Rhinosinusitis. Treatment of acute and chronic rhinosinusitis

• Types of rhinosinusitis
• Factors predisposing to the development of rhinosinusitis
• Reasons for the development of rhinosinusitis
• Development mechanism
• Symptoms of rhinosinusitis
• Diagnosis and recommended clinical studies
• Laboratory research methods
• Instrumental research methods
• Differential diagnosis
• General principles of treatment
• Forecast

Rhinosinusitis is an inflammation of the mucous membrane of the paranasal sinuses.

Types of rhinosinusitis

1. Acute (duration of illness less than 12 weeks and complete disappearance of symptoms after recovery).
2. Recurrent (from 1 to 4 episodes of acute rhinosinusitis per year, periods between exacerbations (when there are no symptoms of the disease and no treatment is carried out) last at least 8 weeks).
3. Chronic (presence of symptoms for more than 12 weeks).

Localization

• maxillary sinus (sinusitis),
• sphenoid sinus (sphenoiditis),
• frontal sinus (frontitis),
• in the cells of the ethmoid bone (ethmoiditis).

Depending on the etiological factors, acute and recurrent rhinosinusitis is divided into:

• viral,
• bacterial,
• fungal.

Chronic are divided into:

• bacterial,
• fungal,
• mixed.

Taking into account the characteristics of pathogenesis:

• hospital,
• odontogenic,
• polyposis,
• developed against the background of immunodeficiency states of rhinosinusitis,
• acute (fulminant) form of mycosis of the paranasal sinuses.

Chronic fungal rhinosinusitis is divided into:

• allergic (eosinophilic) fungal sinusitis,
• mushroom ball,
• superficial sinonasal mycosis,
• chronic invasive form of mycosis.

Diagnostics

To identify a chronic form of rhinosinusitis, the doctor will need to interview you, conduct a physical examination, and rhinoscopy (examination using a nasal speculum). But additional research will be required to determine treatment tactics.

Additional diagnostic methods:

• Endoscopy. A flexible, soft tube (endoscope) with fiberoptic light allows the doctor to see your nasal passages, the sinus area, and sometimes the inside of your sinuses.
• X-ray tomography. Images taken by a computed tomography (CT) scanner can show details of your maxillary sinuses and nasal area. The doctor will determine the volume and nature of the sinus lesions and assess the patency of sinus-nasal communications.
• Sowing from the mucous membrane for flora. Allows you to find out the infectious cause (if any) of sinus inflammation (fungi, bacteria) and prescribe the necessary treatment.
• Allergy testing. If your doctor suspects that the condition is caused by an allergy, you will need to undergo allergy testing (rhinocytogram, blood IgE, eosinophil cationic protein).

Factors predisposing to the development of rhinosinusitis

• Rhinitis.
• Intolerance to non-steroidal anti-inflammatory drugs.
• Anomalies in the structure of the nasal cavity and paranasal sinuses (deviated nasal septum; bulla of the middle turbinate; additional anastomosis of the maxillary sinus, etc.).
• Immunodeficiency states (X-linked agammaglobulinemia; common variable immunological deficiency; deficiency of IgG subclasses; selective IgA deficiency; hyper-IgM syndrome; HIV).
• Diseases accompanied by a slowdown in MCT (Kartagener's syndrome; Young's syndrome; cystic fibrosis).
• Wegener's granulomatosis.
• Hyperplasia of the pharyngeal tonsil, adenoiditis.
• Gastroesophageal reflux disease.
• Fistula between the oral cavity and the maxillary sinus.

Risk factors for acute rhinosinusitis and prevention

Timely, correct diagnosis of diseases and adequate treatment help reduce the risk of unjustified use of antibiotics and possible manifestations of antibiotic resistance.

Risk factors for ARS include older age (over 65 years), smoking, frequent flying, deep-sea diving, swimming, asthma, allergic diseases including allergic rhinitis, dental disease and immunodeficiency conditions.

Author:

Chekaldina Elena Vladimirovna otorhinolaryngologist, Ph.D.

Reasons for the development of rhinosinusitis

The main causative agents of acute bacterial rhinosinusitis are Streptococcus pneumoniae and Haemophilus influenzae. Other pathogens include Moraxellacatarrhalis, Staphylococcusaureus, Streptococcuspyogenes, Streptococcusviridans, etc. The main anaerobic pathogens of rhinosinusitis are anaerobic streptococci. However, the spectrum of pathogens causing acute bacterial rhinosinusitis can vary significantly depending on geographic, socio-economic and other conditions.

The list of nosocomial pathogens that developed against the background of immunodeficiency conditions and odontogenic rhinosinusitis, along with the bacteria mentioned above, includes Staphylococcus epidermidis, Pseudomonasaeruginosa, Proteus spp., and in immunodeficient patients also saprophytic bacteria and fungal microflora. In recent years, the role of chlamydia and other atypical microflora in the etiology of rhinosinusitis has been discussed.

Fungal sinusitis is most often caused by Aspergillus fungi (in most cases A. fumigatus), less often by Candida, Alternaria, Bipolaris, etc.

The acute invasive form of mycosis of the paranasal sinuses is most often caused by fungi of the Mucoraceae family: Rhizopus, Mucor and Absida.

Treatment of chronic rhinosinusitis

The goal of treatment is to reduce the number of exacerbations of sinusitis and reduce or disappear the symptoms of the disease. The main therapy is aimed at improving the drainage of the paranasal sinuses, as well as improving the functioning of the local immunity of the mucous membranes. To do this, it is necessary to eliminate the blockage of the sinus-nasal anastomosis, reduce the viscosity of the mucous secretion, and carry out immunotherapy. Sometimes surgery is required to clear the sinuses.

Drug therapy

The first stage of treatment for chronic rhinosinusitis is conservative therapy.

It includes:

• Regular cleansing of the nasal cavity and sinuses with isotonic sodium chloride solution (sterile saline solution).
• Nasal topical corticosteroids. These are nasal sprays that help reduce inflammation and swelling in the area of ​​sinus anastomosis and improve drainage (mometasone, fluticasone, beclomethasone).
• Inhalation administration of a solution of antibiotics, corticosteroids, mucolytics into the sinuses. The use of sinus inhalers (Pari inhalers) allows medications to be administered precisely into the sinuses.
• Systemic administration of corticosteroids gives a strong anti-edematous, anti-inflammatory effect, reduces nasal polyps, improves drainage, but has serious side effects with long-term use of the drugs.
• Local and systemic use of antibacterial and antifungal agents. The use of antimicrobial agents for infectious chronic rhinosinusitis allows one to cope with exacerbation of the disease.
• Immunotherapy - Your allergist-immunologist may add immune-boosting or allergy-regulating medications to your sinusitis treatment.

Surgery

With low effectiveness of conservative therapy, surgical treatment of chronic rhinosinusitis is indicated. It is aimed at eliminating the mechanical obstacle to sinus drainage (enlarged turbinate, deformed nasal septum, anatomical narrowing of the sinus anastomosis area, polyp in the anastomosis area, etc.), as well as cleansing the sinuses of foreign inclusions (fungal bodies, tooth roots, filling material, material for sinus lifting), cysts, polyps.

Endoscopic sinus surgery

For this procedure, the doctor uses an optical system consisting of a thin tube with magnifying lenses and a camera that transfers the image to a screen. Good visualization of the operated area, the ability to change the viewing angle ensures delicate and safe removal of obstacles at the exit from the sinus, and also allows you to clear it of foreign inclusions.

The surgical treatment performed only creates conditions for improving drainage and cleaning, so it is necessary to continue postoperative treatment to achieve a lasting effect.

Development mechanism

Rhinosinusitis almost always develops when mucociliary clearance is impaired, when optimal conditions are created for the development of a bacterial infection.

The trigger point in the development of acute bacterial rhinosinusitis is usually ARVI. It was revealed that in almost 90% of patients with ARVI, changes in the paranasal sinuses are detected in the form of swelling of the mucous membrane and stagnation of secretions. However, only 1-2% of such patients develop acute bacterial rhinosinusitis.

