Sinusitis in the common cold

Management of acute maxillary sinusitis in Finnish primary care. Results from the nationwide MIKSTRA study

OBJECTIVES

To study the management of acute maxillary sinusitis (AMS) in Finnish primary care and to compare it both to recommendations in national guidelines and to the management of other upper respiratory tract infections (URTI).

DESIGN

A cross-sectional multi-centre epidemiological survey.

SETTING

Thirty primary care health centres in Finland.

SUBJECTS

7284 patients with symptoms of possible acute rhinosinusitis during one week in both November 1998 and November 1999.

MAIN OUTCOME MEASURE

Symptoms and their duration, use of diagnostic tools, choice of antibiotics, patient outcomes.

RESULTS

A total of 1601 patients were diagnosed as having AMS (12% of all patients with infectious disease). In 45% of cases the differentiation between AMS and URTI was based on clinical examination alone. Sinus ultrasound was the most common diagnostic tool used (38%). Sinus radiography or blood tests (CRP or leukocytes) were both studied in 8% of cases. AMS was diagnosed and treated with antibiotics also in the early stages of URTI when viruses are the most likely explanation. In total, 83% of patients with AMS received a prescription for antibiotics; the most common choice was amoxycillin (37%), doxycycline was used in 29% of cases, and macrolides in 15%.

CONCLUSIONS

Antibiotics are prescribed for AMS 2 to 5 times more often than true disease incidence would suggest in Finland. The choice of antibiotics follows the guideline recommendations; however, use of macrolides is higher than recommended. Physicians feel strong pressure from patients to prescribe antibiotics for AMS. Primary care physicians need better support in the accurate diagnosis of AMS.

Do rhinoviruses cause pneumonia in children?

Rhinoviruses are the most common precipitants of the common cold and have been associated with different infections of the respiratory tract, such as otitis media and sinusitis. They have also been implicated in the induction of acute asthma exacerbations, most of which are preceded by a common cold. Although in several occasions, mainly in immunocompromised hosts, severe lower respiratory tract infections have been attributed to rhinovirus infections, it is still unclear whether and to what extent these viruses contribute as pathogens in community-acquired pneumonia. Current mechanistic data suggest that rhinoviruses could be the cause of pneumonia in immunocompetent subjects. This notion is supported by epidemiological evidence, however, more clinical studies are needed to assess the actual burden.

Rhinopharyngites de l’enfant

La rhinopharyngite désigne une inflammation modérée des voies aériennes supérieures d’origine infectieuse. Les signes habituels en sont l’obstruction nasale, la rhinorrhée, l’éternuement, la douleur pharyngée et la toux. Le terme de rhinopharyngite est spécifiquement français. Les auteurs anglo-saxons parlent de rhume (common cold) ou de upper respiratory tract infection (URI) pour décrire une inflammation aiguë des voies aériennes supérieures, et d’adénoïdite chronique (chronic adenoiditis) pour désigner une infection chronique des végétations adénoïdes responsable de rhinorrhées fébriles itératives ou d’obstruction des voies aériennes supérieures. Les rhinopharyngites aiguës non compliquées sont d’origine virale. Leur évolution spontanée est habituellement rapide et non compliquée. Elles ne nécessitent donc ni prélèvement bactériologique ni antibiothérapie systématique. En première intention, elles relèvent exclusivement d’un traitement antalgique et antipyrétique associé à des lavages des fosses nasales au sérum salé iso- ou hypertonique. Les complications des rhinopharyngites sont infectieuses, essentiellement représentées par les otites et les sinusites, et respiratoires obstructives. Le caractère fréquemment itératif des rhinopharyngites à partir de l’âge de 6 mois reflète un processus physiologique de maturation du système immunitaire. En présence de rhinopharyngites fréquentes et invalidantes, les principaux facteurs de risque devant être recherchés et si possible éradiqués sont le tabagisme passif et la fréquentation d’une collectivité d’enfants. L’adénoïdectomie n’est pas indiquée en l’absence de complications. Le développement d’antiviraux efficaces dans la prévention et dans le traitement des rhinopharyngites fait l’objet d’intenses recherches cliniques et expérimentales.

Severe rhinosinusitis

Rhinosinusitis is diagnosed frequently in clinical practice, but the term may in fact encompass a wide spectrum of diseases. Inflammation of the nasal and sinus mucosa can arise from various causes and lead to different sequelae. Moreover, the term rhinosinusitis is more accurate than sinusitis. Causes range from a viral infection leading to the common cold to an invasive, fungal infection. An accurate diagnosis is important because effective therapy is available if recognized early and if specific therapy is used. Importantly, there is a close relationship between upper and lower airway disease and each have unique structural and functional differences that make an understanding of rhinosinusitis important not only for upper airway disease, but also for the management of asthma. All too often, rhinosinusitis becomes chronic and this becomes a challenge because medical therapy may not be sufficient to control disease. Finally, we should note that the differential diagnosis of rhinosinusitis is extensive and physicians should place heavy emphasis not only on the history, but also on appropriate imaging studies. A normal exam does not rule out the possibility of rhinosinusitis. Finally, we should emphasize that effective treatment is dependent on the etiology of the symptoms but also dependent on whether it is acute or chronic.

