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Key Clinical Updates in Infections of the Nose & Paranasal Sinuses

Dupilumab, a monoclonal antibody with inhibition of IL-4 and IL-13, is FDA-approved for patients with chronic sinusitis with nasal polyposis.

Hoy SM. Drugs. [PMID: 32240527]

Rhinosinusitis may be classified by duration of symptoms. Rhinosinusitis is called acute rhinosinusitis if less than 4 weeks’ duration or as chronic rhinosinusitis if lasting more than 12 weeks, with or without acute exacerbations. Acute rhinosinusitis may also be classified by presumed etiology, such as viral rhinosinusitis or acute bacterial rhinosinusitis.

1. VIRAL RHINOSINUSITIS (COMMON COLD)

ESSENTIALS OF DIAGNOSIS

  • Associated malaise, headache, and cough.

  • Nasal congestion, facial pressure, rhinorrhea, and hyposmia.

  • Erythematous, engorged nasal mucosa without intranasal purulence.

  • Symptoms are self-limited, lasting typically < 10 days.

Clinical Findings

Due to the 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, 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 most COVID-19 variants primarily involve 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, the loss of the sense of smell could be permanent (see further information from the CDC 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).

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Najafloo  R  et al. Mechanism of anosmia caused by symptoms of COVID-19 and emerging treatments. ACS Chem Neurosci. 2021;12:3795.
[PubMed: 34609841]  
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Vance  H  et al. Addressing post-COVID symptoms: a guide for primary care physicians. J Am Board Fam Med. 2021;34:1229.
[PubMed: 34772779]  

Treatment

The main treatment for viral rhinitis is supportive care, including rest, hydration, and use of over-the-counter analgesics and decongestants. 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. 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 ...

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