In the development of chronic rhinosinusitis, in addition to disturbances of mucociliary transport, abnormalities in the structure of the intranasal structures and ethmoidal labyrinth play an important role, blocking the patency of the natural openings of the paranasal sinuses and disrupting the mechanisms of sinus cleansing. The presence of two or more anastomoses of the maxillary sinuses also creates conditions for the throwing of infected mucus that has already been in the nasal cavity and back into the sinus. Under conditions of chronic inflammation in the mucous membrane, focal or diffuse metaplasia of multirow columnar epithelium occurs into multilayer epithelium, devoid of cilia and having lost the ability to remove bacteria and viruses from its surface through active mucociliary transport.

Nosocomial rhinosinusitis is most often caused by prolonged nasotracheal intubation.

Odontogenic sinusitis develops against the background of chronic foci of inflammation, cysts or granulomas in the roots of the teeth of the upper jaw, as a result of pieces of filling material, tooth roots entering the maxillary sinuses, or the formation of a fistula between the oral cavity and the maxillary sinus after tooth extraction.

A key role in the pathogenesis of polypous rhinosinusitis is played by eosinophils and IL-5, which causes their proliferation, migration into tissues and degranulation.

Mucopurulent discharge from the affected paranasal sinuses can be transported by the ciliated epithelium directly through the mouth of the auditory tube, which is the trigger point in the development of an exudative or chronic inflammatory process in the middle ear.

Superficial sinonasal mycosis is caused by the growth of fungal mycelium on crusts formed in the cavities of the operated paranasal sinuses, on the surface of neoplasms and on accumulations of antimicrobial drugs or glucocorticosteroids for topical use that remain in the nasal cavity for a long time.

Introduction

Inflammatory diseases of the nose and paranasal sinuses (SNS) at the present stage retain a leading position among all diseases of the upper respiratory tract.
Acute rhinosinusitis (ARS) is one of the most common diseases in most countries of the world and the most common reason for the unnecessary prescription of antibiotics, which becomes extremely relevant in the context of the global increase in antibiotic resistance and the fight against biofilms [1]. In cases of seasonal ARVI diseases, in most cases SNPs are also involved in the inflammatory process. With ARVI of the nasal cavity and paranasal sinuses, the ciliated epithelium loses its cilia and loses the ability to cleanse and protect, as a result of which swelling and inflammation of the mucous membrane develops. Violation of the transport function in the nasal cavity and the SNP leads to stagnation of secretions, acidification of the environment and disruption of the drainage function in the SNP. Long-term exposure to pathogenic flora contributes to the development of post-viral acute bacterial rhinosinusitis (ABRS) [2, 3].

Typically, the dynamics of the incidence of ARS and ARVI are similar, increasing in autumn, winter and early spring. Adults experience an average of 1 to 3 episodes of ARVI (i.e., actually viral ARS) per year, but only 12% of such patients are diagnosed with ARS, despite the fact that using various imaging techniques (CT, MRI, sinus radiography ) detect pathological changes in the SNP during ARVI in more than 90% of cases [4].

Symptoms of rhinosinusitis

The main symptoms of rhinosinusitis are:

• difficulty in nasal breathing,
• headache,
• nasal discharge.

Variable symptoms:

• decreased sense of smell,
• stuffy ears,
• increase in body temperature,
• general malaise,
• cough (more common in children).

With inflammation in the maxillary and frontal sinuses, the pain is localized in the face, nose and eyebrow area. Sphenoiditis is characterized by pain in the center of the head and the back of the head. The discharge is mucous, purulent and can come away when you blow your nose or drain down the back wall of the throat. The latter is more typical for lesions of the sphenoid sinus and the posterior parts of the ethmoid labyrinth. Chronic rhinosinusitis is accompanied by the same symptoms as acute, but outside of exacerbation they are much less pronounced.

Differential diagnosis

ORS should be differentiated from the following processes:

• Fungal rhinosinusitis (acute invasive form) - symptoms are similar to ARS, but the disease progresses more rapidly, in many cases the infection spreads beyond the sinuses.
• Acute respiratory viral infection - the symptoms of a cold and acute respiratory syndrome are often similar. However, patients with a cold usually do not have facial pain, and symptoms often include bouts of sneezing, mucous discharge from the nose, and coughing due to the drainage of mucus from the nasopharynx.
• Allergic and vasomotor rhinitis. In contrast to ARS, symptoms of sneezing, rhinorrhea (profuse mucous, watery discharge), nasal congestion and nasal itching predominate. No facial pain is noted.
• Facial pain. It may be a manifestation of neuralgia, pathology of the temporomandibular joint. There are no nasal symptoms.
• Headache. Frontal sinus pain can be caused by a variety of causes, including migraines, tension headaches, and cluster headaches.

Diagnosis and recommended clinical studies

The diagnosis of rhinosinusitis is established on the basis of:

1. Anamnestic data.
2. Clinical manifestations.
3. Laboratory test results.
4. Results of instrumental examination methods.

Acute bacterial rhinosinusitis is characterized by a connection with an episode of acute respiratory viral infection suffered 5-10 days ago.

Patients with a history of odontogenic and fungal sinusitis often have previous complex fillings of the teeth of the upper jaw, as well as a long history of repeated visits to an otolaryngologist and repeated diagnostic punctures of the maxillary sinuses, during which no contents were obtained.

Polypous rhinosinusitis is characterized by gradual progression of the main symptoms: difficulty in nasal breathing and decreased sense of smell. Often patients are bothered by the painful sensation of constant flow of a very viscous secretion down the back wall of the nasopharynx. In many cases, polypous rhinosinusitis is combined with bronchial asthma, intolerance to non-steroidal anti-inflammatory drugs, and cystic fibrosis.

Complications of chronic rhinosinusitis

Prolonged inflammation carries many dangers, since the sinuses are close to such important structures as the eyes and brain:

• Meningitis (inflammation of the membranes of the brain and spinal cord);
• Sepsis. Generalized infection;
• Other infectious complications. Sometimes the inflammation spreads to the bones (osteomyelitis) or skin (cellulitis);
• Orbital complications. If the infection enters the eye socket, it can cause decreased vision or permanent blindness.
• Partial (or complete) loss of smell. The difficulty of odorants entering the olfactory cleft and inflammation of the olfactory nerve can lead to temporary or permanent loss of odor perception.

Laboratory research methods

Bacteriological research

This is a study designed to isolate bacteria and study their properties in order to make a microbiological diagnosis. The material for the study can be obtained from the nasal cavity or from the affected sinus during puncture. When collecting material, there is a high probability of “traveling” microflora entering.

Study of mucociliary transport

Allows you to assess the condition of the mucociliary apparatus of the mucous membrane, that is, to identify one of the most important pathogenetic disorders in rhinosinusitis.

In clinical practice, the measurement of transport time is most widely used. One of the variations of this method is to measure the time during which a marker (charcoal, carmine, ink, foam, etc.) moves from the anterior parts of the nasal cavity to the nasopharynx. Due to its simplicity, the saccharin test has become more widespread.

Its principle is to measure the time it takes a particle to travel a conventional distance - from the anterior parts of the nasal cavity to the taste buds in the pharynx. Saccharin time in healthy people can range from 1 to 20 minutes, averaging 6 minutes. However, these indicators are very conditional.

Treatment of ARS

According to the EPOS 2022 recommendations, the treatment of ARS in adults should take into account the level of evidence for the effectiveness of the use of drugs from different groups. In cases of viral ARS, it is important to influence the pathogenetic mechanisms of inflammation and prevent the risk of post-viral and bacterial sinusitis.

When treating a patient with viral ARS, general practitioners should recommend symptomatic treatment of colds, the use of paracetamol and NSAIDs, decongestants and antihistamines in short courses in comorbid patients with allergies. Antibiotics and topical glucocorticosteroids (GCS) are not recommended for use [14, 15].

