Help Patients Cope With Rhinosinusitis

Practitioners in primary care and retail health are very familiar with patients complaining about sinus infections multiple times a day during the fall, winter, and spring. Some of the most difficult visits practitioners handle are for the chief complaint of sinus pain. Having specialized knowledge of the different types of rhinosinusitis, getting a patient’s detailed medical history, and conducting a thorough physical exam are a few tools that will make for a successful consultation. Educating patients and guiding them to appropriate treatment plans of which they approve and invest in is a whole other ballgame.

Rhinosinusitis refers to the inflammation of the nasal cavity and paranasal sinuses. The term is the preferred use in the medical community, over sinusitis, because inflammation of the sinuses rarely occurs without inflammation of the nasal mucosa.¹This common condition affects an estimated 35 million people per year in the United States and accounts for nearly 16 million office visits per year.²

Rhinosinusitis is classified based on symptom duration as follows³:

• Acute rhinosinusitis (ARS): <4 li="">
• Chronic rhinosinusitis: >12 weeks
• Recurrent acute rhinosinusitis: 4 or more episodes of ARS within a year, with intermittent symptom resolution
• Subacute rhinosinusitis: 4 to 12 weeks

<4 li="">ARS is then further broken down by and clinical manifestations and etiology³:

• Acute viral rhinosinusitis(AVRS): ARS with viral etiology
• Complicated acute bacterial rhinosinusitis (ABRS): ARS with a bacterial etiology and clinical evidence of extension outside of paranasal sinuses and nasal cavity (ie, neurological, ophthalmologic, soft tissue, etc.)
• Uncomplicated ABRS: ARS with a bacterial etiology and no clinical evidence of extension past the nasal cavity and paranasal sinuses

In this article, we will focus on AVRS, the most common presentation in primary care. Recalling and applying these classifications will help guide practitioners to an efficient and successful treatment plan. Common symptoms of ARS, both ABRS and AVRS, include nasal congestion, purulent nasal discharge, maxillary tooth discomfort, and facial pain that is worse when bending forward.

Other signs and symptoms can include anosmia/hyposmia, cough, ear fullness/pressure, eustachian tube dysfunction, fatigue, fever, and headache.⁴The symptoms of ABRS and AVRS are quite similar, and there are no clinical criteria that have been validated to distinguish between them. However, ABRS and AVRS have different clinical courses, which should provide a strong influence on the treatment plan.⁵

PATIENT DISCUSSIONS ON AVRS

The majority of ARS cases are the result of a viral infection.⁴Rhinovirus, influenza virus, and parainfluenza virus are the most common pathogens found to cause AVRS.⁶Treatment focuses on symptomatic management, as it typically resolves AVRS in 7 to 10 days. In some cases, symptoms may not be completely resolved in 10 days, but it is expected that they will improve.⁵One of the most important tasks of an AVRS visit is to be honest and transparent with the patient about the length of illness. If it is day 2, be honest that the symptoms are just starting and are expected to last another week. If it is day 5, be empathetic and encouraging, sharing that days 4 to 6 are typically when the symptoms are at their worst but that the condition should improve soon.³If it is day 7, reassure the patient that the illness is winding down. Also, provide a basic description of what is happening within the sinuses and how that can affect the ears, nose, throat, etc. When patients have a rudimentary understanding of their illness, they feel more involved in their care and more invested in their treatment plan.

After an honest description of the anticipated length of illness and the simple pathophysiology that is at play, it is important to remind patients that there are treatments that can improve their symptoms. These include the following:

• Analgesics and antipyretics: Acetaminophen and nonsteroidal anti-inflammatory drugs can be used to reduce a fever and pain.^3,5
• Saline irrigation: Mechanical irrigation may improve overall patient comfort and reduce the need for pain medication. Irrigants must be from bottled or sterile water, not tap water.3,5,7
• Intranasal glucocorticoids: These reduce mucosal inflammation and allow for improved sinus drainage in both ABRS and AVRS.^3,5
• Oral decongestants: These are especially helpful when Eustachian tube dysfunction is a factor for patients with AVRS. Use with caution in patients with a history of acute angle closure glaucoma, bladder neck obstruction, cardiovascular disease, and hypertension.⁸

It is also important to impress upon patients that antibiotics are not helpful for AVRS because they only work on bacteria. This can help the patient have a better understanding of the treatment plan. Avoid dismissive statements during discussions, such as “It’s only a virus.” Be empathetic and understanding in terms of patient complaints and generous and truthful with knowledge. As a practitioner sees a patient investing in the treatment plan because of the extra education and knowledge they received, this may change from one of the most challenging visits to one of the most rewarding.

Bethany Rettberg, NPC, is a family nurse practitioner at a CVS Minute Clinic in Mokena, Illinois.

REFERENCES

1. Meltzer EO, Hamilos DL, Hadley JA, et. Al; American Academy of Allergy, Asthma and Immunology; American Academy of Otolaryngic Allergy; American Academy of Otolaryngology-Head and Neck Surgery; American College of Allergy, Asthma and Immunology; American Rhinologic Society. Rhinosinusitis: establishing definitions for clinical research and patient care.Otolaryngol Head Neck Surg.2004;131(suppl6):S1-62.
2. Lucas JW, Schiller JS, Benson V. Summary health statistics for US adults: National Health Interview Survey, 2001. Vital Health Stat 10. 2004;(218):1-134.
3. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et. al. Clinical practice guideline(update): adult sinusitis.Otolaryngol Head Neck Surg. 2015;152(suppl 2):S1-S39. doi:10.1177/0194599815572097.
4. Rosenfeld RM. Clinical practice: acute sinusitis in adults.N Engl J Med.2016;375(10):962-970. doi: 10.1056/NEJMcp1601749.
5. Chow AW, Benninger MS, Brook I, et al; Infectious Diseases Society of America. IDSA clinical practice guideline for cute bacterial rhinosinusitis in children and adults.Clin Infect Dis.2012;54(8):e72-e112. doi: 10.1093/cid/cir1043.
6. Gwaltney JM Jr. Acute community-acquired sinusitis.Clin Infect Dis. 1996;23(6):1209-1223; quiz 1224-5.
7. King D, Mitchell B, Williams CP, Spurling GK, Saline nasal irrigation for acute upper respiratory tract infections.Cochrane Database Syst Rev. 2015;(4):CD006821.doi:10.1002/14651858.CD006821.pub3.
8. Ziment I. Management of respiratory problems in the aged.J Am Geriatr Soc. 1982;30(suppl 11):S36-S44.