#239 Sinusitis: It’s Not That Tricky

October 26, 2020 | By Paul Williams

Get Nose Deep into Rhinosinusitis with Dink Jardine MD

A runny nose won’t have you running in circles this cold season with our fantastic overview of rhinosinusitis in all its forms! We discuss etiology and presentation of viral versus bacterial rhinosinusitis, practical counseling tips for guiding patients on nasal irrigation, and working up chronic rhinosinusitis! Our guest is the fabulous Dr. Dink Jardine, a general otolaryngologist, Commander in the US Navy, and Director for Professional Education (DPE) and Designated Institutional Official (DIO) at Naval Medical Center Camp Lejeune (NMCCL). 

Listeners can claim Free CE credit through VCU Health at http://curbsiders.vcuhealth.org/ (CME goes live at 0900 ET on the episode’s release date).

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Credits

• Written and Produced by: Paul Williams MD, FACP, Beth Garbitelli
• Cover Art: Kate Grant MBChb, MRCGP 
• Infographic by:  Beth Garbitelli
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP
• Editor: Molly Heublein MD (written materials); Clair Morgan of nodderly.com (audio)
• Guest: Dink Jardine, MD

Sponsor

National Internal Medicine Day

Help ACP celebrate National Internal Medicine Day on October 28th. Visit https://www.acponline.org/NIMD20 to learn how you can show your internal medicine pride. Be sure to tag @ACPInternists and use the hashtags #NationalInternalMedicineDay, #IMProud, and #IMEssential.

VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org and search for this episode to claim credit. See info sheet for further directions. Note: A free VCU Health CloudCME account is required in order to seek credit.

How to Claim VCU CME Credit

Time Stamps

• Sponsor – National Internal Medicine Day, The American College of Physicians
• Sponsor – VCU Health Continuing Education
• 00:30 Intro, disclaimer, guest bio
• 03:00 Guest one-liner, Favorite failure, Pick of the Week*:  Still Life by Louise Penny
• Sponsor – National Internal Medicine Day, The American College of Physicians
• 09:30 Case 1 – Acute Viral Rhinosinusitis 
• 10:40 Rhinosinusitis vs. Sinusitis 
• 14:20 Physical exam in rhinosinusitis
• 20:40 Counseling patients about viral vs. bacterial infection
• 22:56  Sinus regimen/nasal irrigation – “Is there a sinus toilet”
• 27:10 Intranasal fluticasone and other intranasal medications 
• 29:40 Rhinitis medicamentosa
• 30:40 Nasal spray positioning
• 33:50 Case 1 – Double Sickening
• 37:40 Worst case scenarios from rhinosinusitis
• 40:40 Antibiotic treatment for bacterial rhinosinusitis
• 43:20 Failed improvement on antibiotics? Second-line options
• 49:30 Case 2 – Chronic rhinosinusitis 
• 52:28 Etiology of chronic rhinosinusitis
• 53:33 Making a diagnosis of chronic rhinosinusitis
• 55:25 Treating chronic rhinosinusitis 
• 58:40 Vasomotor rhinitis 
• 60:40 Sinus irrigation counseling and tips (YouTube)
• 65:30 Case 3 – Allergic Rhinitis 
• 70:13 Oral medications for allergic rhinitis; Chronic allergic/non-allergic rhinitis 
• 73:51 Take-home points

Sinusitis Pearls

1. The standard presentation of  acute viral rhinosinusitis involves symptom duration of less than 10 days (Dykewicz, et al, 2010) (OTO-HNS Clinical Practice Guidelines:  Adult Sinusitis (April 2015))
2. Early bacterial infections in an otherwise healthy person may be watched and frequently will resolve without antibiotic treatment (Rosenfeld, 2016). 
3. Patients who have bacterial rhinosinusitis following viral rhinosinusitis often describe a sour or bad flavor in their mouth and the mucus will be more purulent, per Dr. Jardine. 
4. The otoscope grants a nice anterior rhinoscopy view with light and magnification. Tilt head back slightly, angle away from the septum, angle out towards the turbinate. You may push the nose up (like a ‘pig nose’)and try to look back and up, per Dr. Jardine. 
5. For intranasal steroids, Dr. Jardine advises patients to aim straight back and slightly out to their cheek to avoid epistaxis. 
6. Reach out to your local ENT, as many considerations for imaging and referral are practice dependent, per Dr. Jardine. 
7. Teach sinus irrigation methods!

