Sinusitis

Background

Sinusitis is defined as an inflammation involving the membrane lining of any sinus, and it occurs more frequently in people with HIV infection than in the general population. It commonly occurs as part of a viral upper respiratory infection (URI), and usually is self-limited. Bacterial sinusitis usually occurs as a secondary complication of a viral URI, which causes decreased patency of the nasal ostia, decreased nasal ciliary action, and increased mucus production. Acute sinusitis is defined as lasting up to 4 weeks, whereas chronic sinusitis persists for at least 12 weeks.

HIV-infected patients are susceptible to sinusitis for a number of reasons related to their immunosuppression. Pathophysiologic mechanisms for this susceptibility may include proliferation of lymphatic tissue contributing to nasal obstruction, defects in B-cell and T-cell immunity owing to HIV, and defects in production of immunoglobulins, specifically IgE, resulting in an exaggerated allergic response in the nasal mucosa. As in the general population, the most common pathogens causing acute bacterial sinusitis are Streptococcus pneumoniae, Moraxella catarrhalis, and Haemophilus influenzae. However, HIV-infected patients have a greater incidence of sinusitis caused by Staphylococcus aureus and Pseudomonas aeruginosa. The bacterial causes of chronic sinusitis are not well defined, but may involve more polymicrobial and anaerobic infections. In patients with severe immunosuppression, particularly those with CD4 counts of ≤50 cells/µL, sinusitis may be caused by Aspergillus and other fungal pathogens.

S: Subjective

The patient may complain of facial pain, frontal or maxillary headache, postnasal drip, or fever.

Ask the patient about specific symptoms, the duration and progression of symptoms, and treatments attempted.

  • Fever
  • Facial pain or pressure, headache; positional pain (worse when patient bends forward)
  • Purulent or bloody nasal discharge
  • Postnasal drip
  • Nasal congestion
  • Recent URI
  • Malaise
  • Chronic cough
  • Maxillary tooth pain
  • Ear pressure
  • History of chronic sinusitis, seasonal allergies, antibiotic allergies, atopy
  • Tobacco use, inhaled recreational drugs

O: Objective

  • Document vital signs.
  • Perform a careful physical examination focusing on the head and face, neck, and lungs. Examine the nose, mouth, ears, and sinuses.
    • Look for nares inflammation and drainage from sinus ostia.
    • Examine the tympanic membranes and external auditory canals.
    • Evaluate the oropharynx for mucus drainage, lesions, and exudates.
    • Check the teeth and gums for tenderness and erythema.
    • Palpate for tenderness over frontal and maxillary sinus cavities.
    • Examine the face and orbits for swelling or erythema.
    • Perform cranial nerve examination.
    • Auscultate the chest for abnormal lung sounds.

A: Assessment

A partial differential diagnosis includes the following:

  • Allergic rhinitis
  • Sinus blockage by other lesions such as Kaposi sarcoma or lymphoma (particularly if the CD4 count is <200 cells/µL) or fungal infections (if the CD4 count is <50 cells/µL)
  • Dental abscess, caries
  • Meningitis
  • Vasculitis
  • Trauma

P: Plan

Diagnostic Evaluation

Uncomplicated acute sinusitis usually is a clinical diagnosis. There are no symptoms, physical findings, or tests that reliably distinguish bacterial from viral sinusitis. Patients generally can be assumed to have bacterial sinusitis if symptoms do not resolve, or if they worsen, over the course of 7-10 days. Any patient with high fever or severe or unusual symptoms should be evaluated urgently for other causes of illness.

Imaging studies usually are not indicated for uncomplicated acute sinusitis. In patients with a poor response to empiric antibiotic therapy for acute bacterial sinusitis, worsening symptoms, and those with suspected chronic sinusitis, computed tomography (CT) scans of the paranasal sinuses are the best initial radiologic study. Standard X-rays (sinus series) can detect cloudiness or air-fluid levels and will show mucosal thickening (a nonspecific finding in HIV-infected individuals).

