Grand Rounds Grand Rounds

Rebecca Burton-MacLeodRebecca Burton-MacLeod

R4, Emergency MedicineR4, Emergency Medicine

February 1February 1stst, 2007, 2007

Case Case

• 32M previously healthy presents to 32M previously healthy presents to ED c/o headache. Frontal x 6days. ED c/o headache. Frontal x 6days. Worsens when he chews. No signif Worsens when he chews. No signif relief with tylenol. Low-grade fever. relief with tylenol. Low-grade fever. Recent URTI symptoms (~2wks ago). Recent URTI symptoms (~2wks ago). No hx of headaches. No hx of headaches.

• Exam unremarkable. T 38.1CExam unremarkable. T 38.1C

• Any thoughts ?Any thoughts ?

Acute Sinusitis: Acute Sinusitis: Diagnostic Dilemmas ?Diagnostic Dilemmas ?

Overview Overview

• Introduction to sinusitisIntroduction to sinusitis

• Diagnosis?Diagnosis?

• Imaging?Imaging?

• Who to be worried about?Who to be worried about?

Anatomy Anatomy

Incidence Incidence

• Sinus inflammation occurs in 90% of Sinus inflammation occurs in 90% of individuals with the “common cold”individuals with the “common cold”

• Bacterial infection complicates ~2% of these Bacterial infection complicates ~2% of these casescases

• Almost all cases follow a viral URTI; Almost all cases follow a viral URTI; occasionally a complication of allergic rhinitis occasionally a complication of allergic rhinitis

• The usual ENT culprits—The usual ENT culprits—Strep pneumoniae, H Strep pneumoniae, H flu, Moraxella catarhallis, Staph aureus flu, Moraxella catarhallis, Staph aureus

Classification Classification

• Acute:Acute:– Symptoms up to Symptoms up to

4wks4wks

• Subacute:Subacute:– Symptoms from 4-Symptoms from 4-

12wks 12wks

• Chronic:Chronic:– Symptoms >12wksSymptoms >12wks

• Recurrent acute:Recurrent acute:– 4+ episodes in one 4+ episodes in one

year, each lasting year, each lasting >7days >7days

Pathophysiology Pathophysiology

• Ciliated pseudostratified columnar Ciliated pseudostratified columnar epithelium epithelium – Secretes mucous which traps particlesSecretes mucous which traps particles– Expelled into nasal airway through sinus ostiaExpelled into nasal airway through sinus ostia

• Immunologic host defenses in sinuses Immunologic host defenses in sinuses creates normally sterile environment creates normally sterile environment

• Obstruction of ostia causes stagnant Obstruction of ostia causes stagnant environment allowing bacterial environment allowing bacterial overgrowthovergrowth

Diagnosis Diagnosis American Academy of Otolaryngology-Head and Neck SurgeryAmerican Academy of Otolaryngology-Head and Neck Surgery

Physical examination ?Physical examination ?

• Anterior rhinoscopy with nasal Anterior rhinoscopy with nasal speculum speculum

• Visualization of purulent nasal Visualization of purulent nasal dischargedischarge

• Sinus tendernessSinus tenderness

• Transillumination of sinuses Transillumination of sinuses

Exam findings ?Exam findings ?

• 3/14 pts later diagnosed with acute 3/14 pts later diagnosed with acute sinusitis had any evidence of sinusitis had any evidence of purulent dischargepurulent discharge

• Rhinoscopy only allows visualization Rhinoscopy only allows visualization of anterior nasal cavitiesof anterior nasal cavities

Transillumination? Transillumination?

• Transillumination—Transillumination—sensitivity 73% sensitivity 73% specificity 54%specificity 54%

Exam findings ?Exam findings ?

• Comparison of sinus tenderness with Comparison of sinus tenderness with other systemic tendernessother systemic tenderness

• Sinus pain at lower cutaneous Sinus pain at lower cutaneous pressures if rhinosinusitispressures if rhinosinusitis

• However, chronic fatigue s/o pts had However, chronic fatigue s/o pts had 44% lower thresholds for all locations 44% lower thresholds for all locations of tenderness (including sinus)of tenderness (including sinus)

Imaging optionsImaging options

• XRayXRay

• CTCT

• MRI MRI

• U/S U/S

Xray Xray

• 3 standard views:3 standard views:– Caldwell (AP)Caldwell (AP)– Waters (occipito-mental)Waters (occipito-mental)– Lateral Lateral

Xray diagnosis Xray diagnosis

• Air-fluid levelsAir-fluid levels

• Sinus opacitySinus opacity

• Marked mucosal Marked mucosal thickening (>6mm)thickening (>6mm)

Xray Xray

• ?low sensitivity and specificity vs. gold ?low sensitivity and specificity vs. gold standardstandard

Engels EA et al. Meta-analysis of diagnostic tests for acute sinusitis. J Clin Epi. Engels EA et al. Meta-analysis of diagnostic tests for acute sinusitis. J Clin Epi. 2000.2000.

