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SPECIAL TOPICS IN OTOLARYNGOLOGY

Acute rhinosinusitis: New guidelines for

diagnosis and treatmentJennifer Teeters, ATC; Michelle Boles; Julie Ethier; Ambria Jenkins;

L. Gail Curtis, PA-C, MPAS

Acute rhinosinusitis continues to be one of the mostcommon conditions treated by primary care provid-ers. In adults 18 years or older, almost 13% were

given a diagnosis of rhinosinusitis within 12 months.1Morethan one in five antibiotics prescribed in adults are for acuterhinosinusitis.2This condition can have many causes, fromallergens and environmental irritants to bacteria, fungi,and viral infection, with the latter being the most commoncause of acute rhinosinusitis.3Most cases are preceded by aviral upper respiratory infection (URI). The prevalence in

young children is two to seven episodes per year and twoto three episodes per year in adults.3-5Viral causes accountfor 90% to 98% of cases; bacterial infection accountsfor 2% to 10%.3Secondary bacterial infection occurs in0.5% to 2.0% of adult cases and about 5% of cases inchildren.2-5Lack of sensitive and specific diagnostic testingmeans that clinicians must be able to accurately diagnoseacute rhinosinusitis and, if bacterial infection is suspected,initiate appropriate antimicrobial therapy.

PATHOGENESIS

Acute rhinosinusitis is defined as inflammation of the liningof the nasal mucosa and paranasal sinuses. The paranasal

sinuses include the paired maxillary, frontal, ethmoid, and

the sphenoid sinuses. These sinuses are lined with ciliatedepithelium that contain mucus-producing goblet cells.6A

viral infection causes inflammation of this epithelium andincreased mucus production, which results in impairedmucociliary clearance.6The cessation of mucus clearancecauses obstruction of the sinuses, making it a suitableenvironment for the growth of bacteria. This entire processtypically takes 7 to 10 days.

CLINICAL PRESENTATION AND DIAGNOSIS

The healthcare provider should know not only the signsand symptoms of acute rhinosinusitis but also how todistinguish a viral from a bacterial cause. According to2012 guidelines from the Infectious Diseases Society ofAmerica (IDSA), clinical presentation criteria include dura-

tion of symptoms, typical clinical course, nasal dischargequality and additional symptoms.3Typical clinical courseof a viral infection includes symptoms of nasal discharge,congestion with cough, and often a sore throat.3The nasaldischarge is most often clear at first and becomes thickerand purulent after a few days. A distinguishing sign ofan uncomplicated viral URI is the return of the nasaldischarge to a clear watery consistency without the use ofantimicrobial therapy. Additional symptoms characteristicof a viral URI include headaches and myalgias. Patients

Jennifer Teeters, Michelle Boles, Julie Ethier,and Ambria Jenkins

are graduates of the PA program at Wake Forest School of Medicine,

Winston-Salem, North Carolina. L. Gail Curtisis an associate professor

and vice chair of the department of physician assistant studies at Wake

Forest School of Medicine. The authors have indicated no relationships

to disclose relating to the content of this article.

Roy A. Borchardt, PA-C, PhD,department editor.

DOI: 10.1097/01.JAA.0000431519.28443.5e

Copyright 2013 American Academy of Physician Assistants

Key points

Clinical diagnosis is the most commonly used and cost-

effective approach to distinguish between viral and

bacterial rhinosinusitis.

2012 guidelines from the IDSA provide current evidence-

based recommendations for treatment of rhinosinusitis.

Empiric antibiotic therapy should be reserved for patients

with symptoms of acute bacterial rhinosinusitis that have

persisted for more than 10 days or been severe for more

than 3 days.

The IDSA guidelines are based on data showing increased

resistance to previously accepted antimicrobial therapy

as well as an increase in the incidence of Haemophilus

influenzaeandMoraxella catarrhalis as causative

pathogens of acute bacterial rhinosinusitis.

ABSTRACT

New treatment guidelines for acute rhinosinusitis outlinewhen antibiotic therapy is appropriate, as well as describeevidence-based treatment to relieve symptoms, preventcomplications, and prevent chronic disease.

