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Home , Influenza, Malaise, Moraxella, Sinusitis

Kathleen Fitch, MSN, APRN,BC, FNP Gennine Zinner, RNC, ANP

inusitis is ubiquitous among humans and one of the most common reasons health care office visits in the USA. In 1991 sinusitis accounted for more Sthan 25 million visits to a primary care clinic and was the fifth most common diagnosis for which an was prescribed. Expenditures for the treatment of sinusitis in the USA in 1996 were estimated at $5.8 billion, with 30% of this amount used for pediatric sinusitis.

Sinusitis develops from an interaction of of bacterial sinusitis correlate with those of the environmental and factors. The most common . However, bacterial sinusitis can cause in all age groups is a viral upper respiratory occur throughout the year and is associated with (URI) that results in secondary bacterial , swimming, and nasal obstruction due to overgrowth. Other causes of sinusitis include: polyps, foreign bodies, and tumors. The most allergic; fungal; mucosal or architectural abnor- common associated with sinusitis This man with a mality; periodontal ; immunologic factors; in adults include: pneumoniae (34%); history of multiple and a and environmental exposure to pollutants such (35%); and deviated septum had as tobacco smoke. Clinicians must differentiate catarrhalis (2%). In children, M. catarrhalis and H. recurrent episodes of between acute viral sinusitis (common with colds influenzae are the most common isolated allergic sinusitis. and the flu) and bacterial sinusitis in order to from acute sinusitis. Photo by James O’Connell MD prevent the over-prescription of . (See Viral sinusitis follows a well-established seasonal chapter on The Proper Use of Antibiotics). pattern, with annual in the fall, winter, and spring. Periods of inactivity are common during Prevalence and Distribution the summer months. Different families tend Approximately one billion acute viral respira- to have specific periods of high prevalence; rhino- tory illnesses occur annually in the USA, with as virus is more common in early fall and late spring, many as 90% resulting in viral sinusitis. Fewer whereas , respiratory syncytial virus, and than 2% of viral URIs are complicated by secondary virus are more common in winter and bacterial sinusitis. Children under 15 years of age early spring. and adults between 25 and 64 years of age are most frequently affected. Mode of Transmission The most common cause of bacterial sinusitis Sinusitis generally results from the following is a viral URI. Seasonal trends in the incidence sequence of events. The virus is transmitted from

The Health Care of Homeless Persons - Part I - Sinusitis 141 Figure 1 pollutants should be avoided whenever possible (but very difficult for persons liv- ing in shelters and on the streets); and • educate individuals about viral URIs and how to manage initial symptoms, as well as when to seek evaluation from a doctor or health care provider.

Symptoms Acute sinusitis is heralded by: ; a purulent nasal discharge; a heightened (); facial that is often unilateral; pain in the upper teeth; eye pain; , often increasing in intensity when bending over; and a infected to susceptible persons, usually through that is often worse at night. , , coughing or sneezing, deposited into the nose, and halitosis (), and a due to transported to the posterior nasopharynx. Several post-nasal drip can also occur. Acute sinusitis is inflammatory pathways are stimulated and result usually preceded by a URI that worsens or does not in engorgement of the nasal turbinates along with resolve after 8-10 days. Most common colds and intercellular leakage of plasma into the nose and viral URIs resolve or are much improved by the end sinuses and discharge from seromucous glands and of one week. goblet cells. Chronic sinusitis is more difficult to diagnose The specific factors that determine whether than acute sinusitis, and has a more subtle and indo- bacterial invasion of the will occur during lent course. The symptoms are the same as those a viral sinusitis are unknown. However, the nasal noted above but usually milder and persist for more passages and nasopharynx are colonized with than three months. This chronic infection is more the same bacteria that commonly cause sinusitis common among immunocompromised persons, and most likely serve as a reservoir for infection. atopic individuals with allergies, and those with Sneezing, coughing, and blowing the nose increase severe . Different pathogens are involved in pressure differentials and may force bacteria- chronic sinusitis, requiring more broad-spectrum containing secretions to be deposited in the sinuses. antibiotics and longer courses of treatment than Once deposited into the cavity of a swollen and required for acute sinusitis. obstructed sinus, the conditions are favorable for growth of the bacteria. Diagnosis Despite advances in technology, the diagnosis of Prevention sinusitis remains a challenge. The clinical diagnosis Sinusitis may be prevented in several ways: of acute bacterial sinusitis should be reserved for • prevention of the common cold by hand patients with symptoms lasting seven days or more washing and covering the mouth when and who have maxillary pain with in the sneezing or coughing; face or upper teeth accompanied by purulent nasal • protection against influenza by encourag- secretions. Clinicians should be aware that most ing annual flu ; cases of acute sinusitis are viral and resolve without • use of prophylactic or riman- antibiotics. Bacterial sinusitis tends to be over- datine during periods of influ- diagnosed and antibiotics prescribed too frequently. enza; Because the symptoms are similar for acute viral and • can reduce swelling and bacterial sinusitis, we recommend that antibiotics be prevent the entrance of both and held until symptoms have been present for at least bacteria into the sinus cavities; seven days and reserved for those patients with the • fluids and the use of a humidifier or steam maxillary pain and purulent discharge noted above. keep the mucous in the nasal passages Unfortunately, even the duration of symptoms is from becoming thickened; not always a reliable predictor of bacterial sinusitis, • cigarette smoke and adverse environmental as many viral syndromes can last longer than a week. When symptoms have lasted longer than a week,