• Unable to visualize ethmoid sinuses well in Unable to visualize ethmoid sinuses well in any of 3 views (20% of pts have isolated any of 3 views (20% of pts have isolated ethmoid sinus infections)ethmoid sinus infections)

Slavin RG et al. The diagnosis and management of sinusitis: a practice Slavin RG et al. The diagnosis and management of sinusitis: a practice parameter update. J Allerg Clin Immunol. 2005.parameter update. J Allerg Clin Immunol. 2005.

• Cannot define extent of diseaseCannot define extent of diseaseZinreich JS. Functional anatomy and CT imaging of paranasal sinuses. Am J Med Zinreich JS. Functional anatomy and CT imaging of paranasal sinuses. Am J Med

Sci. 1998.Sci. 1998.

Comparing XR, U/S, clinical Comparing XR, U/S, clinical examexam• Meta-analysis of studies comparing diagnostic modes for Meta-analysis of studies comparing diagnostic modes for

acute maxillary sinusitisacute maxillary sinusitis• Sinus puncture used as gold standardSinus puncture used as gold standard• XR:XR:

– N =996 pts; 7 studiesN =996 pts; 7 studies– Weighted mean sensitivity 87%, specificity 89%Weighted mean sensitivity 87%, specificity 89%

• U/S:U/S:– N=940 pts; 7 studiesN=940 pts; 7 studies– Weighted mean sensitivity 85%, specificity 82%Weighted mean sensitivity 85%, specificity 82%

• Clinical exam:Clinical exam:– N=245 pts; 2 studiesN=245 pts; 2 studies– Weighted mean sensitivity 69%, specificity 79%Weighted mean sensitivity 69%, specificity 79%Varonen H et al. Comparison of U/S, XR, and clinical exam in the diagnosis Varonen H et al. Comparison of U/S, XR, and clinical exam in the diagnosis

of acute maxillary sinusitis: a systematic review. J Clin Epi. 2000.of acute maxillary sinusitis: a systematic review. J Clin Epi. 2000.

CT CT

• Indications:Indications:– Severe unilateral Severe unilateral

maxillary painmaxillary pain– Facial swellingFacial swelling– FeverFever– Changes in mental Changes in mental

statusstatus– Unresponsive to Unresponsive to

abx treatmentabx treatment

• Limitations:Limitations:– Lack of correlation Lack of correlation

b/w sinus symptoms b/w sinus symptoms and CT findingsand CT findings

– Unable to Unable to differentiate viral differentiate viral from bacterial from bacterial sinusitissinusitis

– High frequency of High frequency of abnormal scans in abnormal scans in asymptomatic pts asymptomatic pts

Piccirillo JF. Acute bacterial sinusitis. NEJM. 2004.

CT specificity CT specificity

• 87% of pts with 87% of pts with common cold common cold showed changes in showed changes in sinuses on CTsinuses on CT

• ?differentiate b/w ?differentiate b/w viral and bacterial viral and bacterial causes of causes of rhinosinusitis rhinosinusitis

Gwaltney JM Jr et al. CT study of Gwaltney JM Jr et al. CT study of the common cold. NEJM. 1994. the common cold. NEJM. 1994.

Correlation b/w symptoms Correlation b/w symptoms and CT findings and CT findings • N=200 consecutive pts referred for CT for sinus N=200 consecutive pts referred for CT for sinus

painpain• R temple/forehead most commonly reported R temple/forehead most commonly reported

site of maximal painsite of maximal pain• On CT, maxillary sinus most frequently involvedOn CT, maxillary sinus most frequently involved• Bivariate analysis showed no relationship b/w Bivariate analysis showed no relationship b/w

symptoms and finding on CTsymptoms and finding on CT• Pts with abnormal CT reported 5.45 sites of Pts with abnormal CT reported 5.45 sites of

facial pain vs. 5.88 sites on pts with normal CTfacial pain vs. 5.88 sites on pts with normal CTSikha P et al. Correlation between presumed sinusitis-induced pain and Sikha P et al. Correlation between presumed sinusitis-induced pain and

paranasal sinus CT findings. Ann Allerg Asthma Immunol. 2002.paranasal sinus CT findings. Ann Allerg Asthma Immunol. 2002.