Sinusitis – Show Notes

A Nose By Any Other Name

Rhinosinusitis is probably the most accurate term, as it encompasses the entire region that tends to be inflamed when people say they have something going on with their sinuses.  Almost always, sinusitis is accompanied by rhinitis. Rhinitis involves nasal passages only and can occur in isolation, without sinus involvement.

Case 1 –  Max Linus’ Acute Rhinosinusitis 

The standard presentation of  acute viral rhinosinusitis involves symptoms lasting less than 10 days (Dykewicz, et al, 2010) (OTO-HNS Clinical Practice Guidelines:  Adult Sinusitis (April 2015))

Clinical Pearl: The otoscope grants a nice anterior rhinoscopy-esque view. Tilt head back slightly, angle away from the septum but towards the turbinate. You may push the nose up (like a ‘pig nose’) and try to look back and up.  Septums tend to be a sensitive area, whereas turbinates tend to be relatively insensate, per Dr. Jardine. Dr. Jardine also recommends looking at every nose and ear to get the best sense of normal. 

Infected nasal mucosa will be puffy and erythematous, whereas allergies tend to cause boggy turbinates that look more purple or blue, per Dr. Jardine. A severe infection will have loss of nasal patency.  

Ocular exam is helpful, as conjunctivitis tends to be associated with viral etiology per Dr. Jardine. Cheek/forehead sinus tenderness and transillumination are a part of the exam but these findings don’t make or break, although Dr. Jardine does recommend tapping on teeth to see if there is a dental etiology.  

Viral vs. Bacteria

At an initial presentation, it is not always clear if the infection is viral or bacterial; an early bacterial infection may present like a virus and viral infections can predispose development of bacterial sinusitis by causing obstruction (which may lead to bacterial overgrowth), break down the normal epithelial barrier,  and disrupted mucociliary clearance.  Early bacterial infections in an otherwise healthy person may be watched and frequently will resolve without antibiotic treatment (Rosenfeld, 2016). 

All About Nasal Sprays

In otherwise healthy patients with acute sinusitis, Dr. Jardine advises using a sinus regimen consisting of 3 days of oxymetazoline (2x a day)  and nasal saline rinse/irrigation.  Saline can be used as much as a patient wants, it helps thin the mucus and is especially useful for patients with a history of epistaxis. 

Fluticasone or other nasal steroids are helpful for allergy or chronic sinus congestion.  For intranasal steroids, Dr. Jardine advises patients to aim straight back and slightly out to their cheek to avoid epistaxis. She finds it helpful to demonstrate this maneuver.  Intranasal antihistamines are not helpful unless there is an allergic component. Ipratropium nasal spray is helpful for vasomotor rhinitis. 

We limit oxymetazoline usage because it can lead to rhinitis medicamentosa.  Oxymetazoline overuse causes your nose to become ‘addicted’ to and dependent upon the vasoconstricting properties (Ramey, 2006). 

“Double Sickening”

Patients who have bacterial rhinosinusitis following a viral rhinosinusitis often describe a sour or bad flavor in their mouth and the mucus will be more purulent, per Dr. Jardine. In the history, they often describe they were feeling better and then began to feel worse, or that the sinus infection has been going on for 10 days or more. (OTO-HNS Clinical Practice Guidelines:  Adult Sinusitis (April 2015))

Considering Antibiotics

In rare cases, untreated bacterial sinusitis can lead to orbital or preseptal cellulitis, abscesses in the sinuses, Pott’s Puffy Tumor,  or even cavernous sinus thrombosis, per Dr. Jardine.  