In cases of post-viral ARS, it is important to create favorable conditions to improve the outflow of secretions from the SNP and to establish the drainage function of the anastomosis. In terms of evidence, intranasal and oral corticosteroids take first place in the treatment of post-viral ARS (Ia). Antibiotics are also not recommended. Decongestants, nasal irrigation, bioregulatory drugs, according to EPOS 2022, do not have a sufficient evidence base in the treatment of post-viral ARS.

For ABRS, adults are prescribed antibacterial drugs. However, patients with ABRS who require antibiotics should be carefully selected to avoid unnecessary use and side effects. In these cases, the decision to prescribe general antibiotic therapy should be made after consultation with an otolaryngologist, taking into account the severity of the disease and the risk of complications.

Decongestants, nasal irrigation, bioregulatory drugs, according to EPOS 2022, also do not have a sufficient evidence base in the treatment of ABRS.

However, we must not forget that at the outpatient stage of treatment of all types of acute respiratory syndrome, it is important to influence the key stage of the pathogenesis of any sinusitis - to reduce swelling of the nasal mucosa and improve the drainage function of the nasal passages, and remove the blockage of anastomoses.

A drug such as Sinuforte helps to improve the drainage of the SNP during ARS. The mechanism of its action is based on the ability to cause irritation of the mucous membrane of the nasal cavity, due to which the production of secretions from the mucous membrane is stimulated. This effect is due to the effect of the main component of the drug, cyclamen saponins, on the cells of the mucous membrane, as a result of which the rheological properties of the mucus change [16, 17].

Also noted is the reflex effect of Sinuforte on neurotransmitter transmission and stimulation of the branches of the trigeminal nerve involved in the sensitive and parasympathetic innervation of the nasal cavity, which increases mucus production, improves blood supply and lymphatic drainage.

Within a short time after using Sinuforte, irritation of the mucous membranes and pronounced secretion of mucus from the nose are observed for up to 2 hours. The composition of the mucus immediately changes, its viscosity decreases and the evacuation of mucus from the nose and SNP is facilitated. Another important characteristic of the drug is the absence of a generalized effect on the body, since cyclamen saponins are not absorbed from the mucous membrane and are gradually eliminated from the nasal cavity as rhinorrhea progresses [18–20].

A series of studies conducted in Russia in 2006–2012. multicenter randomized clinical trials of ARS of mild and moderate severity in different age groups, including in children with ARS aged 7 to 15 years, showed that Sinuforte helps resolve ARS symptoms, reduces the time of disease progression and the need for antibiotics or enhance their effect, and can also be considered as an alternative to invasive methods of sanitation of the paranasal sinuses. The drug was used both as monotherapy and in complex therapy of ARS, including those complicated by the development of exudative otitis media [21–23, 27, 28].

Foreign sources also contain data on the use of Sinuforte as a single drug in the initial therapy of patients with mild to moderate ARS. The effectiveness of treatment, according to research results, reached more than 90%, which is comparable to the effectiveness of many traditional drugs prescribed to a patient with ARS. This allows us to recommend the use of Sinuforte for inflammatory processes in the ED and thereby avoid polypharmacy [24, 25].

Instrumental research methods

1. Rhinoscopy. Anterior rhinoscopy against the background of diffuse congestive hyperemia and edema of the nasal mucosa reveals a typical sign of purulent rhinosinusitis - the presence of pathological discharge in the anastomosis area of ​​the affected paranasal sinuses. With sinusitis and frontal sinusitis, the discharge can be seen in the middle nasal passage, and with sphenoiditis - in the upper.
2. Endoscopic examination requires a minimum of time and is painlessly tolerated by the patient. The study includes three main points: sequential examination of the lower, middle and upper nasal passages. The method allows you to identify an additional anastomosis of the maxillary sinus. With a choanal polyp, a formation is detected, the stem of which comes from the anastomosis of the maxillary sinus.
3. Diaphanoscopy. Illumination of pericutaneous formations or cysts with a narrow beam of light. Allows to identify a decrease in pneumatization of the maxillary and frontal sinuses.
4. Ultrasound is a fast, non-invasive method that is used mainly for screening purposes, to diagnose inflammatory diseases and cysts of the maxillary and frontal sinuses. Both special devices for scanning the paranasal sinuses and standard equipment are used. The sensitivity of ultrasound in diagnosing sinusitis is lower than that of X-ray and CT.
5. X-rays of the paranasal sinuses are usually performed in the nasomental projection. To clarify the condition of the frontal and sphenoid sinuses, an additional study can be carried out in the nasofrontal and lateral projections. X-ray of the ethmoid bone sinuses is not very informative. Poor quality radiography often leads to diagnostic errors.
6. CT , which is performed in a coronal projection, is the most informative method and is gradually becoming the “gold standard” for studying the paranasal sinuses. CT not only makes it possible to establish the nature and extent of pathological changes in the paranasal sinuses, but also reveals the causes and individual features of the anatomical structure of the nasal cavity and sinuses, leading to the development and recurrence of rhinosinusitis. High-resolution CT allows you to visualize structures that are not visible with conventional radiography.
7. MRI , although it provides better visualization of soft tissue structures, is not one of the main methods for diagnosing rhinosinusitis. This method gives virtually no idea of ​​the patency of the air spaces connecting the paranasal sinuses with the nasal cavity. MRI is indicated only in certain situations - for example, if a fungal infection of the paranasal sinuses is suspected or the possible tumor nature of the disease, as well as with orbital and intracranial complications of rhinosinusitis. MRI is the most informative method for differential diagnosis between a cerebral hernia (meningoencephalocele) and a tumor or inflammatory process in the roof of the ethmoidal labyrinth.
8. Diagnostic puncture and probing make it possible to assess the volume and nature of the contents of the affected sinus and indirectly obtain an idea of ​​​​the patency of its natural opening.

To assess the patency of the anastomosis of the punctured sinus, a simple scheme is used, taking into account 3 degrees of violation of the patency of the anastomosis (see table). To do this, using a syringe connected to a needle or drainage tube, the contents are first aspirated, and then the sinus is washed.

Assessment of the patency of the natural anastomosis of the paranasal sinuses

Rhinosinusitis or a common cold in children

Acute respiratory viral infections (ARVI) usually occur in a mild form and end with the recovery of patients on days 5–10 of the disease. However, in a number of cases, complications of ARVI are observed in the form of rhinosinusitis, acute otitis media, and adenoiditis.

Acute rhinosinusitis is a disease that is encountered in everyday practice not only by otolaryngologists, but by pediatricians, internists and general practitioners. Thus, according to statistics, 2 cases of rhinosinusitis per 100 thousand people are registered annually in children under 4 years of age, and 18 cases per 100 thousand people in adolescents 12–17 years old [1]. Currently, it is believed that almost any acute respiratory viral infection is, to one degree or another, accompanied by inflammation of the paranasal sinuses and rhinological symptoms. Signs of rhinosinusitis, according to studies using computed tomography, are detected in 95% of cases of acute respiratory viral infection. The Russian Society of Rhinologists recommends using the broader term “rhinosinusitis”, since inflammation in the paranasal sinuses is always accompanied by inflammatory changes in the nasal mucosa [2].

According to the classification of the European consensus document EPOS-2012 (European Position Paper on Rhinosinusitis and Nasal Polyposis - European Consensus on Rhinosinusitis and Nasal Polyps), acute rhinosinusitis (ARS) is divided into viral ARS (common cold), post-viral ARS and bacterial (ABRS).

The main causative agents of ARS are respiratory viruses (rhinoviruses, respiratory syncytial viruses, adenoviruses, coronaviruses). As a result of exposure to viruses, the epithelium of the nasal cavity and paranasal sinuses becomes loose, the cilia of the ciliated epithelium die, and swelling of the mucous membrane and inflammation develop. As a consequence, there is a violation of the aeration of the sinuses, stagnation of the secretion of the mucous glands, a change in pH, a metabolic disorder in the mucous membrane, a violation of mucociliary clearance and the accumulation of serous exudate in the lumen of the paranasal sinuses. Due to a decrease in the rate of beating of cilia and disruption of mucociliary transport, the time of contact of pathogenic bacteria with the mucous membrane increases, which contributes to bacterial infection [3, 4].

