Note to myself-Please review the following in addition to this post:
Useful resources when treating rhinitis, sinusitis, or rhinosinusitis are:
- Nonallergic Rhinitis – Excerpts and Resources
Posted on December 14, 2018 by Tom Wade MD- This post discusses and has resources on the use of nasal steroids, nasal antihistamines, and nasal anticholinergics.
- Medical Outcomes Study Questionnaire Short Form 36
Health Survey (SF-36) [Link is to the PDF] - A Great Resource On Sinus Disease-#239 Sinusitis: It’s Not That Tricky-From Dr Jardine And The Curbsiders
Posted on October 28, 2020 - Adult Rhinoconjunctivitis Quality of Life Questionnaire
- Paediatric Rhinoconjunctivitis Quality of Life Questionnaire
In this post I link to the awesome podcast and show notes from the Curbsiders and Dr Dink Jardine, #239 Sinusitis: It’s Not That Tricky
OCTOBER 26, 2020 By DR PAUL WILLIAMS:
Summary
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).
And here are excerpts [as I frequently note, I post the excerpts as it helps me fix the learning in my mind and I can more easily use my blog’s search function to find the resource]:
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
- 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))
- Early bacterial infections in an otherwise healthy person may be watched and frequently will resolve without antibiotic treatment (Rosenfeld, 2016).
- 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.
- 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.
- For intranasal steroids, Dr. Jardine advises patients to aim straight back and slightly out to their cheek to avoid epistaxis.
- Reach out to your local ENT, as many considerations for imaging and referral are practice dependent, per Dr. Jardine.
- Teach sinus irrigation methods!
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.
*[Limit to no more than 3 days to avoid rhinitis medicamentosa (link is to article in emedicine.medscape).]
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.