A 5 – 10 day course of amoxicillin or amoxicillin/clavulanate are the first line  options for treatment of a bacterial sinusitis (Rosenfeld, 2016).   If a patient returns after no improvement on antibiotics, second line treatment is a course of doxycycline and a prednisone burst, per Dr. Jardine. 

Case 2 – Ethel Moyd’s Chronic Rhinosinusitis 

To make the diagnosis of chronic rhinosinusitis, the patient must have 12 weeks of symptoms with 2 of the following: mucopurulent drainage, nasal obstruction, facial pain/pressure, or decreased sense of smell and signs of inflammation documented by purulent drainage in the middle meatus, polyps, or  via radiographic imaging.  (Sedaghat 2017) (OTO-HNS Clinical Practice Guidelines:  Adult Sinusitis (April 2015))

Chronic rhinosinusitis may be caused by allergies, occupational exposures, undiagnosed cystic fibrosis, or other underlying inflammatory disorders (Hopkins 2019).

Allergy workup can be helpful in a patient with chronic rhinosinusits.  Antibiotics and maximized nasal/sinus irrigation therapy should also be tried, however,  a patient with chronic rhinosinusitis who has gone through these steps may need to be assessed for surgery by an ENT (Hopkins 2019).  Imaging before referral will be practice dependent, per Dr. Jardine.

Vasomotor rhinitis is more of a nuisance and can be assessed via history. Patients with an ongoing vasomotor rhinitis may describe food- or exercise-triggered rhinorrhea, in contrast to the symptoms of chronic rhinosinusitis (Wheeler 2005).

How to Sell Sinus Irrigation

Patients who experience a burning sensation from nasal irrigation are usually using water that is too hot or too cold or doesn’t have enough salt in it,  per Dr. Jardine.  She advises her patients to shake up the mixture so that the salt is evenly distributed and use at baby bottle temperature. 

For patients who experience a gagging sensation, Dr. Jardine recommends bending over so they are parallel to the floor and attempt irrigation over a sink or tub. She advises gently flushing one side; if the patient feels like it’s going down their throat, they should bend over more. Dr. Jardine also advises patients to make a ‘ca-ca’ sound to close the palate. Try at least three times before completely giving up. YouTube videos can be helpful to show patients these methods.

Case 3 – Snotty Pippins’ Allergic Rhinitis 

Cobblestoning can occur with reflux as well, but is a helpful sign of allergic rhinitis,  per Dr. Jardine. 

Work-up will include allergy testing, nasal steroids, and consideration of nasal antihistamines (Sur 2015).  If a patient has chronic  rhinitis, with no response to nasal steroid and negative allergy testing, you may consider ipratropium or other newer surgical methods, per Dr. Jardine.

Links*

1. “Dr. Adappa and Dr. Palmer teach you How to do Nasal Irrigation” https://www.youtube.com/watch?v=Br928VfiC1M
2. Still Life: A Chief Inspector Gamache Novel by Louise Penny,  Chief Inspector Gamache series

Goals

Listeners will develop an approach to the diagnosis and management of rhinosinusitis.

Learning objectives

After listening to this episode listeners will…

1. Classify rhinosinusitis, including acute, chronic, bacterial, and viral.
2. Discuss the microbiology and pathophysiology underpinning rhinitis and sinusitis.
3. Differentiate the presentation and management of acute bacterial and acute viral rhinosinusitis.
4. Develop an approach to the diagnosis and management of allergic rhinosinusitis.
5. Recognize and manage patients with non-allergic rhinitis.
6. Discuss the role of antibiotic therapy and surgery in the management of rhinosinusitis.

Disclosures

Dr. Jardine reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

Williams PN, Garbitelli B, Jardine D, Heublein M, Watto MF.. “#239 Sinusitis: It’s not that tricky.” The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date October 26, 2020.