The common cold or acute rhinosinusitis in children is defined as the sudden onset of two or more symptoms, such as nasal congestion/difficulty in nasal breathing, and/or colorless/light-colored nasal discharge, and/or cough (during the day or night). The presence of symptoms lasts no more than 12 weeks, and asymptomatic intervals may be observed during which there are no symptoms if the disease is recurrent. When collecting anamnesis, it is important to clarify the presence of allergy symptoms (such as sneezing, watery discharge from the nose, itching and watery eyes). Acute rhinosinusitis may occur one or more times over a period of time. It usually manifests as episodes of illness within one year, but there may be complete resolution of symptoms between episodes of illness, which is a criterion for recurrent acute rhinosinusitis. ARS is diagnosed when the symptoms of the disease persist for less than 10 days, post-viral ARS - if there is an increase in symptoms of the disease after the 5th day or persistence of symptoms for more than 10 days, but with a total duration of less than 12 weeks. If the patient experiences an increase in the severity of rhinological symptoms after 5 days from the onset of the disease or symptoms persist for more than 10 days (with complete resolution within 12 weeks), but in the absence of justification for stating the bacterial etiology of acute rhinosinusitis, the EPOS authors recommend a diagnosis of “acute post-viral rhinosinusitis” [12].

Bacterial rhinosinusitis on average accounts for 5–7% of cases of all rhinosinusitis and is most often caused by the following pathogens: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis (mainly in pediatric practice), Streptococcus pyogenes, Staphylococcus aureus (in young children), presented as a monoflora , and bacterial associations [5]. Signs of ABRS that require antibiotics are the diagnostic criteria for ABRS based on clinical data: symptoms do not stop or there is no positive dynamics within 10 days, or most of the symptoms present at the onset of the disease persist for more than 10 days; pronounced symptoms at the onset of the disease - high fever, the presence of purulent discharge from the nose, pain in the paranasal sinuses, a significant disturbance in the general condition, which bother for 3-4 days, there is a tendency to the development of purulent-septic orbital processes or intracranial complications; symptoms are completely or partially relieved within 3–4 days, but within 10 days from the onset of symptoms, a relapse is observed with the resumption of all symptoms [1, 2].

Any of the paranasal sinuses can be involved in the inflammatory process, but in first place in terms of frequency of damage is the maxillary (sinusitis), then the ethmoid (ethmoiditis), frontal (frontal sinusitis), and sphenoid (sphenoiditis). This sequence is typical for adults and children over 7 years of age. In children under 3 years of age, acute inflammation of the ethmoid sinuses predominates (up to 80–90%), and from 3 to 7 years of age, combined damage to the ethmoid and maxillary sinuses predominates [6].

The diagnosis of “acute rhinosinusitis” is usually made by a pediatrician or therapist at the initial visit based on a combination of clinical symptoms and objective examination data; later the patient can be referred to an otolaryngologist. General symptoms of ARVI and ARS include classic signs of inflammation of the nasal mucosa and, with the exception of pain, are limited to local manifestations (difficulty in nasal breathing, nasal discharge of mucous, less often mucopurulent in nature, impaired sense of smell). An important method is anterior rhinoscopy, which should be mastered not only by otolaryngologists, but also by general practitioners. During rhinoscopy against the background of diffuse congestive hyperemia and edema of the nasal mucosa, what is revealed? the presence of pathological discharge in the area of ​​the outlet openings of the affected paranasal sinuses. A pathological secretion can also be detected on the back wall of the pharynx during pharyngoscopy.

Therapeutic measures for infectious MS include etiotropic, pathogenetic and symptomatic therapy. The main goals in the treatment of acute and relapsing MS are:

• pathogen eradication;
• reducing the duration of the disease;
• prevention of the development of orbital and intracranial complications.

Drug treatment, as a rule, consists of antibacterial drugs, “unloading” therapy with the prescription of vasoconstrictors, mucoactive agents, and anti-inflammatory therapy. Both systemic and local drugs are used.

Elimination therapy

One of the methods of treating ARS is irrigation procedures, in particular nasal douche, which involves rinsing and douching the nasal cavity. Rinsing the nasal cavity with saline solutions is carried out to eliminate viruses and bacteria. Preparations for rinsing the nasal cavity are usually prepared on the basis of sea water, sterilizing it and bringing the salt content to isotonic concentration. In case of acute respiratory syndrome, application of an isotonic solution to the mucous membrane helps to normalize the rheological properties of mucus and has a slight decongestive effect, improving nasal breathing, promotes the mechanical removal of pathological discharge and prepares the mucous membrane for the effects of topical drugs. Due to the absence of substances that can cause side effects, these drugs do not require precise dosing, and the frequency of their administration can vary widely according to need.

Antiviral and antibacterial therapy

The division of rhinosinusitis into viral and bacterial is directly related to approaches to therapy. Antiviral drugs are used for severe or moderate ARVI. The most effective are drugs whose leading mechanism of action is the stimulation of the formation of endogenous interferon, which in practice are used to treat most acute respiratory viral infections, regardless of the location of the inflammation. However, it must be taken into account that they are effective mainly in the first 48 hours from the onset of the disease.

The main controversial issue in the treatment of ARS is the prescription of antibacterial drugs. According to studies, more than 90% of general practitioners and otolaryngologists prescribe antibacterial drugs in the presence of symptoms of rhinosinusitis [19]. The widespread use of antibacterial drugs leads to an increase in antibiotic resistance. You should also remember about such often severe complications of antibiotic therapy as hepatotoxicity, allergic reactions, and dysbiosis. Recommendations for the treatment of rhinosinusitis EPOS outline a clear boundary for the use of systemic antibacterial therapy - only for ABRS! For mild ARS, symptomatic and etiopathogenetic drugs prescribed for ARVI are usually sufficient. Only if symptoms persist for 5 days or progress should one consider adding bacterial flora and prescribing systemic antibiotics. Moreover, due to certain difficulties in identifying the pathogen and the inability to wait for laboratory test results, the choice of antibiotics is most often empirical. The criteria for the effectiveness of empirical antibiotic therapy are the dynamics of the main symptoms of rhinosinusitis (headache, discharge, nasal congestion) and the general condition of the patient. Taking into account the spectrum of typical pathogens (Streptococcus pneumoniae and Haemophilus influenzae) and Russian data on their antibiotic resistance, the drug of first choice for acute rhinosinusitis is amoxicillin. However, more than 5% of Haemophilus influenzae strains in Russia are not sensitive to unprotected penicillins. Therefore, if there is no noticeable clinical effect after three days, amoxicillin should be replaced with an antibiotic active against penicillin-resistant pneumococci and β-lactamase-producing strains of Haemophilus influenzae: oral amoxicillin clavulanate, cephalosporins or macrolides (azithromycin and clarithromycin). In children and adolescents, the second-choice drugs prescribed if the first course of antibiotic therapy is ineffective are currently macrolides and clindamycin [2].

Antibacterial drugs for local action on the mucous membranes, if necessary, can be prescribed in combination with the systemic use of antibiotics, and in some cases as an alternative method of treating acute rhinosinusitis. But the issue of local antibiotic therapy for rhinosinusitis is controversial. The main contraindication is a violation of mucociliary clearance of the paranasal sinuses due to the adverse effect of large doses of antibiotic on the ciliated epithelium. There are special forms of antibiotics intended for endonasal administration in the form of a spray, which in the case of catarrhal rhinosinusitis can penetrate through the anastomosis of the paranasal sinuses and directly contact the pathogen at the site of inflammation. However, when filling the sinuses with mucous or mucopurulent exudate, you should first rinse the sinuses with saline solution or use decongestants [6].

