Sinusitis

Background

Sinusitis is defined as an inflammation involving the membrane lining of any sinus, and is a frequent finding in people with HIV infection. It occurs very commonly 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 or 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 is added to other therapies:

• Antihistamine: chlorpheniramine or other
• Decongestant: pseudoephedrine
• Nasal steroid (e.g., budesonide, fluticasone, mometasone, or triamcinolone) (see "Potential ARV Interactions," below)
• Nonsteroidal antiinflammatory drugs (NSAIDs): ibuprofen or other
• Cough suppressant as needed
• Mucolytic agent: guaifenesin
• Inhaled steam and saline nasal irrigation to promote sinus drainage

If acute bacterial sinusitis is suspected, treat as above and add an antibiotic for a 10-14 day course of therapy:

• Amoxicillin 500-1,000 mg TID
• Amoxicillin/clavulanate (Augmentin) 825/125 mg BID
• Cefpodoxime 200-400 mg BID
• Clindamycin 450 mg TID
• Levofloxacin 500 mg once daily or moxifloxacin 400 mg once daily

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.

Patient Education

• Instruct patients in the correct use of medications used to treat sinusitis, including proper technique for nasal irrigation or steam inhalation, as required.
• Instruct patients to take antibiotics on schedule until the entire prescription is gone in order to prevent recurrence of the infection.
• Advise patients that drinking eight glasses (8-12 oz each) of fluid daily helps to keep the mucus thin enough to drain the sinus passages.
• 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

• 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 June 20, 2012.