Cultures of nasal aspirates are not useful for diagnosis, because nasal fluids do not accurately represent pathogens in the paranasal sinuses. Sinus aspirate cultures will give definitive diagnosis of a specific organism in the majority of cases; this may be considered in complicated cases. Definitive diagnosis of invasive fungal sinusitis requires tissue for culture.

Treatment

Treatment is multimodal. For viral sinusitis, treatment is based on symptom suppression; for bacterial sinusitis, an antibiotic can be added to other therapies, e.g., if symptomatic treatment has not resulted in improvement after 10 days.

  • Nasal irrigation with saline solution 1-2 times daily (solution should be prepared from sterile or bottled water)
  • Nasal steroid (e.g., budesonide, fluticasone, mometasone, or triamcinolone) (see "Potential ARV Interactions," below)
  • Nonsteroidal antiinflammatory drugs (NSAIDs): ibuprofen or other
  • Mucolytic agent: guaifenesin
  • Cough suppressant as needed
  • Antihistamine: chlorpheniramine or other
  • Decongestant: e.g., ephedrine, pseudoephedrine

If acute bacterial sinusitis is suspected (e.g., symptoms have not improved within 10 days), treat as above and add an antibiotic for a 5-7 day course of therapy:

  • Amoxicillin/clavulanate (Augmentin) 825/125 mg PO BID or 500/125 mg PO TID (more effective against resistant species of pneumococcus and H. influenza than amoxicillin)
  • Doxycycline 100 mg PO BID
  • Levofloxacin 500 mg QD or moxifloxacin 400 mg QD

For chronic sinusitis, administer multimodal treatments as listed above for 3-4 weeks. The value of antibiotics in chronic sinusitis is unclear; consider especially if a trial of antibiotics has not been undertaken.

If symptoms persist or worsen, refer patients to an otolaryngologist for further evaluation and treatment.

Potential ARV Interactions

Protease inhibitors (PIs) (particularly ritonavir-boosted PIs) or cobicistat may increase serum glucocorticoid levels if used concurrently with nasal steroids. Fluticasone (e.g., Flonase) nasal spray or inhaler should not be used with ritonavir-boosted PIs or cobicistat, and should be avoided, if possible, in patients taking unboosted PIs. Budesonide (Rhinocort Aqua) nasal spray also should be avoided with ritonavir-boosted PIs or cobicistat. Interactions between PIs or cobicistat and other nasal steroids have not been well studied, though available data suggest that beclomethasone has no clinically significant interaction with protease inhibitors.

Patient Education

  • Instruct patients in the correct use of medications used to treat sinusitis, including proper technique for nasal irrigation, as required.
  • Advise patients that drinking eight glasses (8-12 oz each) of fluid daily helps to keep the mucus thin enough to drain from the sinus passages.
  • Instruct patients to take antibiotics on schedule until the entire prescription is gone in order to prevent recurrence of the infection. Advise patients to call or return to clinic for swelling of the face or swelling around the eyes, increased facial tenderness, new or worsening fever, or other concerning symptoms.

References

  • Chow AW, Benninger MS, Brook I, et al.; Infectious Diseases Society of America. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012 Apr;54(8):e72-e112.
  • Gilbert DN, Moellering RC Jr., Eliopoulos GM, et al. The Sanford Guide to Antimicrobial Therapy, 35th Edition. Hyde Park, VT: Antimicrobial Therapy Inc.; 2005.
  • Gurney TA, Lee KC, Murr AH. Contemporary issues in rhinosinusitis and HIV infection. Curr Opin Otolaryngol Head Neck Surg. 2003 Feb;11(1):45-8.
  • Lee KC, Tami TA. Otolaryngologic Manifestations of HIV. In: Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]. San Francisco: UCSF Center for HIV Information; 1998. Accessed December 1, 2013.

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Abbreviations for Dosing Terminology

BID
twice daily
BIW
twice weekly
IM
intramuscular (injection), intramuscularly
IV
intravenous (injection), intravenously
PO
oral, orally
Q2H, Q4H, etc.
every 2 hours, every 4 hours, etc.
QAM
every morning
QD
once daily
QH
every hour
QHS
every night at bedtime
QID
four times daily
QOD
every other day
QPM
every evening
TID
three times daily
TIW
three times weekly