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allergies or NOT?
• An antihistamine nasal spray can be used effectively in older children. The FDA has approved the use of intranasal azelastine in children > 5 years of age and the use of intranasal olopatadine in children > 12 years of age • Glucocorticoid nasal spray is more effective than antihistamines when administered regularly or as needed. For predictable exposures, it is suggested to initiate therapy two days before, continuing through, and for two days after the end of exposure • Cromolyn sodium nasal spray is another option • Persistent or moderate/severe symptoms • Glucocorticoid nasal sprays are the most effective pharmacologic therapy for allergic rhinitis and are recommended by guidelines as the best single ther- apy for patients with persistent or moderate/severe symptoms • Possible addition of an antihistamine (non-sedating) • Moderate/severe asthma • Omalizumab and dupilumab are monoclonal antibodies that are available for moderate/severe asthma that is not controlled with high doses of inhaled glucocorticoids and also improves the symp- toms of allergic rhinitis, although not FDA approved for allergic rhinitis • Older adults • Glucocorticoid nasal sprays are the first-line agents for older adults with allergic rhinitis
PATHOPHYSIOLOGY OF ACUTE BACTERIAL RHINOSINUSITIS (ABRS)
The pathophysiology of acute bacterial rhinosinusitis is identical to the common cold and other upper respiratory viral infections and has already been discussed in previous sections. However, instead of a viral etiology, a bacterial pathogen is the culprit of the condition, with Streptococcus pneumoniae and Haemophilus influenzae being the two most common causing microbes. Other possible pathogens include Moraxella catarrhalis, Streptococcus pyogenes, Staphylococci, gram negative bacilli, and anaerobic bacteria. Patients with nosocomial infections are more likely to have gram negative organisms, while anaerobic sinus infec- tions are often associated with dental infections or procedures.
CLINICAL PRESENTATION OF ABRS
The clinical presentation of ABRS is very similar to that of viral upper respiratory infections, as mentioned earlier. For example, patients with either condition can present with symptoms of nasal congestion, hyposmia/anosmia, postna- sal drip, fever, cough, ear fullness, facial pain/pressure, and sore throat. However, the duration of symptoms is the key differentiating factor when assessing patients for acute bac- terial vs. viral rhinosinusitis. The key differences between infectious vs. allergic rhinosinusitis were discussed in the allergic rhinosinusitis section in the table describing aller- gic rhinitis vs. nonallergic rhinitis. Typically, a viral illness will usually last about 2-7 days, whereas acute bacterial rhinosi- nusitis persists beyond that time frame causing increased purulent nasal drainage and fatigue. Worsening symptoms after 7 days may indicate that a bacterial infection is present.
DIAGNOSIS OF ABRS
ACUTE BACTERIAL RHINOSINUSITIS INTRODUCTION
The diagnosis of acute rhinosinusitis is based upon clinical signs and symptoms and is diagnosed when patients pres- ent with < 4 weeks of purulent nasal drainage and severe nasal obstruction, facial pain/pressure/fullness, or both. The diagnosis is further supported by the presence of sec- ondary symptoms, including anosmia, ear fullness, cough, and headache. Patients are diagnosed with either viral or bacterial acute rhinosinusitis depending on the quality, dura- tion, and progression of symptoms. According to IDSA clinical guidelines for acute bacterial rhinosinusitis, the fol- lowing clinical presentations (any of 3) are recommended for identifying patients with acute bacterial vs. viral rhinosinusitis: • Onset with persistent symptoms or signs com- patible with acute rhinosinusitis, lasting for > 10 days without any evidence of clinical improvement • Onset with severe symptoms or signs of high fever (> 39oC) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of illness • Onset with worsening symptoms or signs character- ized by the new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted 5-6 days and were initially improving (also known as double-sickening)
Acute rhinosinusitis is defined as inflammation or infection of the mucosa of the nasal passage and at least one of the para- nasal sinuses lasting up to 4 weeks. It is one of the ten most common conditions treated in ambulatory practices in the United States. In a national health survey conducted in 2008, nearly 1 in 7 of all non-institutionalized adults aged > 18 years were diagnosed with rhinosinusitis within the previous 12 months. Incidence rates among adults are higher for women than men, and adults between 45 and 74 years are most com- monly affected. Although most cases are caused by viruses and aeroallergens, as mentioned earlier, some cases can be caused by bacteria; these cases are known as acute bacte- rial rhinosinusitis. The signs and symptoms of acute bacterial rhinosinusitis and viral upper respiratory infections are similar, which makes accurate clinical diagnosis and appropriate man- agement difficult. The prevalence of a bacterial infection during acute rhinosinusitis is estimated to be 2-10%, whereas viral causes, like the common cold, account for 90-98%. Despite this significant difference in prevalence rates, antibiotics are frequently prescribed for patients presenting with symptoms of acute rhinosinusitis, being the fifth leading indication for antimicrobial prescriptions by physicians in office practices.
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