Recurrent Acute Rhinosinusitis (2024)

Continuing Education Activity

Sinusitis, also called rhinosinusitis, is the symptomatic inflammation of the paranasal sinuses and nasal cavity mucosa. Viruses, bacteria, fungi, or allergens may cause this inflammation. Recurrent acute sinusitis (RARS) is defined as4 or more rhinosinusitis episodes per year without persistent symptoms between episodes. This activity highlights the role of the interprofessional team in the evaluation and management of patients with recurrent acute sinusitis.

Objectives:

• Identify symptoms and clinical markers of recurrent acute rhinosinusitis.

• Screen patients at risk for recurrent acute rhinosinusitis, focusing on factors such as atopy, previous antibiotic use, and structural nasal abnormalities.

• Implement evidence-based management strategies, including appropriate use of antibiotics, topical treatments, and surgical interventions tailored to individual patient needs.

• Collaborate effectively with other healthcare professionals, including otolaryngologists, rhinologists, pharmacists, and nurses, for a multidisciplinary approach to patient care.

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Introduction

Sinusitis,orrhinosinusitis, is the symptomatic inflammation of the paranasal sinuses and nasal cavity mucosa. This inflammation may be caused by viruses, bacteria, fungi, and allergens,often occurringin combination or sequentially. The Rhinosinusitis Task Force established diagnostic criteria in 1997, categorizing symptoms into major and minor criteria.[1]The diagnosis of sinusitis requires the presence ofeither 2 major factors or1 majorand2 minor factors. The diagnostic criteria are as follows:

Major

• Purulence on nasal examination

• Nasal obstruction/blockage

• Nasal discharge/purulence/discolored postnasal drainage

• Hyposmia/anosmia

• Fever

• Facial pain/pressure

• Facial congestion/fullness

Minor

• Ear pain/pressure/fullness

• Cough

• Dental pain

• Fatigue

• Halitosis

• Fever

• Headache

Rhinosinusitis can be classified according to the duration of symptoms. Acute rhinosinusitis lasts fewer than4 weeks, while subacute sinusitis lasts between 4 and 12 weeks. Chronic sinusitis lasts more than 12 weeks. Recurrent acute rhinosinusitis (RARS) is defined as experiencing 4 or more episodes of acute rhinosinusitis per year, with each episode lasting at least10 days and without persistent symptoms in betweenindividual episodes.[2]Thisactivity will focus primarily on RARSanddetail patient presentation, diagnosis, and intervention.

Etiology

The most common etiologies forRARS mirror those of other sinusitis types. Viral upper respiratory tract infection is the most common cause of sinusitis andis typically self-limiting.[3]In these cases, viral inoculationtriggers inflammation and irritation of the nasal cavity mucosa and paranasal sinuses (see Image. Anatomical Positionof Sinuses). This inflammation reduces the size of the sinus ostia (outflow openings),obstructingthe clearance of nasal flora, mucus, and inhaled particles from the sinuses. Inflammation also impairs ciliary movement and causes mucus stasis, predisposing the sinuses to bacterial infection. Similarly, untreated allergic rhinitis can cause chronic inflammationin the nose and paranasal sinuses,resulting inoutflow tract obstruction, secretion buildup, and potential bacterial infection.

The most common bacterial pathogens causingRARS areStreptococcus pneumoniae,Haemophilus influenzae, otherStreptococcusspecies,Moraxella catarrhalis,andStaphylococcus aureus.[4]Methicillin-resistantSaureus(MRSA) often colonizes the nares and leads to recurrent sinusitis, especially in patients who have undergone multiple courses of antibiotics.

Thereissome etiologic overlap betweenRARSand chronic rhinosinusitis. Noninvasive fungal pathogens such asAspergillus fumigatusmay be isolated in these patients (see Image.Fungal Sinusitis and Image.Axial View Fungal Sinusitis). Anatomic obstructive abnormalities, including turbinate hypertrophy, conchae bullosae, stenosed sinus ostia, Haller cells (ethmoid cells within the medial orbitalfloorimpingingthe maxillary sinus drainage pathway), nasal polyposis, nasal masses, and septal spurs and deviation, can predispose the nasal cavity and sinuses to infection.[5][6]These structural abnormalities are often correctablethrough endoscopic surgical techniques.

