Clinical Practice Guidelines for Adult Sinusitis by the American Academy of Otolaryngology—Head and Neck Surgery Foundation

The American Academy of Otolaryngology—Head and Neck Surgery Foundation has published an updated “Clinical Practice Guideline: Adult Sinusitis” as a supplement to Otolaryngology–Head and Neck Surgery. The guideline recommendations address diagnostic accuracy for adult rhinosinusitis, the appropriate use of ancillary tests to confirm diagnosis and guide management (including radiography, nasal endoscopy, computed tomography, and testing for allergy and immune function), and the judicious use of systemic and topical therapy. Emphasis was also placed on identifying multiple chronic conditions that would modify management of rhinosinusitis, including asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia.

The treatment recommendations include:

Symptoms of viral sinusitis can be treated symptomatically by relieving pain, and administration of nasal steroid sprays, and/or nasal saline rinse (irrigation).

Acute bacterial sinus can be watchful waited without antibiotics or be treated with an antibiotic. If a decision is made to treat acute bacterial sinus infection with an antibiotic, amoxicillin will likely be prescribed. A combination of amoxicillin with clavulanate for 5 to 10 days may also be prescribed as a different treatment. If after 7 days the patient feel worse or does not improve (whether receiving antibiotic treatment or not) he/she should see their healthcare provider. The healthcare provider will review the diagnosis and exclude other causes. The provider may also decide to start or change antibiotics. To relieve symptoms, the healthcare provider may recommend over-the-counter treatments. These include pain relievers, nasal steroid sprays, decongestants, mucus thinners, cough suppressants, and nasal saline rinse. 

Chronic sinusitis may be linked to an hyperactive immune system

A recent study in JAMA Otolaryngology--Head& Neck Surgery, in October 2013, suggested that chronic rhinosinusitis (CRS) may be caused by an overactive immune response to normal microbes, and not necessarily to bacterial infection. Investigators from Saint Louis University School of Medicine in Missouri lead by Dr. Rajeev Aurora found that patients and healthy controls tended to have qualitatively similar microorganisms in their sinus cavity. While control patients sinus lavage samples triggered interleukin (IL)-5 production in peripheral blood leukocytes from patients, this did not occur with leukocytes from controls.

The investigators obtained sinus cavity samples from thirty patients with CRS and 12 controls. They used deep sequencing to characterize the patients' microbiomes and search for pathogens that may potentially trigger an immune response. They also identified the immune cells and cytokines in the specimens. Almost all the recovered fungal and bacterial species were non pathogenic . Although there were higher numbers of these organisms in patients than in controls, the microbiomes in the two groups were qualitatively similar. The fact that only leukocytes from patients with CRS reacted to nasal samples from controls, suggests that CRS patients have an abnormal immune response to normal microorganisms.

The researchers postulated in an interview with Reuters Health that these results indicate that immune cells from a patient with CRS are getting activated by the microbes found in the normal sinus. These non-virulent organisms are most likely picked up from the air the patients breath, and therefore antibiotics cannot eliminate them in the sinus as they re-colonize the sinus with each breath. The authors also believe that these organisms may leads to a persistent inflammation in people whose immune system is aberrantly sensitive to these common organisms.

In an interview with Reuters Health  Dr. Itzhak Brook, a pediatrician at Georgetown University in Washington, D.C., who specializes in sinus infections, called the study "innovative and provocative." However, he noted that 16 of 30 patients in the CRS group were asthma suffers and prone to allergies. "They therefore do not represent the average patient with CRS, but a subgroup in whom the immune system is hyperactive," Dr. Brook added that the findings shouldn't change how doctors treat patients. The fact that the sinus cavity in normal individuals harbors the same bacteria (albeit in greater numbers) as infected sinuses is not new and was describe in study done by Dr. Brook in 1981.  

Patient’s outcome in acute invasive fungal sinusitis

Acute invasive fungal sinusitis (AIFS) is an aggressive and often fatal infection. Despite improvements in medical and surgical therapy, survival remains limited and the factors that contribute to patient outcomes remain poorly understood. Turner et al from the Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee performeda  systematically reviews of  the literature to characterize prognostic factors associated with survival after AIFS..

The authors reviewed 52 studies comprising a total of 807 patients, and analyzed the prognostic factors as they related to the treatment, presentation, and outcomes. Univariate and multivariate logistic regression was used to identify prognostic factors.

The most common presenting symptoms of patients with AIFS were facial swelling (64.5%), fever (62.9%), and nasal congestion (52.2%). Most patients were treated with a combination of intravenous antifungal medication and surgery. The overall survival rate was 49.7%. Poor prognosis was associated with renal/liver failure, altered mental status, and intracranial extension. Patients who were diabetic, had surgery, or received liposomal amphotericin B had an improved chance of survival. Advanced age and intracranial involvement were identified as independent negative prognostic factors. Positive prognostic factors again included diabetes and surgical resection.

The conclusion of the analysis was that the overall mortality of patients with AIFS remains high, with only half of the patients surviving. Diabetic patients appear to have a better overall survival than patients with other comorbidities. Patients who have intracranial involvement, or who do not receive surgery as part of their therapy, have a poor prognosis.

                             

CT scan of acute invasive fungal sinusitis caused by zygomycosis. There is increased attenuation in the ethmoid air cells with destruction of the median wall of the left orbit (arrow).