Rhinosinusitis, acute J01

Acute rhinosinusitis ARS or an episode of recurrent acute rhinosinusitis is diagnosed when typical complaints or symptoms (nasal breathing obstruction, antero-nasal and/or retro-nasal secretion (also known as postnasal drip: nasal secretion running down the throat), facial pain, headache, olfactory disturbance) or facultative complaints or symptoms (persistent fever, strong feeling of illness, pressure pain over the frontal or maxillary sinus, complaints in the area of the teeth and the periodontium, increase in pain when bending forward).

The severity of the disease can be classified as mild, moderate or severe. This can be done with the help of a visual analogue scale (VAS) of 0-10 (10 = maximum disturbance). From a VAS value of 5, a reduction in quality of life is assumed.

In Germany, an estimated 18% of the population is affected by acute rhinosinusitis once a year.

Acute rhinosinusitis is a viral infection of the upper respiratory tract in >95% of cases. A post-viral symptomatology is assumed if the symptoms of a viral respiratory tract infection increase after 5 days or persist after 10 days.

Acute bacterial rhinosinusitis (ABRS) occurs with a temporal latency in about 0.5 to 2.0% of patients and is characterized by a strong, purulent inflammatory infiltration and secretion of the rhino-sinusoidal mucosa. S. pneumoniae and H. influenzae are predominantly detected.

In the first 3-4 days, it is only rarely possible to distinguish clinically between acute viral and early stages of acute bacterial rhinosinusitis.

Only in patients with unusually severe disease or with complications outside the paranasal sinuses, e.g. pain in the eye area or involvement of surrounding tissues and bones, should one immediately assume bacterial disease.

If a deterioration occurs again after initial recovery, this biphasic course indicates acute bacterial rhinosinusitis.

Without therapy, in 60-80% of the patients a complete healing of ARS occurs within 2 weeks and in 90% within 6 weeks. CRS may be associated with a course that lasts for years or even a lifetime.

Imaging procedures are not necessary in the diagnosis of ARS.

Determination of inflammation parameters like CRP, BSG. Further laboratory parameters are not necessary.

Microbiology: In therapy-resistant RS and in patients with immune deficiency, a smear with an antibiogram and, if necessary, further microbiological test procedures can be the basis of a targeted therapy. Sampling from the middle nasal passage!

ARS is usually diagnosed by the clinical symptoms and clinical findings.

The following clinical examination procedures are diagnostic:

• general clinical impression, inspection, pressure/tapping pain over maxillary or frontal sinuses, temperature measurement
• Rhinoscopy and/or nasal endoscopy.

Allergological tests: Routine allergological tests are not indicated in the diagnosis of ARS. In cases of aetiologically unexplained, recurrent acute rhinosinusitis, and in cases where there are anamnestic or corresponding anamnestic clinical indications of allergic etiology, allergological diagnosis(prick test, determination of specific IgE from serum) is indicated.

Serious complications are rare; orbital and intracranial inflammation may occur. Furthermore, involvement of the surrounding soft tissue and bone is possible.

Nasal rinsing with saline solution: For the symptomatic therapy of CRS, the consistent use of nasal rinsing with saline solutions, e.g. as voluminous (≥150 ml), iso- to slightly hypertonic solutions in the form of a nasal douche, is useful. However, they should not be used as the sole measure because of their relatively small effect. The use of seawater solutions is recommended.

Phytotherapeutically proven in practice is the secretolysis with a combination preparation containingverbena (Verbenae Herba): together with Gentianae radix (gentian root)+ Herba Rumicis acetosae (garden sorrel)+ Sambuci flos (elderflower)+ Primulae flos (cowslip with calyx) as Sinupret forte® (dosage: 1-1-1Drg) or as Sinupret Saft® (7.0ml-7.0ml-7.0ml p.o. - for children from 2-5-LJ: 2.1ml-2.1ml-2.1ml p.o.; for children from 6-11-LJ: 3.5ml-3.5ml-3.5ml p.o.). In the German guideline bromelain is also mentioned. Bromelain in addition to the standard therapy (e.g. antibiotics for bacterial rhinosinusitis) seems to alleviate symptoms.