"Unloading" therapy

Since the key link in the pathogenesis of acute rhinosinusitis is the blockade of the anastomosis of the paranasal sinuses due to swelling of the mucous membrane, one of the main directions of symptomatic and pathogenetic therapy is the restoration of the patency of these anastomoses - “unloading therapy” [6]. For this purpose, vasoconstrictors (decongestants) and mucolytic (secretolytic) agents are used.

Decongestants (oxymetazoline, xylometazoline, tetrizoline, phenylephrine, etc.), activating adrenergic receptors, cause vasospasm of the nasal mucosa, reducing its hyperemia and swelling, dilating the nasal passages and improving nasal breathing. Due to their rapid relief of nasal breathing, they are widely used to relieve symptoms such as rhinorrhea and nasal congestion and are very popular among patients. With strict adherence to the recommended dosage regimen, methods of application and duration of the course, side effects and adverse events when using topical vasoconstrictor drugs are rare. However, violations of the recommended dosage regimen (increasing single doses or frequency of use) can lead to an overdose with the development of serious pathological conditions. With prolonged and uncontrolled use of local decongestants, atrophy of the nasal mucosa may develop [5]. There is probably no doctor who does not remember that these drugs, when used for a long time, cause the development of “rebound” syndrome. However, unfortunately, patients or parents of patients do not always remember this. It should be noted that in children, especially young children, despite the local method of application, the use of decongestants may be accompanied by the development of systemic undesirable effects. An increased entry of local decongestants into the systemic circulation is also facilitated by trauma to the mucous membrane, which often occurs due to defects in the toileting of the nasal passages. Therefore, the use of topical decongestants should be limited. From the point of view of symptomatic therapy, the use of local drugs is more indicated, but from the point of view of the influence on pathogenesis, the use of systemic decongestants is indicated, since topical drugs cannot affect the swelling of the sinus mucosa. In this case, if possible, it is necessary to limit the use of decongestants to a short period (3-4 days) in minimal doses, since they can impair mucociliary transport.

Mucolytic therapy

The use of mucolytics refers to pathogenetic therapy. As already noted, an imbalance between the production of secretions in goblet cells and serous-mucosal glands and the evacuation of secretions by ciliated epithelial cells is one of the most important links in the pathogenesis of rhinosinusitis. Therefore, diluting viscous, thick secretions is important in the treatment of ARS. Taking medications with a differentiated effect on secretion production, reducing the viscosity of mucus and the function of cilia can restore impaired mucociliary transport. Mucolytic drugs change the physicochemical properties of the secretion by reducing its viscosity [6]. The international recommendations EPOS-2012 do not include mucolytic therapy, presumably due to the lack of a reliable method of experimental confirmation of their effectiveness. However, the use of mucolytics in acute rhinosinusitis is justified from a physiological point of view and is confirmed by long-term observations indicating the beneficial effect of mucolytic drugs on the course of acute rhinosinusitis, therefore mucolytic therapy, namely acetylcysteine ​​and carbocysteine, are included in domestic standards of therapy and clinical recommendations [2, 6–9 ].

In the practice of a local doctor, a group of mucoactive drugs is most often routinely used for diseases of the lower respiratory tract. Of course, one should not extrapolate to the upper respiratory tract the effect of all mucolytics (ambroxol, bromhexine, etc.), widely used for bronchial pathology. Of the mucolytic agents in the treatment of rhinosinusitis, due to their mechanism of action and the presence of application points in the upper respiratory tract, only cysteine ​​derivatives (acetylcysteine, carbocysteine) are used. Acetylcysteine ​​is able to break disulfide bridges in acidic mucopolysaccharides and thus reduce the viscosity of mucus, the mucus loses its ability to be viscous and is gently removed by blowing the nose and sneezing, resulting in the restoration of normal drainage and aeration of the paranasal sinuses.

It should be noted that in addition to the direct mucolytic effect, acetylcysteine ​​also has antioxidant and anti-inflammatory effects, which is extremely important in the treatment of rhinosinusitis. The effect on antioxidant systems helps protect cells from free radical damage, which leads to a decrease in inflammation on the mucous membranes of the respiratory tract and an improvement in clinical symptoms [10].

There is another important point: acetylcysteine ​​reduces the adhesion of pathogenic bacteria to the epithelial cells of the mucous membrane of the respiratory tract and therefore reduces the colonization of the respiratory tract by pathogenic microbes [11, 12]. As discussed above, the prescription of antibiotics for viral ARS is not indicated. All the more valuable is the fact that the use of acetylcysteine ​​reduces the likelihood of bacterial colonization and thereby reduces the likelihood of bacterial complications of rhinosinusitis. In addition, acetylcysteine ​​leads to a decrease in the formation of biofilms by gram-positive and gram-negative bacteria and fungi; reduces the production of extracellular polysaccharide matrix, which contributes to the destruction of mature biofilms [13–15]. It is likely that acetylcysteine ​​can destroy the disulfide bonds of bacterial enzymes, affecting the main component of the biofilm matrix (exopolysaccharides) involved in their formation or excretion. And due to its antioxidant properties and influence on the metabolism of bacterial cells, acetylcysteine ​​can disrupt the functioning of bacterial adhesive proteins [16], which is confirmed by the culture method and electron microscopy [17]. Thus, the use of acetylcysteine ​​in acute rhinosinusitis helps prevent the development of bacterial complications and chronicity of the process. It should be noted that according to in vitro studies published in 2016, acetylcysteine ​​is not an antagonist for most antibiotics used to treat respiratory infections [18], which means it can safely be prescribed simultaneously with antibiotics in the case of bacterial rhinosinusitis.

There are forms for using acetylcysteine ​​both internally and topically. However, if there are symptoms of rhinosinusitis accompanied by a cough, with simultaneous damage to the upper and lower respiratory tract, it would be advisable to prescribe acetylcysteine ​​orally, since in this case it simultaneously thins both viscous bronchial and nasal secretions, and in addition, has a systemic antioxidant and anti-inflammatory effect. action.

Anti-inflammatory therapy

In the EPOS-2012 recommendations, the main direction in the treatment of rhinosinusitis is topical endonasal corticosteroid therapy. Topical corticosteroids (mometasone furoate, fluticasone dipropionate, budesonide) have relatively recently entered the main arsenal of drugs for the treatment of ARS. Due to the pronounced anti-inflammatory effect of these drugs, which reduces swelling, the prescription of any other unloading therapy is considered unnecessary abroad. In Russian standards in the treatment of rhinosinusitis, unloading therapy retains its rather significant share, although in recent years it has been used more and more widely [6]. Glucocorticosteroids primarily suppress the development of edema by influencing the inflammation of the lamina propria of the mucous membrane. The functional ability of the anastomosis is restored - a key link in the pathogenesis of sinusitis and rhinosinusitis. In addition, corticosteroids actively suppress the release of fluid from the vascular bed and the production of mucus, which is an important factor in the pathogenetic therapy of acute rhinosinusitis. It must be remembered that the use of topical glucocorticosteroids is not indicated for children under 12 years of age.

The drugs of choice from the group of antipyretic and anti-inflammatory drugs are paracetamol and ibuprofen and their combinations at the height of acute manifestations of ARVI [6].

In conclusion, I would like to note that children with acute rhinosinusitis first of all go to pediatricians, and only then, if necessary, to an otolaryngologist. Since acute rhinosinusitis in the practice of a local doctor most often occurs not as an independent disease, but as part of an acute respiratory viral infection, the doctor is faced with the need to eliminate several symptoms at once. It is quite understandable that the doctor wants to influence all stages of etiopathogenesis at once, but most often this leads to the prescription of 4–5, and often more, drugs. At the same time, it is worth remembering that polypharmacy leads not only to higher treatment costs, but to an increased drug burden on the body, which is often accompanied by drug-drug interactions and the development of adverse drug reactions. In this regard, preference should be given to well-studied drugs with a complex effect, which makes it possible to simultaneously influence the main links of pathogenesis or several symptoms at once.