Genetic factors affecting nasociliary motion or mucus production, like Kartagener syndrome, have also beensuggested to play a role in sinus disease pathophysiology. Environmental factors, such as tobacco smoke and chronic exposure to inhaled irritants, have been implicated in the development or exacerbation of RARS. These factors impair ciliary motility and disruptcell signaling in the innate immune system, exacerbating the condition.[7][8]

Epidemiology

Sinusitis ranks among the most common conditionspromptingmedical attention, with1 in 8 adultsreceiving a sinusitis diagnosis at leastonce in their lifetime.[9]Sinusitisaccounts for 20% of all antibiotic prescriptions.[10]In the United States alone, in 2015, there were 30 million diagnosed sinusitis cases,incurring a substantialtreatment cost exceeding$11 billion: $3 billionallocated to acute sinusitis and $8.3 billionto chronic sinusitis.[4]A comprehensive review of a medical claims databaseencompassing 13.1 million people from 2003 to 2008 revealed aRARS prevalence of1 in 3,000.Within this population, females constitutedthe majority (72.1%) of affectedindividuals, witha mean age of 43.5 years. Onaverage, patients had 5.6 annual healthcare visits and filled 9.4 prescriptions per year, resulting in an annual direct cost burden of $1,091 per patient.[11]

Pathophysiology

The pathogenesis of rhinosinusitis likely involves a combination of viscous sinus secretions and dysfunction of the sinus ostia and ciliary apparatus. Viral upper respiratory infections and allergens cause mucosal edema, narrowing the sinus ostia and causing direct mechanical obstruction. Obstruction of the sinus may lead tothe accumulation of secretions,providing an environment conducive to bacterial and fungal growth (see Image.Sinus Anatomy). Outflow blockagemay alsocausepressure changes within the sinus as oxygen is resorbed by the mucosa, resulting in a partial vacuum. This negative pressurecan be painful and result in the transudation of more fluid into the sinus. The excess fluid, combined with inflammation and theinflux of neutrophils and lymphocytes,can ultimatelycreateexcessive positive pressure,causing discomfort forpatients.

Incertain cases, typically chronic sinusitis, negative pressurecan persist to theextent that it causes contraction of the maxillary sinus, a conditiontermed"silent sinus syndrome." This process maylead to thedescent of the orbital floor and enophthalmos.[12]

In rhinosinusitis, altered sinus secretionsexacerbatethesusceptibilityto persistent infection and subsequent inflammation. Normally, the mucous blanket in the respiratory tract consists of2 distinct layers: the periciliary liquid phase, a thin, low-viscosity layer surrounding the cilia shaftallowingfree ciliary movement, and the gel phase, a more viscous layeratop the periciliary liquid. In the presence of inflammation, derangements in the mucous layer separationcanimpair ciliary movementby disrupting theusual low-viscosity environment.[13]

Additionally, bacterial biofilmscontribute to sinusitis pathogenesis, although they are more prevalentin chronic cases rather than in RARS.[14] Biofilmshinder antibiotic penetration because bacteria withinthis layer are not only attached firmly to one another as well as their substrate but they are alsosurrounded by a protective proteinaceous or polysaccharide matrix.[15]Saureus, notably, is adept atproducing biofilms, which often requirechemical and possibly mechanical disruption for definitive infection clearance.

History and Physical

Individuals experiencingacute sinusitis typically present with symptomspersisting forless than4 weeks. Specific symptoms may include nasal or postnasal (nasopharyngeal) purulence, nasal obstruction, hyposmia, anosmia, fever, facial pain or pressure, maxillary dental pain, fatigue, halitosis, and headache, among other complaints[10]. Patients with RARS, by definition, will haveencountered at least 4 of these episodes within thepreceding year, often necessitating multiple treatment regimensinvolving nasal sprays, steroids, and antibiotics.

During aphysical examination,observable signsmayinclude purulent rhinorrhea or pharyngeal drainage, turbinate hypertrophy, mucosal edema, or erythemaobserved onanterior rhinoscopy. External tendernessupon palpation of the frontal, ethmoid, or maxillary sinuses might be present. Patients could displayfever or tachycardia due to generalized facial pain. Although rare, acute sinusitis can lead to complications such as orbital cellulitis, preseptal cellulitis, or cavernous sinus thrombosis.[16]Cranial nerve evaluation and close orbit inspection should be performed to rule out these complications.

