Acute rhinitis and rhinosinusitis

Classification and etiology

Globally, the pathology is divided into three groups depending on the triggering factor: infectious, allergic, and non-allergic non-infectious rhinitis (NANIPER — a heterogeneous group including reactions to medications, occupational hazards, hormonal shifts, and vasomotor rhinitis).

The vast majority of acute episodes are of infectious origin.

• Viral infection: is the root cause in the majority of cases. The absolute leader among pathogens is rhinoviruses.
• Bacterial infection: rarely acts as a primary factor. This is a typical superinfection, joining in approximately 5% of cases. The main causative agents are pneumococcus (Streptococcus pneumoniae) and Haemophilus influenzae (Haemophilus influenzae). Moraxella, Staphylococcus aureus, pyogenic streptococci, and anaerobic flora are less common.

Important: In children, the localization of inflammation depends on age. Up to three years of age, almost exclusively the ethmoid labyrinth is affected. In children aged 3 to 7 years, the process becomes combined — the ethmoid and maxillary sinuses become inflamed.

Clinical picture: viruses or bacteria?

The entire logic of diagnosis is based on distinguishing between viral and bacterial inflammation. Treatment tactics depend on this.

Viral etiology is confirmed in the presence of 2–3 basic symptoms:

• Nasal obstruction (nasal congestion, breathing difficulty).
• Rhinorrhea or post-nasal drip (discharge flowing into the nasopharynx).
• Cough (occurs at any time of day, often reflex in nature due to mucus irritation of the pharynx).

The duration of a viral episode usually does not exceed 10 days. Fever and intoxication are variable. Inflammation of the lower respiratory tract (laryngitis, tracheobronchitis) frequently joins.

Bacterial process is reasonably suspected if at least three criteria are present:

1. Purulent discharge in the nasal passages (often asymmetric).
2. Protracted course (no improvement for 10 days or more).
3. Pronounced unilateral facial pain in the projection of the sinuses.
4. Febrile fever (above 38 °C).
5. Severe onset: a combination of high temperature, intoxication, and purulent rhinorrhea in the first 3–4 days.

Diagnostics and differential search

Objective examination is based on visual assessment of the mucous membranes:

• Anterior rhinoscopy reveals edema, sharp hyperemia, and narrowing of the nasal passages. It allows assessment of the nature of the exudate, which evolves from mucous to mucopurulent.
• Pharyngoscopy is necessary to detect post-nasal drip syndrome.
• Otoscopy is performed to rule out middle ear involvement.

X-ray of the paranasal sinuses is not recommended today due to the high risk of false results and low informativeness. If orbital or intracranial complications are suspected, head CT and MRI are the methods of choice. Endoscopy allows a detailed assessment of anatomy, detection of polyps, adenoids, and biopsy.

Acute rhinosinusitis most often needs to be differentiated from adenoiditis (leading symptom is discharge with cough) and nasal foreign body (key sign is strictly unilateral purulent discharge).

Pharmacotherapy

The conservative management algorithm includes several areas:

• Elimination and irrigation therapy: nasal hygiene with saline solutions for mechanical cleansing. It is strictly important to follow the technique so that infected exudate does not enter the middle ear cavity through the Eustachian tube (risk of otitis media).
• Topical decongestants: relieve edema. Benzolmethanol derivatives (phenylephrine) constrict only mucosal veins, while imidazoline derivatives (xylometazoline) constrict both veins and arterioles. They can be used for no longer than 5–7 days to avoid the rebound syndrome (medicamentous rhinitis).
• Mucolytics: indicated for thick, viscous secretions.
• Intranasal glucocorticosteroids (INGS): for infectious origin, only mometasone is allowed, and strictly for patients over 12 years old.
• Systemic antibiotics: are prescribed only in the presence of clinical and laboratory signs of bacterial infection (neutrophilia, left shift). Drugs of choice are aminopenicillins or cephalosporins.

Why are complications dangerous?

The development of complications is based on pronounced mucosal edema, which blocks the drainage of the paranasal sinuses and the middle ear cavity.

In infants, nasal congestion makes normal feeding impossible, leading to systemic anxiety and impaired suckling. Early age anatomy predisposes to the frequent onset of acute otitis media.

Formidable complications of acute rhinosinusitis are divided into two groups:

• Orbital: periorbital and orbital cellulitis, subperiosteal and intraorbital abscesses.
• Intracranial (rare): meningitis, encephalitis, abscesses (epidural, subdural, brain), venous sinus thrombosis (cavernous or superior sagittal).

When such conditions develop, mandatory hospitalization in a specialized inpatient unit with the involvement of a multidisciplinary team is indicated.

Class and exam questions

What else to study on this topic

• Pathogenesis of the development of rebound syndrome (medicamentous rhinitis)
• Algorithm and technique of safe nasal cavity lavage in children
• Mechanism of action and pharmacokinetics of topical decongestants
• Management tactics for patients with orbital complications of rhinosinusitis
• Features of INGS (mometasone) use in pediatric practice

Other topics in "Chapter 4. Respiratory Diseases"

Prepared by WhiteCoat Pro faculty in accordance with the medical school curriculum. For educational purposes only.