142 The Health Care of Homeless Persons - Part I - Sinusitis The Health Care of Homeless Persons - Part I - Sinusitis 143 Table 1: Bacterial Etiology of Sinusitis Percent of Adult Cases by Sinus Aspirate Organism Acute Chronic 40 7

Haemophilus influenzae 30 10

Moraxella catarrhalis 7 -

Anaerobic bacteria 8 50-100

Staphylococcus aureus 3 17

Streptococcus pyogenes 3 -

Streptococcus viridans 3 15

Gram-negative bacteria - 5 (including enteric gram-negative bacilli)

Table 2: Viral Etiology of Sinusitis All viruses which cause upper may act as initiating triggers for sinusitis Adapted from Saccho, H. and Schoub, B., Relatively mild tissue damage may result in a reduction of local mucosal immunity rendering the individual susceptible to Lessons in Infectious secondary bacterial infection , 4(12).

The majority of bacterial sinusitis is probably initiated by a preceding viral infection

clinicians should investigate for allergic and fungal ratory investigation may be necessary in individuals as well as bacterial causes of sinusitis. with chronic or recurrent sinusitis in order to eluci- The physical exam should include a fairly date the underlying cause. Such testing may include comprehensive head and exam together with HIV or other testing, allergy examination of the lungs and cervical lymph nodes. testing, and even sweat chloride testing for cystic Anterior rhinoscopy should be performed to check fibrosis (for children with recurrent symptoms). the appearance of inferior turbinates and nasal secretions, as well as for the presence of nasal polyps. Treatment Transillumination as a diagnostic tool is the subject Most cases of sinusitis are viral and will gener- of considerable controversy and is often limited by ally resolve without antibiotic treatment. Once a the skills and experience of the examiner. Cultures bacterial etiology has been determined, the goal of of nasal secretions are not generally useful, limited treatment is twofold: relieve symptoms and cure the by lack of sensitivity for detecting sinusitis. Sinus infection. puncture and aspiration of purulent secretions is the Symptomatic relief can be achieved with gold standard but not used much due to invasive- , warm compresses, steam humidifica- ness and pain. This test is reserved for complicated tion, cough suppressants, and pain relievers. Nasal cases and generally not performed in a primary care are useful but cause rebound conges- setting. tion after three to five days; oral decongestants A CT scan is an excellent tool for diagnosis and may be preferable. Nasal steroid sprays such as has replaced sinus x-rays as the diagnostic image of fluticasone (Flonase™) may help relieve swelling, choice for sinusitis. CT scans are not recommended especially in patients with allergic symptoms and for routine use, due to a lack of specificity and polyps. However, both oral and topical steroids frequent abnormal findings in viral sinusitis. Clini- should not be used in non-allergic acute sinusitis cians may choose to reserve with CT but reserved for chronic cases and patients with a scans for antibiotic treatment failures. history of atopy. Antihistamines may also provide Laboratory tests are not specific and thus not relief for and various allergic symptoms. helpful in the diagnosis of bacterial sinusitis. Labo- Antibiotics are usually reserved for moderate to

