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Primary Care Corner with Geoffrey Modest MD: Sinusitis guidelines

23 Apr, 15 | by EBM

By: Dr. Geoffrey Modest

The Am Acad of Otolaryngology — Head and Neck Surgery just published a clinical practice guideline on adult sinusitis (for exec summary, see Otolaryng Head Neck Surg. 2015, Vol. 152(4) 598–609​)​, updating their 2007 guideline.

General background and definitions:

–Sinusitis is common, affecting 1 in 8 adults in the US and with more than 30 million annual diagnoses

–More than 20% of antibiotics prescribed for adults are for sinusitis (fifth most common diagnosis responsible for antibiotic prescriptions).

–Acute rhinosinusitis (ARS) definition: up to 4 weeks of purulent nasal discharge accompanied by nasal obstruction, facial pain/pressure/fullness, or both:

–purulent nasal discharge is cloudy or colored

–nasal obstruction is reported by patient as obstruction, congestion, blockage, or stuffiness, or may be found on PE

–facial pain/pressure/fullness involves anterior face or periorbital region, and may present as headache which is localized or diffuse

​–Viral rhinosinusitis (VRS): when symptoms of acute rhinosinusitis are present < 10 days and are not worsening

–Acute bacterial rhinosinusitis (ABRS): symptoms of acute rhinosinusitis fail to improve in 10 days beyond the onset of upper respiratory symptoms, or worsen within 10 days after an initial improvement

–Chronic rhinosinusitis (CRS): symptoms last > 12 weeks

​–Recurrent rhinosinusitis: 4 or more annual episodes of acute rhinosinusitis

Recommendations:

–differentiate ABRS from VRS as per the definition above (strong recommendation)

–radiology: not get imaging for ABRS or VRS unless a complication or alternative diagnosis is suspected (eg severe headache, proptosis, cranial nerve palsies, facial swelling)

–symptomatic relief of VRS or ABRS: by analgesics, topical steroids or saline irrigation (optional)

–initial management of uncomplicated ABRS: offer watchful waiting (without antibiotics, but only if there is reasonable assurance that the patient will get antibiotics if the condition fails to improve by 7 days after the ABRS diagnosis or sooner if it worsens), or give antibiotics (recommendation)

–choice of antibiotics: amoxicillin with or without clavulanate is first-line therapy, for 5-10 days (recommendation). Systematic review does not show consistent benefit of longer course

–treatment failure for ABRS: reassess patient to confirm diagnosis, change antibiotics (recommendation). not mention what would be their suggested next drug

–CRS diagnosis: differentiate CRS from recurrent ARS; if CRS, confirm sinonasal inflammation by rhinoscopy, nasal endoscopy, or CT scan (strong recommendation)

–Modifying factors: assess patient with CRS or recurrent ARS for chronic conditions that would modify management: asthma, cystic fibrosis, immunocompromise, ciliary dyskinesia (recommendation)

–allergy and immune functioning testing: optional

–polyps: examine for polyps if CRS, and treat with saline nasal irrigation, topical steroids or both (recommendation)

–don’t give topical or systemic antifungal therapy for CRS

Also, there is a useful patient information sheet (their table 4)

Major changes were:

–an extension of watchful waiting as initial management of ABRS regardless of severity (not just in mild cases, as in prior guideline)

–change in antibiotics recommended from amoxacillin to amoxacillin with or without clavulanate

–addition of asthma as a chronic condition that modifies management for CRS (chronic rhinosinusitis)

–treating nasal polyps as a modifying factor with topical intranasal therapy (saline irrigations, steroids)

So, to me these recommendations seem pretty reasonable. The data on the utility of nasal steroids and/or antibiotics is quite mixed, with some good studies showing no benefit of either. So the move to less aggressive antibiotic therapy seems to be a good one. I have been promoting watchfully waiting for the past couple of years, often giving the patient an antibiotic prescription but suggesting that they take them only if the symptoms don’t improve by 10 days or get worse, and indicating the downside of antibiotics (adverse effects, general effects on microbiome, potential for developing resistant organisms). Not exactly sure what the patients do with the prescriptions, but my sense is that patients are coming here with lower expectations of getting antibiotics for likely viral infections than they used to.

A point of clarification: Acute rhinosinusitis can last up to 4 weeks (with chronic after 12 weeks, and the amorphous “subacute” in between). That being said, most acute rhinosinusitis is only 1-2 weeks. Viral is presumed if the purulent discharge lasts <10 days and is improving over time. Bacterial is presumed if it lasts >10 days or is getting worse. The purpose of watchful waiting is that even their presumptive bacterial rhinosinusitis may still get better over the next week on its own (Because it never really was bacterial, vs. the body handling the bacterium by itself without the assistance of antibiotics).

Primary Care Corner with Geoffrey Modest MD: Hearing loss prevention in teens/young adults

16 Mar, 15 | by EBM

By: Dr. Geoffrey Modest

noise

The World Health Organization just highlighted “a serious threat posed by exposure to recreational noise”, with 1.1 billion people at risk of hearing loss. These are mostly teenagers and young adults who unsafely use personal audio devices (eg smartphones) and are exposed to damaging levels of sound at nightclubs, bars, sporting events. For people aged 12-35 in middle- and high-income countries, “nearly 50% are exposed to unsafe levels of sound from the use of personal audio devices and around 40% are exposed to potentially damaging levels of sound at entertainment venues”, which is defined as exposures >85 db for 8 hours, or 100 db for 15 minutes. (see the WHO news release). and, we all know that once hearing loss occurs, it doesn’t come back….

Their recommendations:

–highest level of workplace noise exposure is 85db for up to a maximum of 8 hours

–teenagers and young adults should keep the volume down on personal audio devices, wearing earplugs at noisy venues, and using fitted noise-cancelling earphones/headphones. also, take short listening breaks and restrict daily use of personal audio devices to < 1 hour [good luck with that recommendation…]

–governments should have a role in developing and enforcing strict legislation on noise exposures.

As a point of reference, see graph. of note, a 10db increase in noise level is a doubling of subjective sound.

So, I do realize that teenagers are likely remarkably unresponsive to this message (and, I personally have a “rock-and-roll” notch in my audiogram, reflecting listening to loud music as a “invulnerable” teen). But it does make sense for us as providers to discuss excessive noise issues with teens and young adults, and it would really be helpful if there were a broad public health initiative to decrease noise exposures. It turns out that March 3rd was International Ear Care Day, and WHO was launching the “Make Listening Safe” initiative to mark that event.  And, of course, it is not just young people who may suffer permanent hearing loss: many workers are in very loud work environments with similar threats to their future hearing.

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