Canada vs. US facial pain Canada vs. US facial pain and CT findings and CT findings • N=51pts; 27 were recruited in EdmontonN=51pts; 27 were recruited in Edmonton• Questionnaire completed prior to CT to r/o Questionnaire completed prior to CT to r/o

rhinosinusitisrhinosinusitis• No correlation b/w pain severity and disease No correlation b/w pain severity and disease

severity on CT (p>0.05)severity on CT (p>0.05)• Mean pain score for US pts 7.3 vs. 5.2 for Mean pain score for US pts 7.3 vs. 5.2 for

Canadian ptsCanadian pts• Canadian pts had more severe disease on CT Canadian pts had more severe disease on CT

while reporting less pain (p=0.004)while reporting less pain (p=0.004)Shields G et al. Correlation between facial pain or headache and CT in Shields G et al. Correlation between facial pain or headache and CT in

rhinosinusitis in Canadian and US subjects. Laryngoscope. 2003. rhinosinusitis in Canadian and US subjects. Laryngoscope. 2003.

Comparing CT and XRComparing CT and XR

• N=47 consecutive pts over 6mosN=47 consecutive pts over 6mos• XR and CT on the same dayXR and CT on the same day• Calculated sensitivity of XR for each sinus:Calculated sensitivity of XR for each sinus:

– Maxillary 80%Maxillary 80%– Ethmoid 41%Ethmoid 41%– Frontal 39 %Frontal 39 %– Sphenoid 47%Sphenoid 47%

• Specificity 92-100%Specificity 92-100%• Time spent performing each study (5-9min for Time spent performing each study (5-9min for

CT); half of time spent doing XRCT); half of time spent doing XRAalokken TM. Conventional sinus XR compared with CT in the diagnosis of acute Aalokken TM. Conventional sinus XR compared with CT in the diagnosis of acute

sinusitis. DentoMaxilloFacial Radiog. 2003.sinusitis. DentoMaxilloFacial Radiog. 2003.

Cost-effectiveness Cost-effectiveness • Model to examine different strategies for Model to examine different strategies for

treatment of acute sinusitis:treatment of acute sinusitis:– Use of clinical criteria-guided treatment was cost-Use of clinical criteria-guided treatment was cost-

effective in most caseseffective in most cases– Sinus XR-guided treatment not cost-effective for initial Sinus XR-guided treatment not cost-effective for initial

treatmenttreatmentBalk EM et al. Strategies for diagnosing and treating suspected acute bacterial Balk EM et al. Strategies for diagnosing and treating suspected acute bacterial

sinusitis: a cost-effectiveness analysis. J Gen Intern Med. 2001.sinusitis: a cost-effectiveness analysis. J Gen Intern Med. 2001.

• Consensus statement from variety of N. Am Consensus statement from variety of N. Am experts stated radiography not warranted when experts stated radiography not warranted when likelihood of acute sinusitis is HIGH or LOW but likelihood of acute sinusitis is HIGH or LOW but useful when diagnosis in doubtuseful when diagnosis in doubt

Anzai Y et al. Imaging evaluation of sinusitis: diagnostic performance and Anzai Y et al. Imaging evaluation of sinusitis: diagnostic performance and impact on health outcome. Neuroimag Clin N Am. 2003.impact on health outcome. Neuroimag Clin N Am. 2003.

Bottom-line Bottom-line

• Xrays—inadequate to aid in diagnosisXrays—inadequate to aid in diagnosis

• CT—useful if confirmation of diagnosis is CT—useful if confirmation of diagnosis is indicated as views all sinuses and looks indicated as views all sinuses and looks for potential complications for potential complications

• MRI—unlikely to add information to CT MRI—unlikely to add information to CT

• U/S—not used in N. Am for diagnosis of U/S—not used in N. Am for diagnosis of sinusitis sinusitis

So, what’s the rush in So, what’s the rush in diagnosing…diagnosing…

Complications Complications

• Local:Local:

• Intracranial:Intracranial:– MeningitisMeningitis– Abscess Abscess – Pott’s puffy tumorPott’s puffy tumor– Sagittal sinus thrombosisSagittal sinus thrombosis– Cavernous sinus Cavernous sinus

thrombosisthrombosis

• Orbital complications:Orbital complications:– CellulitisCellulitis– Abscess Abscess

• Distant:Distant:

• Pulmonary Pulmonary (exacerbations of):(exacerbations of):– AsthmaAsthma– BronchitisBronchitis– COPDCOPD– CFCF

• Systemic:Systemic:– SepsisSepsis– Toxic shock s/oToxic shock s/o

Intracranial complications Intracranial complications

Who to watch for…Who to watch for…

• Majority are young adult malesMajority are young adult males• Male:Female is 2:1 up to 4.5:1Male:Female is 2:1 up to 4.5:1• Mean age 24 yearsMean age 24 years• Average from onset of URTI symptoms to Average from onset of URTI symptoms to

complication is 15dayscomplication is 15daysJones et al. The intracranial complications of rhinosinusitis: can they be Jones et al. The intracranial complications of rhinosinusitis: can they be

prevented? Laryngoscope. 2002.prevented? Laryngoscope. 2002.