PatientswithRARS often experience symptoms similar to those of acute sinusitis. A viral origin is presumed if the patient reports symptoms lasting fewer than 10 days during an acute sinusitis episode.[1]The diagnosis of acute bacterial rhinosinusitis should be consideredifsymptoms last more than7 days or worsen within2 days after initial improvement, also known as "double worsening" or "second sickening."[10][17]Most episodes of acute sinusitis, whether viral or bacterial in etiology, resolve within 10 to 14 days.

Evaluation

History and physical examination are crucial to diagnosing RARS. In most cases, healthcare providers canaccuratelydiagnose RARS byevaluating theduration and progressionof symptoms, along with applying the major and minor diagnostic criteria setoutlined by the American Academy of Otolaryngology-Head and Neck Surgery.[18]Patients exhibiting unilateral disease without septal deviation, experiencing severe and debilitating symptoms, or those whose symptoms persist despite appropriate empirical treatment should undergo nasal endoscopy for further evaluation.[1]

Radiological imaging is not routinely recommended to evaluate patients with presumed uncomplicated RARS. However, a noncontrastcomputed tomography scan of the sinuses is indicated for patients with chronic rhinosinusitis, suspected anatomical abnormalities, or possible orbital complications (see Image.Axial CT of Sphenoid Sinus). Additionally, CT scansare integral topresurgical planning for procedures like balloon sinuplasty and functional endoscopic sinus surgery (FESS).[19]Research suggests that imaging is overutilized for patients with sinusitis. According to a 2012 study published by Bhattacharyya et al, 11.4% of patients with uncomplicatedRARS received a CT scan within1 year of diagnosis; the number increased to 39.9% at4 years.[11]

In cases of persistent or chronic sinusitis, cultures obtained from sinus aspirates or endoscopymight benecessary to identify resistant bacterial or fungal pathogens. The mostcommon pathogens involved inRARSoverlap those causingacute sinusitis, includingSpneumoniae,Hinfluenzae,otherStreptococcusspecies, Mcatarrhalis, and Saureus.[4]

Treatment / Management

Medical managementstands as the primary approach fortreating RARS. Many patients require a combination of therapies addressing different components of the complex pathophysiology underlying RARS. These treatments are outlined below.

• Topical intranasal therapy

• • Nasal saline irrigation effectively removes or reduces debris and pathogens from the nares,offering potentialsymptomatic relief.The efficacy of hypertonic versus isotonic saline solutions is debated,with hypertonic saline causing more adverse effects like increased nasal discharge and local discomfort. Excessive irrigation may disrupt natural protective mechanisms within the nose and paranasal sinusesbydisruptingthe mucus layer, reducing effectiveness.[20][21]

• Topical corticosteroid nasal sprays reduce mucosal inflammation,decreasing stenosis of sinus drainage pathways.These sprays are beneficial aspreventive measures and also during acute infections.

• Topical antihistamines, such as azelastine, can helpalleviate mucosal inflammation and irritation, reduce nasal passage edema, and open the sinus ostia.

• Topical decongestant sprays such as oxymetazoline and phenylephrinecan reduce congestion via local vasoconstriction. Patients should be cautioned aboutrebound congestion, a potential side effect of prolonged use. The use of these medications should be limited to 3to 5 consecutive days.[22]

• Antibiotics

• • Bacterial sinusitis complicates only0.5% to 2% of cases of viral sinusitis.[21]Therefore, antibiotic therapy should be started only if the symptoms persist for more than7 days without improvement or if symptoms worsen after an initial improvement period.