Clinical response to antibiotic therapy for community-acquired pneumonia

Childhood community-acquired pneumonia is a common and potentially serious problem worldwide. Unless the patient has bacteraemia or pleural empyema, aetiological diagnostics are limited and antibiotic treatment is empirical. Published data on expected response to therapy are scarce. To determine the clinical response to antibiotic treatment in a developed country in otherwise healthy children with community-acquired pneumonia, we conducted a prospective study of 153 hospitalised children with pneumonia. The role of 17 microbes as potential causative agents was evaluated. The duration of fever (>37.5 degrees C) and hospitalisation were studied as objective measures of recovery. A potential aetiology was found in 83% of 153 patients: 29% of the patients had sole viral and 26% sole bacterial and 29% mixed viral-bacterial infections. The median duration of fever after the onset of antibiotic treatment (mainly penicillin G) was 14 h and the median duration of hospitalisation was 48 h. Patients with mixed viral-bacterial infection became afebrile more slowly than those with either sole viral or sole bacterial infections.

CONCLUSION

the findings indicate that in a developed country, children with pneumonia make a rapid, uneventful recovery needing only a short hospital stay. Expensive and time-consuming microbiological investigations are not required once bacterial sepsis has been excluded.

Rinofaringitis infantiles

La rinofaringitis designa una inflamación moderada de las vías respiratorias superiores de origen infeccioso. Sus signos habituales son obstrucción nasal, rinorrea, estornudos, dolor faríngeo y tos. Los autores anglosajones hablan de catarro (common cold) o de infección de vías respiratorias altas para describir una inflamación de las vías respiratorias superiores, y de adenoiditis crónica (chronic adenoiditis) para designar una infección crónica de las vegetaciones adenoides que produce rinorrea febril recidivante u obstrucción de las vías respiratorias altas. Las rinofaringitis agudas no complicadas son de origen vírico. Habitualmente su evolución espontánea es rápida y sin complicaciones. Por tanto, no hay que obtener muestras bacteriológicas ni hacer un tratamiento antibiótico sistemático. Como tratamiento de primera línea, sólo precisan analgésicos y antipiréticos asociados a lavados de las fosas nasales con suero salino isotónico o hipertónico. Las complicaciones de las rinofaringitis son infecciosas –representadas esencialmente por las otitis y las sinusitis– y respiratorias obstructivas. El carácter a menudo repetitivo de las rinofaringitis a partir de los 6 meses de edad refleja un proceso fisiológico de maduración del sistema inmunitario. Cuando existen rinofaringitis frecuentes e invalidantes, los principales factores de riesgo que se deben buscar, y de ser posible erradicar, son el tabaquismo pasivo y los contactos con una población infantil. La adenoidectomía ya no está indicada si no existen complicaciones. Se están realizando investigaciones clínicas y experimentales sobre el desarrollo de fármacos antivíricos eficaces para la prevención y el tratamiento de las rinofaringitis.

Paranasal sinus findings in children during respiratory infection evaluated with magnetic resonance imaging

OBJECTIVE

The spreading of acute respiratory infection into the paranasal sinuses in children is poorly defined. The main objective of this study was to evaluate the frequency and spontaneous resolution of paranasal sinus abnormalities in children with acute respiratory infection using magnetic resonance imaging (MRI).

METHODS

We examined 60 children with MRI (mean age: 5.7 years) with symptoms of acute respiratory infection. Twenty-six children with major abnormalities in the first MRI scan had a follow-up MRI taken 2 weeks later.

RESULTS

The children had had symptoms of uncomplicated acute respiratory infection for an average of 6 days before the first examination (mean duration: 6.5; standard deviation: 3.0). Approximately 60% of the children had major abnormalities in their maxillary and ethmoidal sinuses, 35% in the sphenoidal sinuses, and 18% in the frontal sinuses. The most common abnormal finding was mucosal swelling. The mean overall MRI scores correlated significantly with the symptom scores (r(s) = 0.3). Of the individual symptoms, nasal obstruction, nasal discharge, and fever were significantly related to the MRI scores. Among the 26 children with major abnormalities in the first MRI, the findings subsequently improved significantly (mean [standard deviation] score: 12.7 [5.6] to 5.7 [5.2]), irrespective of the resolution of symptoms.

