8-10: Infections of the Nose & Paranasal Sinuses

1. ACUTE VIRAL RHINOSINUSITIS (COMMON COLD)

Clinical Findings

Because there are numerous serologic types of rhinoviruses, adenoviruses, and other viruses, patients remain susceptible to the common cold throughout life. These infections, while generally quite benign and self-limited, have been implicated in the development or exacerbation of more serious conditions, such as acute bacterial sinusitis and acute otitis media, asthma, cystic fibrosis, and bronchitis. Nasal congestion, decreased sense of smell, watery rhinorrhea, and sneezing, accompanied by general malaise, throat discomfort and, occasionally, headache, are typical in viral infections. Nasal examination usually shows erythematous, edematous mucosa and a watery discharge. The presence of purulent nasal discharge suggests bacterial rhinosinusitis.

In 2020, the World Health Organization (WHO) designated a novel coronavirus called SARS-CoV-2 as the cause of a respiratory syndrome known as COVID-19. On March 11, 2020, the WHO declared it a global pandemic. While COVID-19 primarily involves the lower respiratory system, the viral prodrome is similar to that of other upper respiratory viruses with fever, nasal inflammation, rhinorrhea, cough, myalgias, and fatigue. Peculiar to SARS-CoV-2 is its propensity to cause hyposmia and anosmia, which are considered pathognomonic for COVID-19. While this altered olfaction was thought to be temporary, it became clear by late 2020 that the loss of the sense of smell could be permanent (see further information from the Centers for Disease Control and Prevention at https://cdc.gov/coronavirus/2019-ncov/symptoms-testing/symptoms.html and from the WHO at https://who.int/health-topics/coronavirus#tab=tab_3).

Treatment

There are no effective antiviral therapies for either the prevention or treatment of most viral rhinitis despite a common misperception among patients that antibiotics are helpful. Prevention of influenza virus infection by boosting the immune system using the annually created vaccine may be the most effective management strategy. Oseltamivir is the first neuraminidase inhibitor approved for the treatment and prevention of influenza virus infection, but its use is generally limited to those patients considered high risk. These high-risk patients include young children, pregnant women, and adults older than 65 years of age. Oseltamivir is hard to use because it must be started within 48 hours for optimal effect. Other specific antiviral medications are available or in clinical trials but have not achieved significant use. Zinc for the treatment of viral rhinitis has been controversial. A meta-analysis of randomized controlled trials demonstrated no benefit in five studies that used less than 75 mg of zinc acetate daily, but significant reduction in duration of cold symptoms was noted in all three studies that used zinc acetate in daily doses of over 75 mg. The effect with zinc salts other than acetate was also significant at doses greater than 75 mg/day, but not as high as the zinc ...