The Many Faces of Rhinosinusitis: Case Challenges

Gordon H. Sun, MD, MS

September 22, 2015

Classifying Rhinosinusitis

In April 2015, the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) published an update[1] to a 2007 clinical practice guideline for the management of adult rhinosinusitis, a condition affecting more than 30 million people in the United States with annual direct costs exceeding $11 billion. Rhinosinusitis is the fifth most common diagnosis for which an antibiotic is prescribed in the United States, accounting for 21% of all adult antibiotic prescriptions written in 2002.[2]

According to the AAO-HNSF, diagnosis of acute rhinosinusitis (ARS) requires up to 4 weeks of purulent rhinorrhea, plus nasal obstruction or facial pain, pressure, or fullness. Although the diagnosis of ARS is predicated on these three cardinal symptoms, patients often present with other findings, such as fever, cough, fatigue, hyposmia, dental pain, or aural fullness.[1] The requirement for a 4-week duration of symptoms is based more on consensus among guideline development groups than clinical evidence.[1,3,4]

ARS can be categorized further into viral rhinosinusitis and acute bacterial rhinosinusitis (ABRS). Viral rhinosinusitis and ABRS are differentiated by two factors: duration of symptoms and change in severity over time. Symptoms of viral rhinosinusitis are caused by a presumed viral infection, lasting fewer than 10 days and not worsening. In contrast, symptoms of ABRS are presumed to be caused by bacterial infection, either lasting at least 10 days without improvement or worsening within 10 days after a period of initial improvement (a phenomenon known as "double worsening").

Recurrent ARS is diagnosed when patients experience at least four episodes of rhinosinusitis annually, without persistent symptoms between episodes. By definition, this patient does not have recurrent ARS because she has had only two episodes of pertinent symptoms over the past year. This should be distinguished from chronic rhinosinusitis (CRS), which is characterized by symptoms lasting more than 12 weeks continuously, with or without intervening acute exacerbations.

Clinical Presentation: Second Case—Bacterial Invasion

A 30-year-old laboratory technician presented to his family physician with a 14-day history of bilateral nasal obstruction, cloudy nasal discharge, and pain in the cheeks and upper teeth. The patient reported that he took his temperature at home yesterday and that he had no fever. He had tried over-the-counter cold medicine, with no change in his symptoms.

The patient was previously healthy, denied tobacco or alcohol use, and reported no known drug allergies. After examining the patient, the physician diagnosed him with acute ABRS.

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