• For RARS, the recommended initial antibiotic therapy is amoxicillin with or without clavulanate for 5 to 10 days.A 2021 study published by Rovelsky et alindicates that amoxicillin is as effective as amoxicillin-clavulanate in treating acute sinusitis but causes fewer adverse gastrointestinal symptoms.[23]Alternatives for penicillin-allergic patients or resistant infections include doxycyclineand respiratory fluoroquinolones (levofloxacin, moxifloxacin). Otheroptionsinclude third-generation cephalosporins with or without clindamycin, depending on the clinical situation.[4]

• Intravenous antibiotics are the mainstay of treatment for patients with orbital cellulitis or moderate-to-severe preseptal cellulitis. Recommended antibiotics include vancomycin and ampicillin-sulbactam, clindamycin, third-generation cephalosporins, or piperacillin-tazobactam.[24]

• Decongestants

• • Oral decongestants provide symptomatic relief by reducing inflammation and secretionsin the nasal, sinus, and respiratory tract mucosa.They may also help maintain patency of the nasal ostia, leading to a reduction of sinus pressure.

• Oral antihistamines

• • Oral antihistaminesdisrupt the biological histamine pathway, preventing mucosal edema and inflammationtriggered by inhaled allergens in sensitized patients. Theycanbenefit patients whose sinusitis issuspected to be precipitated or exacerbated by allergic rhinitis.[25]

• Oral steroids

• • Oral steroids are not recommended as a monotherapy for acute rhinosinusitis. Limited evidencesupports the use oforal steroids as an adjunct treatment alongside antimicrobial therapy for acute sinusitis.[26]

• Oral leukotriene modifiers

• • Leukotriene modifiers, such as montelukast, are effective treatments for allergic rhinitis and nasal polyposis. Theycan beparticularlybeneficial for patients with rhinosinusitis who have asthma, allergic rhinitis, or nasal polyposis.[27]

Surgical intervention for recurrent acute rhinosinusitis can be considered for patients who do not respond to medical management, particularly if they have documented anatomic abnormalities that correlate with their symptoms. Surgery has been shown to decrease symptoms and improve the quality of life for appropriately selected patients.[9][28][29]Surgical intervention is also often required for patients with sinusitis-related complications such as subperiosteal abscess, orbital abscess, or cavernous sinus thrombosis. Specific surgical approaches aredetailed below.

Functional endoscopic sinus surgerycan correct anatomic abnormalities that prevent optimal sinus drainage. Various procedures, including maxillary antrostomy, uncinate process resection, ethmoidectomy, and Draf I-III frontal sinusotomies can be performed depending on the location and severity of the individual patient’s pathology. Before surgical intervention, a noncontrastCT of the sinuses should be performed to confirm the diagnosis and localize the pathology for surgical planning.[19]Preoperative CT imaging can also aid intraoperative navigation, improving outcomes andreducing complication rates, particularly in revision cases.[30][31]

Balloon sinuplastyis a tissue-sparing proceduredesigned to permanently dilate the sinus ostia and drainage pathwaysthrough localized microfracturingvia balloon insufflation. This procedure enhancesmucus drainage and reduces negative pressurewithin the sinus cavities. Balloon sinuplasty treats patients with RARS and chronic rhinosinusitis without nasal polyposis (CRSsNP).[28]This minimally invasive procedure may be performed in an operating room or office setting.

Septoplasty is a surgical option for patients with obstructive nasal septal deviations. The procedure reduces impingement of the sinus ostia, improves airflow, and facilitates proper mucociliary clearance.

Turbinate reductionmay alleviate nasal obstruction and allow further anterior drainage of nasal and sinus contents in patients with hypertrophy of the inferior turbinates.

Differential Diagnosis

Several disease processes share overlapping symptomswithRARS, necessitating careful consideration of differential diagnoses. Before confirming the diagnosis, other diseasesand conditions that should be ruled out include:

• Allergic rhinosinusitis

• Acute rhinosinusitis

• Chronic rhinosinusitis with nasal polyposis (CRSwNP)

• Chronic rhinosinusitis without nasal polyposis (CRSsNP)

• Subacute rhinosinusitis

• Viral rhinosinusitis (upper respiratory tract infection)

• Noninvasive fungal rhinosinusitis

• Invasive fungal rhinosinusitis

• Adenoiditis

• Cerebrospinal fluid (CSF) rhinorrhea

• Vasomotor rhinitis

• Laryngopharyngeal/gastroesophageal reflux disease

Prognosis

The prognosis for recurrent acute rhinosinusitis is generally good. Most patientsrespond wellto medical management, including topical nasal sprays and oral antibiotics. Patients rarely develop complications requiring hospitalization for immediate surgical intervention or intravenous antibiotics. Appropriately selected patients who undergo surgery typically experience symptomatic relief and appreciable improvement in quality of life.[28][29][32]