Keywords:acute rhinosinusitis, inflammation, IDSA, antibi-otics, bacterial

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58 www.JAAPA.com Volume 26 Number 7 July 2013

SPECIAL TOPICS IN OTOLARYNGOLOGY

treatment for acute bacterial rhinosinusitis includes anti-biotics to eradicate the infection, prevent complications,and prevent chronic disease.6

Nonpharmacologic therapyMost healthcare providerswill recommend nonpharmacologic treatments such asincreased fluid intake, rest, and good personal hygiene.

Water is the recommended fluid for avoiding dehydrationand keeping mucous membranes moist, with increasedintake requirements for illness. An adequate amount of restprovides time to fight off infection and is important for aprompt recovery. Proper hand washing techniques reducethe spread of virus and bacteria that cause rhinosinusitisand other illnesses.7

Ancillary therapyCommon ancillary therapies includesaline nasal spray, mucolytic agents, antipyretics/analge-sics, decongestants, and antihistamines, but not all arefavored by the IDSA guidelines. Saline spray can be usedto irrigate the nasal cavity to soften secretions and improvemucociliary clearance.8The IDSA guidelines recommend

the use of nasal saline spray as an adjunctive treatment forrhinosinusitis in adults with low to moderate symptoms.3The most common mucolytic agent is guaifenesin, which isused to thin mucus secretions and improve drainage.6Noclinical trials validate the use of guaifenesin, so the IDSAguidelines do not recommend it as adjunctive therapy foracute rhinosinusitis.3Analgesics are used to relieve pain, andhelp patients to rest. Acetaminophen or an NSAID may beused for mild to moderate pain.8Acetaminophen is also aneffective antipyretic. Oral or topical decongestants and/orantihistamines are not recommended as adjunctive treat-ment in patients with acute bacterial rhinosinusitis becauseof their adverse effects in adults and children.3 Topical

decongestants may induce inflammation and reboundcongestion.6Oral antihistamines may cause drowsinessand xerostomia.6The FDA recommends that these drugs,found in OTC products, not be given to children youngerthan 2 years because of their potentially serious adversereactions.3

Antibacterial therapyAccording to the IDSA guide-lines, antibacterial therapy should be initiated as soon asthe diagnosis of acute bacterial rhinosinusitis has beenestablished. The recommended first-line drug for bothchildren and adults is amoxicillin-clavulanate.3Acutebacterial rhinosinusitis caused by Haemophilus influen-zaeand Moraxella catarrhalishas increased in children;

and amoxicillin-clavulanate offers greater coverage ofampicillin-resistant strains of these bacteria. Doxycyclinemay be used as an alternative for empiric therapy forpatients who cannot tolerate amoxicillin-clavulanate. Inpatients with a penicillin allergy, the recommendationsinclude doxycycline or a respiratory fluoroquinolone suchas levofloxacin or moxifloxacin. Because of high rates ofresistance among Streptococcus pneumoniae, macrolides,trimethoprim-sulfamethoxazole, or third-generationcephalosporins are not recommended for empiric therapy.

may also develop fever early in the illness.3Respiratorysymptoms of an uncomplicated viral URI will usually lastbetween 5 and 10 days.3

One way to distinguish an uncomplicated viral upperrespiratory infection from acute bacterial rhinosinusitisis by noting the typical clinical pattern of acute bacterial

rhinosinusitis3:persistent symptoms lasting more than 10 days with noevidence of improvementonset with severe symptoms, including fever of 39C(102F) or higher or purulent nasal discharge at onseta double-sickening pattern, which includes new-onsetfever, headache or increase in rhinorrhea that worsen orreturn after a 5- to 6-day viral presentation which wasinitially improving.