142 The Health Care of Homeless Persons - Part I - Sinusitis The Health Care of Homeless Persons - Part I - Sinusitis 143 severe cases. The emergence of drug-resistant strains • chronic sinusitis; of bacteria has created controversy in the treat- • (of facial bones); ment of acute bacterial sinusitis. Most consensus • ; guideline committees still recommend the less • orbital or (orbital compli- expensive and narrow spectrum antibiotics as first- cations more common in young children); line : (Amoxil™); • abscess formation (brain) and subdural (Vibramycin™); and trimethoprim-sulfamethoxa- ; zole (Bactrim™, Septra™). The reasons for • cavernous sinus thrombosis (and cortical using these are the self-limited nature vein thrombosis). of sinusitis in most cases, the difficulty with the Bacterial resistance to certain common anti- overuse of antibiotics in this common and often biotics may also occur, as well as exacerbation of misdiagnosed infection, and the rare incidence asthma and . Sinopulmonary disease is a of complications. Some clinicians argue that the generally recognized combination, especially when high incidence of antibiotic resistance merits more the condition has become chronic. Urgent referral to aggressive use of broad-spectrum antibiotics as first- an otolaryngologist is in order if symptoms become line therapy, specifically amoxicillin-clavulanate markedly worse after 2-3 days of broad-spectrum (Augmentin™), (Vantin™), and antibiotics or if a provider notes possible signs of (Levaquin™). However, we believe intracranial or orbital extension of infection. that the use of narrow-spectrum antibiotics is still the preferable treatment among homeless popula- Special Considerations for Homeless Populations tions. The recommended course of treatment is 10 Homeless people are more likely to develop days for acute bacterial sinusitis and 3-8 weeks for sinusitis than the general population due to both - chronic sinus infections. style and environmental risk factors. For example, Intravenous antibiotics are usually reserved smoking cigarettes is considered a for for complicated infections or when intracranial or both acute and chronic sinusitis. Drinking alcohol orbital extension is suspected. Fungal infections causes nasal and sinus membranes to swell, which and those involving polyps are more complicated may inhibit the resolution of sinusitis and exacer- and may require surgery and different antibiotics. bate symptoms. Drugs such as and Referral to an otolaryngologist is necessary if symp- may have a deleterious effect on the toms worsen after 2-3 days of a broad-spectrum when “snorted” or ingested intranasally. Outside antibiotic or at any time that complications are temperature fluctuations, poor , dehydra- suspected. Surgery may be necessary to clean and tion and poor nutrition, nasal trauma from falls or drain the sinuses, especially in the patient with assaults, and constant exposure to environmental recurrent episodes despite treatment. Consultation allergens and pollutants may all lead to frequent or with an otolaryngologist is advised for these cases. complicated episodes of sinusitis. Surgical repair of a deviated septum or nasal polyps Homeless people have a high incidence of may prevent recurrence. upper respiratory illnesses and pulmonary disease With children, problems are often eliminated when compared to the general population. These by removal of adenoids that block nasal and sinus and various other co-morbid illnesses such , passages. The most common type of surgery today liver disease, and HIV/AIDS are associated with is functional endoscopic sinus surgery, in which the complicated and recurrent sinus infections. natural openings from the sinuses are enlarged to Oral infections due to poor dental hygiene are allow adequate drainage. endemic in homeless populations, further compli- cating the clinical presentation and successful treat- Complications ment of sinusitis. Also, completing a full course of Sinusitis very rarely can result in intracranial, antibiotics may be difficult for the homeless patient orbital, and respiratory complications. Complica- and may lead to treatment failure or recurrence of tions should be suspected whenever a patient reports symptoms. Various ancillary treatments, such as a high fever, severe pain, extreme headache, visual humidification with steam, are impractical for most changes, papillary or extraocular movement (EOM) shelter residents or people who sleep on the street abnormalities, or meningeal symptoms. Complica- and are thus likely neglected in the treatment of tions of sinusitis may include: sinusitis.

144 The Health Care of Homeless Persons - Part I - Sinusitis The Health Care of Homeless Persons - Part I - Sinusitis 145 Summary lungs and cervical lymph nodes, can help confirm Sinusitis is an extremely common infection, a bacterial etiology. Offering adjunctive most likely with an even greater incidence in the such as sinus irrigation, antihistamines, deconges- homeless population. Viral sinusitis is far more tants, cough suppressants, and warm compresses common than bacterial, and the diagnostic chal- are prudent for all cases of sinusitis, regardless of lenge for clinicians is to distinguish between these etiology. Avoiding unnecessary antibiotic use will two types of sinusitis. Judicious use of antibiotics is help prevent drug resistance; overzealous use of warranted, and antibiotics should only be prescribed antibiotics in the past has resulted in resistance when bacterial sinusitis is suspected or determined. among many strains of the common pathogens and The presence of typical symptoms for longer than changed the antibiotics of choice for this infection. one week, accompanied by purulent nasal discharge Consultation with an otolaryngologist (ear, nose, and facial pain over the maxillary area or upper and throat specialist) is recommended for patients teeth, are suggestive of a bacterial sinusitis. A careful with recurrent or resistant cases of sinusitis or when examination of the head and neck, as well as the complications arise. E

Sinusitis List

Generic Brand Name Cost

amoxicillin-clavulanate Augmentin $$$

cefpodoxime Vantin $$$

cefuroxime Ceftin $$$

fluticasone nasal spray 0.05% Flonase $$$

levofloxacin Levaquin $$$

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Gwaltney JM. Acute sinusitis (rhinosinusitis). UpToDate; 2002. http://www.uptodate.com

Hickner JM, Bartlett JG, Bessner RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Annals of 2001;134(6):498-505.

Kaliner M. Medical management of sinusitis. The American Journal of the Medical Sciences 1998;318(1):21-28.

National Library of Allergy and Infectious Diseases. Fact sheet: Sinusitis. National Institutes of Health, 2002. http://www.niaid.nih.gov/factsheets/sinusitis.htm

Osguthorpe JD, Hadley JA. Rhinosinusitis: current concepts in evaluation and management. Medical Clinics of North America 1999;83(1):27-41.

Snow V, Mottur-Pilson C, Hickner JM. Principles of appropriate antibiotic use for acute sinusitis in adults. Annals of Internal Medicine 2001;134(6):495-497.

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144 The Health Care of Homeless Persons - Part I - Sinusitis The Health Care of Homeless Persons - Part I - Sinusitis 145