• Reported rate from hospitalized pts is 3.7-Reported rate from hospitalized pts is 3.7-47.6% (likely over-estimated)47.6% (likely over-estimated)

Osborn MK et al. Subdural empyema and other suppurative complications of paranasal Osborn MK et al. Subdural empyema and other suppurative complications of paranasal sinusitis. Lancet Infect Dis. 2007. sinusitis. Lancet Infect Dis. 2007.

Common s/sCommon s/s

• Headache, fever, nuchal rigidity, vomiting, Headache, fever, nuchal rigidity, vomiting, behaviour changes, seizuresbehaviour changes, seizures

Younis et al. Sinusitis complicated by meningitis: current management. Younis et al. Sinusitis complicated by meningitis: current management. Laryngoscope. 2001.Laryngoscope. 2001.

• Headache, fever, lethargy, focal neuro Headache, fever, lethargy, focal neuro deficit, seizuresdeficit, seizures

Lang EE et al. Intracranial complications of acute frontal sinusitis. Clin Lang EE et al. Intracranial complications of acute frontal sinusitis. Clin Otolarygnol. 2001.Otolarygnol. 2001.

• Fever, altered LOC, focal neuro findings, Fever, altered LOC, focal neuro findings, orbital findings, also “silent” (asymptomatic)orbital findings, also “silent” (asymptomatic)

Osborn MK et al. Subdural empyema and other suppurative Osborn MK et al. Subdural empyema and other suppurative complications of paranasal sinusitis. Lancet Infect Dis. 2007. complications of paranasal sinusitis. Lancet Infect Dis. 2007.

Investigations Investigations

• Labwork—not usefulLabwork—not useful– 30% of pts have normal WBC30% of pts have normal WBC– ESR and CRP may be elevatedESR and CRP may be elevated

• XR—not usefulXR—not useful

• CT—diagnostic tool of choice (with contrast)CT—diagnostic tool of choice (with contrast)

• LP—only perform after CT!LP—only perform after CT!Jones et al. The intracranial complications of rhinosinusitis: can they be Jones et al. The intracranial complications of rhinosinusitis: can they be

prevented? Laryngo. 2002.prevented? Laryngo. 2002.

Younis et al. Sinusitis complicated by meningitis: current management. Younis et al. Sinusitis complicated by meningitis: current management. Laryngo. 2001.Laryngo. 2001.

Which sinuses?Which sinuses?

• Review of 82 pts over 15years Review of 82 pts over 15years admitted with sinusitis complications:admitted with sinusitis complications:– With meningitis: ethmoid and sphenoid With meningitis: ethmoid and sphenoid

sinuses involved in all 21pts (may be sinuses involved in all 21pts (may be unilateral)unilateral)

– With abscesses: pansinusitis most With abscesses: pansinusitis most common finding (16 pts); frontal sinuses common finding (16 pts); frontal sinuses most frequently involved (11pts)most frequently involved (11pts)

Younis et al. Intracranial complications of sinusitis: a 15 year Younis et al. Intracranial complications of sinusitis: a 15 year review of 39 cases. ENT Journal 2002.review of 39 cases. ENT Journal 2002.

Treatment Treatment

• 33rdrd generation cephalosporin and generation cephalosporin and metronidazolemetronidazole

• Tailored once antimicrobial Tailored once antimicrobial identification and susceptability identification and susceptability identifiedidentified

Outcomes Outcomes

Younis et al. Sinusitis complicated by meningitis: current management. Laryngo 2001.

Local opinions Local opinions

• ““possible ENT consult warranted if possible ENT consult warranted if evidence of frontal/sphenoid sinusitis evidence of frontal/sphenoid sinusitis and pt toxic”and pt toxic”

• ““only admit if evidence of only admit if evidence of complications”complications”

• Reassess in few days if no Reassess in few days if no improvement despite treatmentimprovement despite treatment

Dr’s. Bosch, Hui, Park (ENT surgeons)Dr’s. Bosch, Hui, Park (ENT surgeons)

Questions ?Questions ?