CONCLUSIONS

These observations indicate that acute respiratory infection mostly spreads into the paranasal sinuses of children in the form of mucosal edema and that these abnormalities tend to resolve spontaneously without antimicrobial treatment.

The common cold

Despite great advances in medicine, the common cold continues to be a great burden on society in terms of human suffering and economic losses. Of the several viruses that cause the disease, the role of rhinoviruses is most prominent. About a quarter of all colds are still without proven cause, and the recent discovery of human metapneumovirus suggests that other viruses could remain undiscovered. Research into the inflammatory mechanisms of the common cold has elucidated the complexity of the virus-host relation. Increasing evidence is also available for the central role of viruses in predisposing to complications. New antivirals for the treatment of colds are being developed, but optimum use of these agents would require rapid detection of the specific virus causing the infection. Although vaccines against many respiratory viruses could also become available, the ultimate prevention of the common cold seems to remain a distant aim.

Pulmonary imaging and function in the common cold

The common cold is generally considered to be an upper respiratory tract infection. We studied the lower respiratory tract in 76 otherwise healthy young adults with the common cold. Viral infection was diagnosed in 56 (74%) of the 76 subjects. Rhinovirus was detected in 42 (55%) subjects. Chest radiography (CR) and high-resolution computerized tomography (HRCT) were carried out in 40 subjects on day 7, and pulmonary function testing with bronchodilator challenge was carried out in 36 patients on days 7 and 21 of the study. Clinical examinations were carried out on days 1, 7 and 21. The subjects recorded their symptoms on a diary card for 20 d. The mean duration of cough was 8.4 (SD 6.5) d and that of sputum production 5.9 (SD 6.4) d. No abnormal findings were detected in the lungs on auscultation. CR and HRCT showed no pulmonary changes associated with the common cold. No clinically remarkable increases were seen in peak expiratory flow, forced expiration volume in 1 s or forced vital capacity after bronchodilator challenge on either days 7 or 21. All patients made a clinical recovery without antimicrobial therapy within 21 d. We conclude that the common cold in young otherwise healthy adults is an upper respiratory tract infection and that clinically important abnormalities in the lower respiratory tract are rare.

Drugs in pregnancy. Respiratory disease

Respiratory illnesses are the commonest cause of patient visits to physicians. Although the common cold, sinusitis and bronchitis may be lacking in drama, they account for a substantial amount of morbidity among women of reproductive age and are frequently encountered by physicians caring for pregnant women. Present knowledge about the management of these common conditions and the safety of the medications often used to treat them are reviewed in this chapter. Asthma and community-acquired pneumonia are more serious respiratory illnesses that are also often encountered in pregnancy. Present evidence suggests that community-acquired pneumonia is best treated empirically, with additional investigation usually necessary only if there is a failure of initial treatment. The recognition of asthma as an inflammatory condition has led to a very specific approach to its management that can readily and safely be applied to the pregnant woman. Treatment of HIV and tuberculosis should not be withheld during pregnancy because of the life-threatening nature of these infections and the importance of preventing vertical transmission.

Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background

The following principles of appropriate antibiotic use for adults with acute rhinosinusitis apply to the diagnosis and treatment of acute maxillary and ethmoid rhinosinusitis in adults who are not immunocompromised. Most cases of acute rhinosinusitis diagnosed in ambulatory care are caused by uncomplicated viral upper respiratory tract infections. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more who have maxillary pain or tenderness in the face or teeth (especially when unilateral) and purulent nasal secretions. Patients with rhinosinusitis symptoms that last less than 7 days are unlikely to have bacterial infection, although rarely some patients with acute bacterial rhinosinusitis present with dramatic symptoms of severe unilateral maxillary pain, swelling, and fever. Sinus radiography is not recommended for diagnosis in routine cases. Acute rhinosinusitis resolves without antibiotic treatment in most cases. Symptomatic treatment and reassurance is the preferred initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients with moderately severe symptoms who meet the criteria for the clinical diagnosis of acute bacterial rhinosinusitis and for those with severe rhinosinusitis symptoms-especially those with unilateral facial pain-regardless of duration of illness. For initial treatment, the most narrow-spectrum agent active against the likely pathogens, Streptococcus pneumoniae and Haemophilus influenzae, should be used.