The classic presentation of acute bacterial rhinosinusitisin adults is characterized by a triad of symptoms includ-ing headache, facial pain, and fever. The most commonlyreported symptoms include nasal congestion, purulent rhi-norrhea, and facial pain or pressure.5In children, the mostcommon symptoms include cough with nasal discharge,fever, and malodorous breath.3

The diagnosis of acute rhinosinusitis is primarily basedon clinical presentation. The conventional criteria for theclinical diagnosis of acute bacterial rhinosinusitis involvesthe presence of at least two major symptoms (such aspurulent discharge and facial pain) or one major and two

minor symptoms (such as headache and dental pain); fordetails, see the 2012 IDSA guidelines.3The most accuratediagnostic approach is acquiring a quality history of diseasepattern and progression and performing an appropriatephysical examination.3

TREATMENT FOR RHINOSINUSITIS

The clinical picture will dictate the course of treatment.The primary objectives for acute viral rhinosinusitis areto relieve symptoms of nasal obstruction and rhinorrhea;

Because of high rates

of resistance among

Streptococcus pneumoniae,

macrolides, trimethoprim-

sulfamethoxazole, or

third-generation cephalosporins

are not recommended for

empiric therapy.

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Acute rhinosinusitis: New guidelines for diagnosis and treatment

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Journal of the American Academy of Physician Assistants www.JAAPA.com 59

such as endoscopic evaluation of the sinuses with directsinus aspiration for culture.

Acute bacterial rhinosinusitis is a common complicationof acute viral rhinosinusitis, so differentiating betweenviral and bacterial causes is imperative to determiningproper management. The IDSAs minor and major clinical

symptoms serve as strong indicators to assist clinicians withdiagnosis. When the clinical picture suggests a bacterialcause, current evidence-based recommendations are for useof amoxicillin-clavulanate as first-line empiric treatment.Healthcare providers should familiarize themselves withthe 2012 IDSA guidelines and use appropriate prescribingcriteria to prevent antimicrobial resistance and furthercomplications.JAAPA

REFERENCES1. Schiller J, Lucas J, Ward B, Peregoy J. Summary health statistics

for U.S. adults: national health interview survey, 2010.NationalCenter for Health Statistics. Vital Health Stat. 2012;10(252).

2. Rosenfeld RM, Andes D, Neil B, et al. Clinical practice guide-line: Adult sinusitis. Otolaryngol Head Neck Surg. 2007;137(3suppl):S1-S31.

3. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practiceguideline for acute bacterial rhinosinusitis in children and adults.Clin Infect Dis. 2012;54(8):e72-e112.

4. Revai K, Dobbs LA, Nair S, et al. Incidence of acute otitis mediaand sinusitis complicating upper respiratory tract infection: theeffect of age. Pediatrics.2007;119(6):e1408-e1412.

5. Meltzer E, Hamilos D. Rhinosinusitis Diagnosis and manage-ment for the clinician: a synopsis of recent consensus guidelines.Mayo Clin Proc. 2011;86(5):427-443.

6. Masood A, Moumoulidis I, Panesar J. Acute rhinosinusitis inadults: an update on current management. Postgrad Med J.2007;83(980):402-408.

7. Fashner J, Ericson K, Werner S. Treatment of the common coldin children and adults. Am Fam Physician. 2012;86(2):153-159.

8. Aring A, Miriam C. Acute rhinosinusitis in adults. Am Fam

Physician. 2011;83(9):1057-1063.

The IDSA guidelines list potential causative agents foracute bacterial rhinosinusitis in Table 6; first-line andsecond-line antimicrobial therapies are listed in Table

10.3Treatment duration recommendations include 5 to7 days for adults and 10 to 14 days for children, basedon symptomatic improvement. Figure 1 in the IDSAguidelines is an algorithm for management.

CONCLUSION

Clinicians must treat acute bacterial rhinosinusitis withthe appropriate antimicrobial therapy and understandhow to manage patients who fail to respond to this ther-apy. Consider an alternate plan if the patients symptomsworsen after a 2- to 3-day trial of antibiotics or if thereis no response after 3 to 5 days. The antimicrobial agentneeds to be reevaluated and consideration must be given to

noninfectious causes. Further workup should be initiated,

Acute bacterial rhinosinusitis

is a common complication

of acute viral rhinosinusitis,so differentiating between

viral and bacterial causes is

imperative to determining

proper management.

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