Secretolytic effects (especially suitable for children) are mainly achieved by steam inhalations, e.g. with thyme herb or chamomile flowers. Application: Camomile flowers are to be poured over with boiling water in a large bowl. Cover the head well with a large bath towel; inhale for 5-10 minutes for children and 10-15 minutes for adults. Cave: Children must be monitored permanently! For older children or adults, the inhalate can be supplemented with 2 drops of tymian oil/eucalyptus oil. Alternatively 1 tablespoon of table salt.

At elevated temperature with a general feeling of illness, nasturtium can be used in combination with horseradish roots (Angocin Anti-Infekt® (dosage: 4-4-4 film-bl. p.o. after meals).

Extracts of camomile blossom (e.g. Soledum med.® nasal drops, 1-2 sprays several times a day) have proven effective as herbal decongestives. Furthermore, essential oils such as eucalyptus oil, pine needle oil, levomenthol (available as a combination preparation in Pinimethol® cold ointment (dosage: for rubbing in or inhaling 2-3 times a day; for inhaling, a 10 cm long ointment strand is applied to hot water in a small bowl). Also possible as bath additive. Camphor is to be mentioned in addition.

Decongestives can be used for symptomatic relief of ARS. Topical decongestives should be free of benzalkonium chloride and should not be used for more than 10 days. In ARS, painkillers may be recommended for symptomatic relief.

In the European as well as in the German guideline, combination therapy with topical glucocorticoids(fluticasone, mometasone, betamethasone) alone or in combination with systemic antibiotics - is recommended for both acute bacterial rhinosinusitis and the chronic form. Local glucocorticoid applications are also recommended in acute allergic rhinosinusitis.

Antibiotic therapy: In the case of non-complicative ARS or acute exacerbation of recurrent ARS, antibiotics are generally not required. Antibiotics are indicated in patients with special risk factors . These include chronic inflammatory lung diseases, genetic immunodeficiencies or drug or disease-related immunosuppression.

Antibiotic therapy is recommended in the case of ARS (or in the case of acute exacerbation of recurrent ARS) with considerable pain and increased inflammation values (CRP > 10 mg/l or significantly increased BSG and/or fever > 38.5 °C. The first choice is amoxicillin (dosage: 3x500mg/day p.o.) or a cephalosporin derivative (e.g. cefuroxime 2 x 250mg/day p.o.). Alternatively macrolides (e.g. azithromycin 500mg/day p.o.) or doxycycline or co-trimoxazole or amoxicillin in combination with clavulanic acid.

Analgesics/non-steroidal anti-inflammatory drugs (NSAIDs): A meta-analysis from 2013 (1069 patients), concludes that NSAIDs such as ibuprofen effectively relieve symptoms such as fatigue, cold pains (headache, sore throat, earache, limb pain), sneezing attacks. Similar results are available for paracetamol and acetylsalicylic acid. The German guideline also mentions diclofenac as an alternative to ibuprofen as comparably effective.

In addition to symptomatic therapeutic approaches, virustatics (neuraminidase inhibitors) may be considered. The inhibitors oseltamivir and zanamivir are possibilities for the treatment of risk patients.

Probiotics: The prophylactic effect of probiotics, especially lactobacilli and bifidobacteria, against respiratory tract infections (metaanlayse from 2011) is not proven.

Traditional Chinese Medicine: No recommendation is explicitly made for Traditional Chinese Medicine due to insufficient data. The data situation for preparations containing echinacea is contradictory; their use is not recommended for therapy.

menthol. Campfer and Cineal are contraindicated in the treatment of infants and toddlers or patients with obstructive pulmonary diseases. If infants are to be treated with essential oils, the corresponding preparation should only be dripped onto the pillow or bib!

An adaptive deactivation treatment should be performed in patients with confirmed NERD syndrome (NSAR-Exacerbated Resipratory Disease, Analgesic Intolerance Syndrome) and CRScNP in case of recurrent polyposis.

A positive recommendation is given by the European guideline (recommendation level A) for nasal sprays containing ipratropium, which are not approved in Germany, for the treatment of a viral infection of the upper respiratory tract.

If one follows the treatment scheme of the European guideline for the treatment of upper respiratory tract infections, there is a clearly defined period for self-medication of "colds". If the symptoms do not improve after 5 days (becoming constant or stronger) or persist for > 10 days, the patient should consult his or her family doctor. It is then probably a (possibly additional) bacterial (super) infection.

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