Detection by reverse transcription-polymerase chain reaction of influenza C in nasopharyngeal secretions of adults with a common cold

The lack of practical methods for a laboratory diagnosis of influenza C virus infections and the seemingly benign nature of the virus contribute to the fact that 50 years after its first isolation, relatively little is known about the epidemiology and the clinical impact of this virus. Reverse transcription-polymerase chain reaction (RT-PCR) was used to amplify influenza C RNA fragments from clinical specimens. Two hundred otherwise healthy adults with recent onset of a common cold were studied. Nasopharyngeal aspirates were collected at entry to the study and 1 week later. Serum samples for antibody determinations were obtained at the first visit and after 3 weeks. Influenza C was detected in 7 of the 200 patients by 2 different RT-PCR formats. All 7 patients had a significant increase in antibody titers between serum samples collected during the acute and convalescent phases of the illness. Influenza C appears to be one of the many viruses that cause acute upper respiratory tract infections in adults.

Other anti-inflammatory uses of intranasal corticosteroids in upper respiratory inflammatory diseases

Topical corticosteroids are an effective treatment for nasal polyposis and other conditions associated with rhinitis. There is evidence that asthma, otitis media with effusion, and acute sinusitis may all benefit from such therapy. Fluticasone propionate (FP) drops have been shown to reduce polyp size, and to improve nasal inspiratory flow, while avoiding the side-effects of, for example, topical betamethasone therapy. In small children with allergic rhinitis, fluticasone propionate aqueous nasal spray (FPANS) has been shown to be significantly more effective than ketotifen in relieving night and daytime symptoms, and nasal blockage. There is also preliminary evidence of efficacy in obstructive sleep apnoea and acute sinusitis. The advent of FP, with its low propensity to cause systemic side-effects, makes it possible to use topical corticosteroid therapy safely for prolonged periods to treat many inflammatory diseases of the upper respiratory tract.

Intranasal fluticasone propionate does not prevent acute otitis media during viral upper respiratory infection in children

BACKGROUND

Acute otitis media (AOM) is the most common complication of a viral upper respiratory infection (URI) in children. The virus-induced host inflammatory response in the nasopharynx plays a key role in the pathogenesis of AOM. Suppression of this inflammatory process might prevent the development of AOM as a complication.

OBJECTIVE

We sought to assess the effect of intranasally administered fluticasone propionate on prevention of AOM during a viral respiratory infection.

METHODS

A total of 210 children (mean age, 2.1 years; range, 0.7-3.9 years) with normal middle ear status and URI of 48 hours' duration or less were randomly allocated to receive either fluticasone (100 microg twice daily) or placebo for 7 days. The specific viral cause of the infection was determined from nasopharyngeal aspirates obtained at the first visit. The children were re-examined at the end of the 7-day medication period.

RESULTS

In the fluticasone group AOM developed in 40 (38.1%) of 105 children compared with 29 (28.2%) of 103 children receiving placebo (P =.13). The viral cause of the respiratory infection was determined in 167 (86.1%) of 194 children from whom a nasopharyngeal aspirate was obtained. In children with rhinovirus infection, AOM developed significantly more often in the fluticasone group (45.7%) than in the placebo group (14.7%, P =.005).

CONCLUSION

Intranasally administered fluticasone does not prevent the development of AOM during URI but may increase the incidence of AOM during rhinovirus infection.

Acute and chronic sinusitis in children

There is one subject in recent publications on pediatric sinusitis on which most authors agree, and that is that the public cannot continue to receive antibiotics on demand solely because of purulent nasal discharge, and that clinicians cannot continue to prescribe broad-spectrum and expensive antibiotics for minimal indications. Two publications show that the prevalence of various anatomical variations is no greater in children with rhinosinusitis than in a control group. This mirrors recent work in adults and implies that immunity and the way the mucosa reacts to pathogens is likely to be of primary importance, rather than the anatomy. Several good reviews on the management of rhinosinusitis in children all emphasize the need for medical and not surgical management of these patients except in cases in which the complications of sinusitis develop. The fact that computed tomography is poor at diagnosing sinusitis in children is also a recurring theme.

Nose blowing propels nasal fluid into the paranasal sinuses

Intranasal pressures were measured in adults during nose blowing, sneezing, and coughing and were used for fluid dynamic modeling. Sinus CT scans were performed after instillation of radiopaque contrast medium into the nasopharynx followed by nose blowing, sneezing, and coughing. The mean (+/-SD) maximal intranasal pressure was 66 (+/-14) mm Hg during 35 nose blows, 4.6 (+/-3.8) mm Hg during 13 sneezes, and 6.6 (+/-3.8) mm Hg during 18 coughing bouts. A single nose blow can propel up to 1 mL of viscous fluid in the middle meatus into the maxillary sinus. Sneezing and coughing do not generate sufficient pressure to propel viscous fluid into the sinus. Contrast medium from the nasopharynx appeared in >/=1 sinuses in 4 of 4 subjects after a nose blow but not after sneezing or coughing.