. There is also very strong evidence
associating inhalant allergic sensitivities with sinusitis,
underscoring the need for a thorough allergy evaluation in patients
suffering from recurring sinusitis.

Some patients may have associated sinusitis characterized by nasal
polyposis, aspirin sensitivity, and asthma. This has been termed
"Samter's triad." Treatment of these patients may be challenging, and
they may require oral corticosteroids, in addition to antibiotics, for
successful treatment of their rhinosinusitis. Avoidance of aspirin and
nonsteroidal anti-inflammatory drugs is important, and
leukotriene-modifying agents may be helpful in this population of
patients. Some evidence suggests that the addition of nasal
corticosteroid sprays may also help speed the resolution of bacterial
sinusitis, and may also help prevent recurrence. More data are needed
in this area to further clarify the optimal use of this class of
medications in the management of acute and chronic rhinosinusitis.

In summary, rhinosinusitis may be acute, recurrent acute, persistent
(unresolved acute), or chronic. Symptoms may not be a reliable
indicator of rhinosinusitis, and sinus CT (coronal views) is currently
the diagnostic gold standard. MRI is not usually helpful unless tumor
or fungal sinusitis is being considered. Antibiotics should be used
judiciously, in order to delay or prevent the development of resistant
bacterial organisms. With proper diagnosis and management of this
common condition, it is possible to significantly improve the quality
of life for our patients.

Antibiotic Resistance as a Cause for Rhinosinusitis

In his discussion, Marvin Turck, MD,[12] Professor of Medicine,
University of Washington School of Medicine, Seattle, Washington,
noted that diseases such as acute otitis media, acute maxillary
sinusitis, acute exacerbations of chronic obstructive pulmonary
disease, and community-acquired pneumonia are commonly caused by
organisms such as Streptococcus pneumoniae, Haemophilus influenzae,
and Moraxella catarrhalis, as well as others.

Of these pathogens, S pneumoniae is the most common and causes the
greatest morbidity and the greatest mortality. Dr. Turck stated that
currently approximately 35% of S pneumoniae is penicillin-resistant.
Resistance of this organism to macrolides has also increased
dramatically over the last decade, going from approximately 5% to more
than 20%. The frequency of multidrug-resistant S pneumoniae has also
gone from nearly zero 15 years ago to approximately 20% now.

There may be several mechanisms of antibiotic resistance to
macrolides. The first involves methylation of A2058, mediated by genes
termed "erm genes," resulting in a high order of resistance. The
second involves active efflux of the antibiotic from the cell,
mediated by genes termed "mef genes," which results in a lower order
of resistance.

Fortunately, S pneumoniae resistance to the fluoroquinolone class of
antibiotics is still relatively low in the United States (1.2% to
1.6%), with no evidence of major changes between 1988 and 2000.

Some studies suggest that higher doses of antibiotics for a shorter
period of time may result in a reduced incidence of resistant
bacterial organisms. New agents, with novel mechanisms of action, are
needed to stay "ahead of the curve" of developing bacterial resistance
to antibiotics. One such new agent is the new ketolide antibiotic
telithromycin, which has a novel mechanism of action and is designed
to overcome macrolide resistance in Gram-positive cocci.

Other important steps needed to effectively deal with emerging
antibiotic resistance include prevention of infection using
immunoprophylaxis (eg, HIB and pneumovax vaccines), infection control
measures, and appropriate education of physicians, the lay public, and
healthcare organizations regarding the need for the judicious use of
antibiotics.

In summary, Dr. Turck emphasized the alarming increase in the
prevalence of antibiotic resistance of S pneumoniae, which threatens
the usefulness of our current panel of antibiotics. He noted that
individual antibiotics differ with respect to cost, pharmacology,
effectiveness, and toxicity; and that new antibiotics that are active
against emerging resistant organisms are needed to maintain acceptable
clinical and economic outcomes.

Allergic Fungal Sinusitis (AFS)

Bradley F. Marple, MD,[13] of the Department of Otolaryngology,
University of Texas Southwestern Medical Center, Dallas, Texas, urged
attendees to think about sinusitis as similar to an abscess.
Therefore, treatment principles would include drainage, maintaining
sinus opening (ostial) patency, and appropriate use of antibiotics.

The incidence of AFS is unknown. This may be due to a number of
factors, including a lack of recognition, failure to appropriately
culture, and various changes in fungal taxonomy.

Primary diagnostic criteria for AFS include:

History of radiologically documented chronic sinusitis of at least
6-months duration

History and physical examination do not suggest another etiology

Nasal polyposis

Characteristic CT or MRI findings

Mucin from the sinus typical for AFS (essential)

Absence of fungal tissue invasion (essential)

Presence of fungus in allergic mucin demonstrated by histology and/or
culture (newer fluorescein-labeled staining method to detect chitin
found in fungal cell walls is more consistent than previous staining
methods)

History of allergic disease demonstrated by specific immunoglobulin
(Ig) E (usually present)

Indicative laboratory findings

The clinical presentation of AFS may have an indolent course, with
patients having a mean age of 21.9 years.[14] Between 60% and 70% have
an atopic history, with 50% having asthma.[14] There is no linkage to
aspirin-sensitive "Samter's triad" asthma.[14] The clinical history
may be subtle, and, surprisingly, headache is typically absent. There
is often nasal obstruction, and there may be visual disturbance.[12]
The physical examination findings may be dramatic, with nasal
polyposis, and facial deformity with telecanthus, proptosis, and
maxillary area fullness.[12]

Sinus CT scan findings may include the presence of an allergic mucin
mucocele, associated obstructive sinusitis, and a multidensity
appearance to the sinus obstructive material (which contains calcium,
chelated iron, and manganese).[15] Of concern, there may be
intracranial or orbital extension of this process.

There is conflicting evidence regarding the importance of positive
fungal cultures in patients with chronic sinusitis. Some promising
early research from the Mayo Clinic involving antifungal treatment for
patients with chronic rhinosinusitis may provide an additional tool
for managing this disorder. The role of fungal infection or
colonization in the pathogenesis of chronic rhinosinusitis clearly
warrants further research. Because fungal sinusitis is not a common
disorder, the clinician needs to have an index of suspicion in order
to correctly identify patients with this disease.

References
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