Literature

1. Fokkens W., Lund V., Mullol J. et al. European position paper on rhinosinusitis and nasal polyps 2012 (EP3 OS) // Rhinology. 2012. Vol. 50 (23). P. 1–299.
2. Lopatin A. S., Svistushkin A. M. Acute rhinosinusitis: etiology, pathogenesis, diagnosis and principles of treatment. Clinical recommendations. M., 2009. 25 p.
3. Lopatin A. S. Rhinitis. M.: Litterra, 2010. P. 122, 126–127.
4. Ryazantsev S.V., Kocherovets V.I. Etiopathogenetic therapy of diseases of the upper respiratory tract and ear. Guidelines. St. Petersburg, 2008. 120 p.
5. Karpova E. P., Vagina E. E. The role of nasal decongestants in the complex treatment of acute rhinosinusitis in children // Medical Council. 2013, no. 1, p. 46–48.
6. Abdulkerimov Kh. T., Garashchenko T. I., Koshel V. I., Ryazantsev S. V., Svistushkin V. M. Principles of etiopathogenetic therapy of acute sinusitis: methodological recommendations / Ed. S. V. Ryazantseva. St. Petersburg: Polyforum Group, 2014. 40 p.
7. Order of the Ministry of Health of Russia dated December 20, 2012 N 1201n “On approval of the standard of primary health care for acute sinusitis” (registered with the Ministry of Justice of Russia on March 15, 2013 N 27696).
8. Order of the Ministry of Health of Russia dated November 9, 2012 N798n “On approval of the standard of specialized medical care for children with acute respiratory diseases of moderate severity” (registered with the Ministry of Justice of Russia on March 12, 2013 N 27623).
9. Order of the Ministry of Health of Russia dated December 24, 2012 N1395n “On approval of the standard of primary health care for chronic sinusitis” (registered with the Ministry of Justice of Russia on February 26, 2013 N 27331).
10. Geppe N. A., Snegotskaya M. N., Penkina M. V. Algorithm for the treatment of cough in children // Farmateka. 2014. No. 1. P. 71–75.
11. Singh M., Singh M. Heated, humidified air for the common cold. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD001728. DOI: 10.1002/14651858. CD001728.pub5.
12. Smith SM, Schroeder K., Fahey T. Over-the-counter (OTC) medications for acute cough in children and adults in community settings // Cochrane Database Syst Rev. 2014, Nov 24; 11: CD001831. DOI: 10.1002/14651858. CD001831.pub5.
13. Riise G., Qvarfordt I., Larsson S. et al. Inhibitory effect of N-acetylcysteine ​​on adherence of Streptococcus pneumoniae and Haemophilus influenzae to human oropharyngeal epithelial cells in vitro // Respiration. 2000; 67:552–558.
14. Aslam S., Darouiche R. Role of antibiofilm-antimicrobial agents in controlling device-related infections // Int. J. Artif. Organs. 2011; 34(9):752–758.
15. Rubin B. Mucolytics, expectorants, and mucokinetic medications // Respir. Care. 2007; 52:859–865.
16. Schwandt L., Weissenbruch R., Stokroos I. et al. Prevention of biofilm formation by dairy products and N-acetylcysteine ​​on voice prostheses in an artificial throat // Acta Otolaryngol. 2004; 124:726–731.
17. Zhao T., Liu Y. N-Acetylcysteine ​​inhibit biofilms produced by Pseudomonas aeruginosa // BMC Microbiol. 2010; 10:140.
18. Landini G. et al. Effect of N-acetylcysteine ​​on the activity of antibiotics against relevant respiratory pathogens, ERS Congress, 2016.
19. Little DR, Mann BL, Godbout CJ How family Phisitians distinguish acute sinusitis from upperrespirator tract infrctions: a retrospective analysis // J Am Board Fam Pract. 2000. Vol. 13. R. 101–106.

RU1611561073

E. P. Karpova, Doctor of Medical Sciences, Professor

Federal State Budgetary Educational Institution of Further Professional Education RMAPO Ministry of Health of the Russian Federation, Moscow

Contact Information

Differential diagnosis

For viral and bacterial MS, simultaneous damage to several sinuses ( polysinusitis ) is more typical.

Isolated damage to one sinus ( monosinusitis ) is typical of fungal and odontogenic rhinosinusitis .

Signs of rhinosinusitis caused by typical pathogens (S. pneumoniae and H. influenzae) are a decrease in the sense of smell, the presence of a fluid level on the X-ray and the effectiveness of traditional therapy.

Distinctive features of rhinosinusitis caused by other microorganisms: foul-smelling nasal discharge, a total decrease in pneumatization of the paranasal sinuses on X-ray, slower positive dynamics of the X-ray picture during treatment.

Allergic (or eosinophilic) fungal rhinosinusitis is characterized by the detection of multiple polyps during endoscopy, as well as a very characteristic discharge of yellow, green or brown color with a very viscous rubber-like consistency. A similar discharge - allergic mucin - is found in all affected sinuses during surgery.

Odontogenic sinusitis usually acquires a primarily chronic course, accompanied by the formation of polyps, granulations or fungal stones in the sinus.

The chronic invasive form of mycosis is accompanied by the formation of fungal granulomas with their invasion into bone structures and soft tissues of the face.

Polypous rhinosinusitis is characterized by the formation and recurrent growth of polyps, consisting predominantly of edematous tissue infiltrated with eosinophils.

Pathogenesis of development

The main reason for the development of the pathological condition is considered to be a hereditary predisposition to it. The disease also manifests itself under the influence of the following factors:

• a high level of immune reactivity to the allergen that provoked rhinosinusopathy;
• allergies to medications;
• IgE-dependent allergic reaction;
• food allergies;
• bronchial asthma in close relatives;
• allergies to plants;
• penetration of pathogenic microorganisms into the nasopharynx;
• allergies to household chemicals and chemicals;
• frequent contact with paints and varnishes;
• allergy to dust;
• enlarged adenoids.

Any allergy, even in mild form, can develop into rhinosinusitis. This occurs under the influence of any irritant.

General principles of treatment

The main goals of treatment for rhinosinusitis are:

1. Reducing the duration of the disease.
2. Prevention of the development of orbital and intracranial complications.
3. Eradication of the pathogen.

From this perspective, the basic method of treating acute bacterial rhinosinusitis (moderate and severe forms) and exacerbation of chronic rhinosinusitis is empirical antibacterial therapy.

The main indications for prescribing antimicrobial drugs include:

1. Anamnesis characteristic of rhinosinusitis.
2. Severity of clinical manifestations.
3. The presence of purulent discharge in the nasal passages.

Antibacterial therapy, taking into account the type and sensitivity of a specific pathogen identified during a bacteriological study, does not at all guarantee success due to the high probability of “traveling” microflora entering the test material during sampling. In addition, the results of in vitro sensitivity studies of the identified microorganism do not always correlate with the clinical effectiveness of individual antibacterial drugs. The reasons for this may be a significant increase in antibacterial activity as a result of the unidirectional effect of the antibiotic and its metabolite and the ability to specifically achieve bactericidal concentrations precisely at the site of infection.

Antibacterial therapy for acute bacterial rhinosinusitis

On an outpatient basis, oral antimicrobial drugs are predominantly prescribed.

Taking into account the spectrum of typical pathogens and Russian data on their antibiotic resistance, the drug of first choice for acute bacterial rhinosinusitis is amoxicillin.

In the absence of a noticeable clinical effect, after three days the drug should be replaced with an antibiotic active against penicillin-resistant S. pneumonia and β-lactamase-producing H. influenzae. In this case, III-IV generation cephalosparins or new fluoroquinolones are prescribed.

If you are intolerant to penicillin drugs (and due to possible cross-allergic reactions, cephalosporins should also not be prescribed), the drugs of choice are macrolides.

If the patient is hospitalized, the parenteral route of administration of antimicrobial drugs is preferable.

Antibacterial therapy for exacerbations of chronic rhinosinusitis

When treating exacerbations of chronic rhinosinusitis, oral amoxicillin/clavulanate is considered the drug of choice.

