Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 3) Clinical Manifestations Most cases of acute sinusitis present after or in conjunction with a viral URI, and it can be difficult to discriminate the clinical features of one from the other. A large proportion of patients with colds have sinus inflammation, although bacterial sinusitis complicates only 0.2–2% of these viral infections. Common presenting symptoms of sinusitis include nasal drainage and congestion, facial pain or pressure, and headache. Thick, purulent or discolored nasal discharge is often thought to indicate bacterial sinusitis but also occurs early in viral infections such as the common cold and is not specific to bacterial infection. Other nonspecific manifestations include cough, sneezing, and fever. Tooth pain, most often involving the upper molars, is associated with bacterial sinusitis, as is halitosis. In acute sinusitis, sinus pain or pressure often localizes to the involved sinus (particularly the maxillary sinus) and can be worse when the patient bends over or is supine. Although rare, manifestations of advanced sphenoid or ethmoid sinus infection can be profound, including severe frontal or retroorbital pain radiating to the occiput, thrombosis of the cavernous sinus, and signs of orbital cellulitis. Acute focal sinusitis is uncommon but should be considered in the patient with severe symptoms over the maxillary sinus and fever, regardless of illness duration. Similarly, advanced frontal sinusitis can present with a condition known as Pott's puffy tumor, with soft tissue swelling and pitting edema over the frontal bone from a communicating subperiosteal abscess. Life-threatening complications include meningitis, epidural abscess, and cerebral abscess. Patients with acute fungal sinusitis (such as mucormycosis) often present with symptoms related to pressure effects, particularly when the infection has spread to the orbits and cavernous sinus. Signs such as orbital swelling and cellulitis, proptosis, ptosis, and decreased extraocular movement are common, as is retroorbital or periorbital pain. Nasopharyngeal ulcerations, epistaxis, and headaches are also frequent, and involvement of cranial nerves V and VII has been described in more advanced cases. Bony erosion may be evident on examination. Oftentimes, the patient does not appear seriously ill despite the rapidly progressive nature of these infections. Patients with acute nosocomial sinusitis are often critically ill and thus do not manifest the typical clinical features of sinus disease. This diagnosis should be suspected, however, when hospitalized patients who have appropriate risk factors (e.g., nasotracheal intubation) develop fever of unknown origin. Diagnosis Distinguishing viral from bacterial sinusitis in the ambulatory setting is usually difficult, given the relatively low sensitivity and specificity of the common clinical features. One clinical feature that has been used to help guide diagnostic and therapeutic decision-making is illness duration. Because acute bacterial sinusitis is uncommon in patients whose symptoms have lasted <7 days, several authorities now recommend reserving this diagnosis for patients with "persistent" symptoms (i.e., symptoms lasting >7 days in adults or >10–14 days in children) accompanied by purulent nasal discharge (Table 31-1). Even among the patients who meet these criteria, only 40–50% have true bacterial sinusitis. The use of CT or sinus radiography is not recommended for routine cases, particularly early in the course of illness (i.e., at <7 days), given the high prevalence of similar abnormalities among cases of acute viral rhinosinusitis. In the evaluation of persistent, recurrent, or chronic sinusitis, CT of the sinuses is the radiographic study of choice. Table 31-1 Guidelines for the Diagnosis and Treatment of Acute Sinusitis Age Group Diagnostic Criteria Treatment Recommendations a Moderate symptoms (e.g., nasal purulence/ congestion or cough) for >7 d or Initial therapy Severe sym ptoms of any duration, including unilateral/focal facial swelling or tooth pain Amoxicillin, 500 mg PO tid or 875 mg PO bid, or TMP- SMX, 1 DS tablet PO bid for 10–14 d Adults Exposure to antibiotics within 30 d or >30% prevalence of penicillin- resistant S. pneumoniae Amoxicillin, 1000 mg PO tid, or Amoxicillin/clavulanate (extended release), 2000 mg PO bid, or Antipneumococcal fluoroquinolone (e.g., levofloxacin, 500 mg PO qd) Recent treatment failure Amoxicillin/clavulanate (extended release), 2000 mg PO bid, or Amoxicillin, 1500 mg bid, plus clindamycin, 300 mg PO qid, or Antipneumococcal fluoroquinolone (e.g., levofloxacin, 500 mg PO qd) Moderate symptoms (e.g., nasal purulence/congestion or cough) for >10–14 d or Initial therapy Severe symptoms of any duration, including fever (>102°F), unilateral/focal facial swelling or pain Amoxicillin, 45– 90 mg/kg qd (up to 2 g) PO in divided doses (bid or tid), or Cefuroxime axetil, 30 mg/kg qd PO in divided doses (bid), or Cefdinir, 14 mg/kg PO qd Children Exposure to antibiotics within 30 d, recent treatment failure, or >30% prevalence of penicillin - resistant S. pneumoniae Amoxicillin, 90 mg/kg qd (up to 2 g) PO in divided doses (bid), plus clavu lanate, 6.4 mg/kg qd PO in divided doses (bid) (extra- strength suspension), or Cefuroxime axetil, 30 mg/kg qd PO in divided doses (bid), or Cefdinir, 14 mg/kg PO qd a Unless otherwise specified, the duration of therapy is generally 10 d, with appropriate follow-up. Note: DS, double-strength; TMP-SMX, trimethoprim-sulfamethoxazole. Sources: American Academy of Pediatrics Subcommittee on Management of Sinusitis and Committee on Quality Improvement, 2001; Hickner et al, 2001; Piccirillo, 2004; and Sinus and Allergy Health Partnership, 2004. The clinical history and/or setting can often identify cases of acute anaerobic bacterial sinusitis, acute fungal sinusitis, or sinusitis from noninfectious causes (e.g., allergic rhinosinusitis). In the case of an immunocompromised patient with acute fungal sinus infection, immediate examination by an otolaryngologist is required. Biopsy specimens from involved areas should be examined by a pathologist for evidence of fungal hyphal elements and tissue invasion. Cases of suspected acute nosocomial sinusitis should be confirmed by sinus CT. Because therapy should target the offending organism, a sinus aspirate should be obtained, if possible, for culture and susceptibility testing. . Chapter 031. Pharyngitis, Sinusitis, Otitis, and Other Upper Respiratory Tract Infections (Part 3) Clinical Manifestations Most cases of acute. viral infections such as the common cold and is not specific to bacterial infection. Other nonspecific manifestations include cough, sneezing, and fever. Tooth pain, most often involving the upper. associated with bacterial sinusitis, as is halitosis. In acute sinusitis, sinus pain or pressure often localizes to the involved sinus (particularly the maxillary sinus) and can be worse when