Complications

Although rare, complications of recurrent acute rhinosinusitis include but are not limited to the following:

• Persistent hyposmia/anosmia

• Preseptal cellulitis

• Orbital cellulitis

  See Also

  Sinusitis Post Nasal and Sinus Pressure and the Allergy

• Subperiosteal abscess

• Orbital abscess

• Cavernous sinus thrombosis

Consultations

Consultation with an ophthalmologist may benecessary for additional evaluation and management of orbital complications. Patients who require revision endoscopic sinus surgery may be better served by a subspecialist, such as a rhinologist, rather than a general otolaryngologist-head and neck surgeon.

Deterrence and Patient Education

Educating patients about the expectedprogression of symptoms, home management strategies, and circumstanceswarrantingmedical attention is crucial. This anticipatory guidance empowers patients to recognize and treat their symptoms earlier in the course of illness. Effective early symptom managementcan decrease symptom escalation, reducing thenecessityfor more aggressive and costly therapies. In cases whereadditional treatment is necessary, providing education about medication regimens, common adverse effects, and expected outcomescanincrease patient satisfaction and understanding.

Pearls and Other Issues

Key points to remember regarding the diagnosis and treatment of RARS include:

• Recurrent sinusitis is a clinical diagnosis defined by4 or more distinct episodes of sinusitis per year, with symptom-free intervals between episodes.

• Routine diagnostic imaging is not recommended for uncomplicated RARS; however, a noncontrast CT scan may demonstrate anatomical obstructions and provide valuable information for surgical planning.

• Symptomatic treatment with a trial of a decongestant nasal spray, daily intranasal irrigation, and a corticosteroid nasal spray is the mainstay of treatment during the first7 days of symptoms.

• A variety of antibiotics may be used to treat suspected bacterial sinusitis. The specific choice of medication should be based on local antibiograms, patient risk factors, allergies, and comorbidities. Drug resistance should be considered in refractory cases, and cultures should be obtained to inform targeted therapy.

• While medical therapy is the mainstay of treatment for most patients, research indicates that surgical intervention benefits a subset of patients with RARS. Outcomes are similar to those seen in patients surgically treated for chronic rhinosinusitis.

• Endoscopic surgical techniques benefit patients with proven turbinate hypertrophy, conchae bullosa, stenosed sinus ostia, frontal sinus cells, Haller cells, and septal spurs.

• Balloon sinus dilation is a minimally invasive endoscopic approach that effectively treats RARS andCRSsNP.

• Orbital complications ofRARS, such as preseptal cellulitis, orbital cellulitis, and cavernous sinus thrombosis, necessitate vigilant monitoring for the development of cranial nerve deficits or other signs of orbital involvement, ensuring immediate treatment when indicated.

Enhancing Healthcare Team Outcomes

RARScanpose significant challengesfor patients and clinicians due to its recurring nature. Establishing a medical home, where primary care providers can monitorpatientsover time and coordinate their care, proves beneficial. Collaborating with interprofessional team members, including general otolaryngologists, rhinologists, pharmacists, nurses, and, in some cases, ophthalmologists, is essential. Tailoring management to each patient’s needs is crucial, as responses to specific treatments vary.

Primary and specialty care providers are pivotal indiagnosing and formulating evidence-basedtreatment plans. Pharmacistsare instrumental in ensuringappropriate medication selection and dosing, considering patient allergies and comorbidities. Nurses provide direct patient care, offer education, and often facilitate communication between patients and physicians. Otolaryngologists, rhinologists, and ophthalmologists are usually required to manage complications or perform surgical procedures when medical management fails. Effective collaboration among these professionals is criticalfor comprehensive and successful management.

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Disclosure: Gyanendra Sharma declares no relevant financial relationships with ineligible companies.

Disclosure: Daniel Lofgren declares no relevant financial relationships with ineligible companies.

Disclosure: Marc Hohman declares no relevant financial relationships with ineligible companies.

Disclosure: Henry Taliaferro declares no relevant financial relationships with ineligible companies.