Alternative drugs (prescribed in case of ineffectiveness of the antimicrobial drugs of choice) currently include fluoroquinolones of the III-IV generations. In patients under 16 years of age, alternative drugs include macrolides. Considering the significant role of obstruction of the natural openings of the paranasal sinuses in the pathogenesis of rhinosinusitis, vasoconstrictor drugs, which are prescribed either locally or orally, are of great importance in its treatment.

In the treatment of acute and chronic rhinosinusitis, herbal medicines that have anti-inflammatory and mucolytic effects are also used.

Puncture and probing of the paranasal sinuses

These methods allow you to rinse the affected sinus with an antiseptic solution, remove pathological secretions from it, and administer medications (antiseptics, proteolytic enzymes, glucocorticosteroids). In some cases, puncture and lavage of the paranasal sinuses can eliminate the blockade of its natural anastomosis. It is believed that regular removal of exudate during purulent rhinosinusitis protects local immune factors from proteolysis and increases the content of Ig and complement in the affected sinus by 2-3 times, stimulating the mechanisms of local antibacterial defense. The most common and easier to perform is puncture of the maxillary sinus. It is most often used in the treatment of rhinosinusitis.

Forced drainage method

The method has certain advantages over treatment with repeated punctures. The presence of a catheter creates an additional path for evacuating secretions from the affected sinus, increases air exchange, and eliminates negative pressure when the natural anastomosis is blocked or acts as a valve.

Other methods

Nasal showers, rinsing the nasal cavity with a warm isotonic solution and physiotherapy (ultrahigh-frequency currents, microwave therapy, ultrasound).

Surgery

Indications for surgical treatment for bacterial rhinosinusitis arise when antibiotic therapy is ineffective and orbital or intracranial complications develop.

In surgical treatment, the prevailing trend is towards minimal invasiveness. Less traumatic functional endoscopic interventions give better results, are accompanied by fewer complications, and are less likely to contribute to the progression of the disease and the development of bronchial asthma than classical operations with radical removal of the mucous membrane and nasal turbinates.

Therapy for fungal forms of rhinosinusitis

For a fungal ball, antifungal medications are not prescribed. Treatment is surgical (endoscopic). Complete removal of fungal masses from the paranasal sinuses guarantees recovery. Treatment of allergic fungal rhinosinusitis is surgical (in the presence of large polyps). Treatment of superficial sinonasal mycosis involves removing the substrate for the growth of fungal mycelium.

Treatment of acute rhinosinusitis

Symptomatic therapy is indicated for patients with ARRS.

• Analgesics and antipyretics - ibuprofen or paracetamol can be used to relieve pain and reduce fever as needed.
• Saline irrigation therapy - Irrigation of the nasal cavity with saline or hypertonic saline can reduce the need for pain medications and improve overall health. It is important that nasal irrigation solutions are sterile, as there is evidence of amoebic encephalitis due to the use of tap water for nasal irrigation.
• Intranasal glucocorticoids (inGCS) - studies have shown small symptomatic benefits and minimal side effects with short-term use of inGCS in patients with both viral and bacterial ARS. InGCS are more effective in patients with concomitant allergic rhinitis. A meta-analysis of three studies in patients with ARS found that intranasal steroids increased the rate of symptom resolution compared with placebo. However, there is also evidence that only 1 out of 15 patients will have a significant reduction in clinical symptoms during treatment with inhaled corticosteroids.
• Ipratropium bromide is an anticholinergic spray that may help reduce rhinorrhea in patients with underlying cold symptoms.
• Oral decongestants may be useful for eustachian tube dysfunction.
• Intranasal vasoconstrictors are often used by patients as symptomatic therapy. Sprays containing oxymetazoline or xylometazoline may provide temporary relief of nasal congestion, but there is no evidence that they are significantly effective for ARS.

In cases of mild, uncomplicated ABRS, there are no indications for prescribing systemic antibiotics; treatment is carried out symptomatically, as in cases of viral infection.

For ABRS, a wait-and-see approach is recommended for 7 days. Systematic reviews and meta-analyses have shown that about 80% of patients with clinically diagnosed ABRS recover without antibiotic therapy within two weeks.

If health does not improve within 7 days or worsens after symptomatic treatment, systemic antibacterial therapy should be added.

The drugs of choice for ABRS are amoxicillin or amoxicillin-clavulanate. The use of an antibiotic with clavulanic acid in its composition expands the spectrum of action of the drug, including against ampicillin-resistant bacteria Haemophilus influenzae or Moraxella catarrhalis. This is not necessary in every case. There is evidence that the use of amoxicillin-clavulanate is preferable in children than in adults. It should also be understood that resistance rates vary depending on the region, which must also be taken into account when selecting therapy.

Preference should be given to amoxicillin-clavulanate in the following cases.

• The patient lives in a region with high rates of penicillin-resistant S. pneumoniae strains (more than 10%).
• Age ≥ 65 years.
• Hospitalization in the last five days.
• Use of antibiotics in the previous month.
• Immunocompromised patients.
• Patients with underlying medical conditions such as diabetes, chronic heart, liver or kidney disease.
• Severe or complicated course of the disease.

If you are allergic to penicillin antibiotics, options for prescribing doxycycline, cephalosporin antibiotics, and clindamycin are considered. Another alternative for patients allergic to penicillins is respiratory fluoroquinolones. However, these drugs should only be used when there is no alternative due to serious side effects.

The duration of the course of antibacterial therapy in adults is usually 5-7 days, in children - 10-14 days. There are studies showing that short courses of antibiotic therapy are not inferior in effectiveness to long courses.

If there is no effect from the first course of antibiotics, the next drug prescribed should have a broader spectrum of activity and/or belong to a different class of drugs.

How is acute rhinosinusitis treated at the Rassvet Clinic?

• We carefully collect anamnesis and conduct an examination.
• We do not prescribe antibiotics unless there is clear evidence that a bacterial infection is developing.
• We do not routinely order x-rays, bacteriological examinations or blood tests. It is not necessary.
• We adhere to the principles of evidence-based medicine, which means that if there are indications for antibiotic therapy, we always give preference to systemic antibiotics, usually oral. Administration of the drug intramuscularly has no proven advantages over tablet forms.
• Not a single local antibiotic has been shown to be effective for ARS, so we do not perform “cuckoo” or multiple punctures of the sinuses and rinse them with “complex solutions.”
• At the Rassvet clinic, you do not need to come to the doctor for control every 2-3 days in cases of the standard course of the disease.

Diagnosis of rhinosinusitis

With symptoms of rhinosinusitis in adults that are severe or persist for a long time, or if home treatment is ineffective, it is better to schedule an examination at the clinic. You can contact either a therapist or an otolaryngologist. The doctor will analyze the complaints, find out how long ago the signs of the disease appeared, and also conduct an examination. The nature of the course of the disease can be determined by the appearance of the nasal mucosa and visible copious discharge.

The specialist may refer you for an ultrasound, radiography or computed tomography (CT). In this case, the boundaries of inflammation are very clearly defined in the image - both the fluid level and the thickened mucosa will be visible. If necessary, a diagnostic and therapeutic puncture of the sinuses is performed.

There is no need for microbiological diagnostic methods, namely nasal smears for rhinosinusitis, in uncomplicated cases. But they are prescribed if the previous treatment is ineffective or if possible complications are suspected.

Description

Allergic rhinosinusopathy (or rhinosinusitis) refers to a type of pathological condition. The disease manifests itself in the form of damage to the nasal mucosa and its paranasal sinuses. The development of the disease occurs due to disturbances in reactivity processes (in particular, the immune system). Damage to the nasal mucous membranes is almost never isolated, but additionally affects the skin, larynx, bronchi, lungs and mucous membranes of the eyes.

Rhinosinusopathy is determined by duration:

• episodic acute (inflammation of the nasopharyngeal mucosa goes away quickly when contact with inhaled allergens, as well as animal hair or bird feathers is avoided);
• seasonal (characterized by damage to mucous membranes only during the flowering period of plants);
• year-round or persistent (observed for at least nine months a year).

According to statistics, allergic rhinosinusopathy occurs in 20% of the total world population.

Prevention

To prevent the development of sinusitis, it is necessary to treat the diseases that cause it and, if possible, eliminate predisposing factors. If inflammation develops, you cannot self-medicate - you must consult a doctor. Only he can prescribe the correct treatment for sinusitis. Strict implementation of these recommendations will help you recover quickly and prevent complications13.

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“The information in this article is for reference only and does not replace professional advice from a doctor. To make a diagnosis and prescribe treatment, consult a qualified specialist."

Literature

1. Ryazantsev S.V., Fanta I.V., Pavlova S.S. Pathogenetic therapy of rhinosinusitis in the practice of an otolaryngologist. Medical advice. 2019; 6: 68-73. DOI: https://doi.org/10.21518/2079-701X-2019-6-68-73
2. Boykova N. E., Rybalkin S. V. Acute rhinosinusitis. The role of topical therapy // Medical Council / No. 06. – 2016. – pp. 18-21.
3. Ryazantsev S.V., Karneeva O.V., Garashchenko T.I. Acute sinusitis // Clinical recommendations of the Ministry of Health of the Russian Federation - 2016.
4. Shakhova E. G. Sinusitis: clinical picture, diagnosis, drug treatment // Bulletin of VolSMU / No. 4 (20). – 2006. – P. 78-84. — UDC 616.216–07–085.
5. Derbeneva M. L., Guseva A. L. Acute rhinosinusitis: diagnosis and treatment. Consilium Medicum. 2018; 20 (3): 58–60. DOI: 10.26442/2075-1753_20.3.58-60
6. Kryukov A. I., Turovsky A. B., Kolbanova I. G., Luchsheva Yu. V., Musaev K. M., Karasov A. B. The problem of treating sinusitis against the background of allergic rhinitis. Medical advice. 2019; 8: 110-114. DOI: https://doi.org/10.21518/2079-701X-2019-8-110-114.
7. Shilenkova V.V. Therapy of rhinosinusitis: present and future // Medical Council / No. 16. – 2022. – P. 96-100.
8. Svistushkin V.M., Nikiforova G.N., Shevchik E.A. et al. Possibilities of pathogenetic therapy for patients with inflammatory diseases of the paranasal sinuses. Consilium Medicum. 2019; 21 (11): 57–62. DOI: 10.26442/20751753.2019.11.190648
9. Turovsky A. B., Kolbanova I. G., Kudryavtseva Yu. S. Evidence-based approach to the treatment of acute sinusitis. Consilium Medicum. 2018; 20 (3): 85–89. DOI: 10.26442/2075-1753_20.3.85-89.
10. Instructions for use of the drug TIZIN® Classic // Registration number P N014038/01 // GRLS of the Russian Federation. – URL: https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=93fbeb97-51eb-4e1b-bd2a-82dbeb93d3d7&t= (access date: 06/25/2008).
11. Instructions for use of the drug TIZIN® Expert // Registration number LSR-009878/09 // GRLS of the Russian Federation. – URL: https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=08fa133c-a9ca-45d7-b5de-2cd76bf825c0&t= (access date: 12/04/2009).
12. Instructions for use of the drug TIZIN® Alergy // Registration number P N014198/02 // GRLS of the Russian Federation. – URL: https://grls.rosminzdrav.ru/Grls_View_v2.aspx?routingGuid=aa7246a7-e710-413d-9155-6c7a9b4e9491&t= (date of access: 07/07/2010).
13. Official website of the drug
14. Topical decongestants in the complex therapy of acute respiratory infections in children, A. B. Malakhov et al. Medical Council No. 14, 2015

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Symptoms of rhinosinusitis

The symptoms of rhinosinusitis are largely determined by the type of inflammatory disease. In acute forms of the disease, the symptoms are more vivid and the onset is sudden. Since in most cases, rhinosinusitis develops as one of the manifestations of ARVI, symptoms such as nasal congestion, copious nasal discharge, and lacrimation may be accompanied by headache, high body temperature, and general loss of strength.

Specific symptoms vary depending on the form of rhinosinusitis. For example, against the background of rhinitis complicated by sinusitis, symptoms such as pain in the nose appear, radiating to the cheekbones, area under the eyes, temple or the entire half of the face and intensifying when pressed. There may be swelling of the cheek or eyelid on one or both sides, which is an alarming symptom and requires immediate medical attention.

Damage to the frontal sinus is often accompanied by pain in the forehead and severe headaches. With ethmoiditis, pain is noted in the area of ​​the bridge of the nose and the root of the nose, and loss or impairment of the sense of smell often occurs. Sphenoiditis is more often than other forms accompanied by occipital headaches.

Chronic rhinosinusitis rarely occurs with fever. Headaches may not be as severe and occur from time to time. There is nasal congestion, copious discharge, deterioration of taste and smell, swelling and pressure in the nose.

Typically, chronic rhinosinusitis is a consequence of acute rhinosinusitis, with symptoms persisting for more than 12 weeks. Periodically, exacerbations of a chronic illness may occur, during which the symptoms intensify and the body temperature rises.

Frontit

Frontal sinusitis (frontal sinusitis) is an inflammatory disease of the frontal paranasal sinus. This type of sinusitis is the most severe. There are forms of acute and chronic frontal sinusitis.

Symptoms of sinusitis

Acute frontal sinusitis, symptoms:

• pain and swelling around the nose and eyes;
• increased pain when tapping in the projection area of ​​the inflamed sinuses;
• heavy breathing due to inflammation of the nasal passages;
• runny nose with thick yellow or green mucus;
• increase in body temperature to 38-39 degrees;
• severe headache (minor relief occurs when lying down);
• pain radiating to the ears and teeth;
• fear of light;
• severe weakness;
• sometimes sore throat, difficulty identifying odors, decreased pungency of taste.

Chronic frontal sinusitis, symptoms:

• aching headache;
• purulent, unpleasant-smelling nasal discharge in the morning;
• slight increase in temperature;
• difficulty breathing through the nose;
• sputum discharge in the morning.

Causes of frontal sinusitis

The following reasons for the development of frontal sinusitis are distinguished:

• viral, bacterial or fungal infection;
• complication after influenza, ARVI, etc.;
• getting foreign objects into the nose;
• long-term infectious or allergic rhinitis (rhinitis);
• deviated nasal septum;
• adenoids;
• allergy;
• nasal polyps.

Treatment of frontal sinusitis

How to treat frontal sinusitis? Definitely under the supervision of an otolaryngologist! The disease is not only difficult for many patients to tolerate, but also has dangerous complications, including orbital abscess, meningitis, sepsis, etc.

Treatment of sinusitis is aimed at eliminating infection in the sinuses and stopping inflammation. Medicines will help relieve swelling, improve ventilation of the sinuses and lead to the discharge of contents from them. If the disease is viral in nature, then antibiotics for frontal sinusitis are mandatory!

The following antibiotics are used to treat sinusitis:

• penicillin antibiotics (semi-synthetic or synthetic amoxicillin preparations);
• cephalosporin antibiotics;
• macrolide antibiotics (they do not affect the intestinal microflora);
• local antibiotics in the form of nasal drops, nasal spray, aerosol;
• homeopathic medicines;
• symptomatic remedies for frontal sinusitis in the form of vasoconstrictor nasal drops, antipyretics and anti-inflammatory drugs.

In case of severe frontal sinusitis and insufficient effectiveness of conservative treatment, sinus lavage using the method of displacement and puncture is prescribed.

1 Rhinoscopy in MedicCity

2 Consultation with an ENT specialist in MedicCity

3 ENT consultation in MedicCity

Prevention of frontal sinusitis

To prevent frontal sinusitis, you need to monitor the state of your immune system, promptly eliminate foci of inflammation in the ENT organs, harden your body, and lead a healthy lifestyle.