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Acute Sinusitis

Risk Factors page ITC3-3

Diagnosis page ITC3-4

Treatment page ITC3-8

Practice Improvement page ITC3-13

CME Questions page ITC3-16

Section EditorsBarbara J. Turner MD, MSEDSankey Williams, MDDarren Taichman, MD, PhD

Science WriterJennifer F. Wilson

The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), includingPIER (Physicians’ Information and Education Resource) and MKSAP (MedicalKnowledge and Self-Assessment Program). Annals of Internal Medicineeditors develop In the Clinic from these primary sources in collaboration withthe ACP’s Medical Education and Publishing Division and with the assistance of science writers and physician writers. Editorial consultants fromPIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consulthttp://pier.acponline.org, http://www.acponline.org/products_services/mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.

CME Objective: To review current evidence for the risk factors, diagnosis, andtreatment of acute sinusitis.

The information contained herein should never be used as a substitute for clini-cal judgment.

© 2010 American College of Physicians

This article has been corrected. The specific correction appears on the last page of this document. For original version, click "Original Full Text (PDF)" in column 2 of the article at www.annals.org.

© 2010 American College of Physicians ITC3-2 In the Clinic Annals of Internal Medicine 7 September 2010

1. Anand VK. Epidemiol-ogy and economicimpact of rhinosinusi-tis. Ann Otol RhinolLaryngol Suppl.2004;193:3-5.[PMID: 15174752]

2. Ahovuo-Saloranta A,Borisenko OV, Kova-nen N, et al. Antibi-otics for acute maxil-lary sinusitis.Cochrane DatabaseSyst Rev.2008:CD000243.[PMID: 18425861]

3. Mahakit P, PumhirunP. A preliminary studyof nasal mucociliaryclearance in smokers,sinusitis and allergicrhinitis patients. AsianPac J Allergy Im-munol. 1995;13:119-21. [PMID: 8703239]

Acute sinusitis affects millions of persons in the United States everyyear and is among the most common reasons for physician visits,prompting over 3 million visits annually (1). The more accurate term

for this condition is acute rhinosinusitis, because symptoms involve both thenasal cavity and the sinuses. For simplicity, this review uses the term “sinusi-tis” for rhinosinusitis. There are 4 pairs of air-filled paranasal sinuses: thefrontal, maxillary, ethmoid, and sphenoid sinuses. Acute sinusitis typically oc-curs in the maxillary sinuses (Figure). Sinusitis is characterized as acute whenthe duration of symptoms is shorter than 4 weeks, subacute when the dura-tion is from 4 weeks to 12 weeks, and chronic when the duration is morethan 12 weeks. Sinusitis seems to be due to congestion and blockage of thenasal passages, usually in response to viral infection or allergic rhinitis but oc-casionally to other stimuli. The paranasal sinuses become inflamed, and mu-cus cannot drain properly, providing an environment where bacteria, or rarelyfungus, can thrive. Persons with chronic nasal congestion, and particularlythose with allergies and asthma, may be more prone to developing acute si-nusitis, but it can affect anyone. Suggestive symptoms include headache, con-gestion, facial pain, fatigue, and cough, all of which can be disruptive to usualactivities but are rarely severe.

The diagnosis is usually based on clinical signs and symptoms. Radiologictests are not recommended initially and, to make the diagnosis from culture,primary care physicians do not typically perform anterior rhinoscopy orantral puncture with aspiration. Evidence is lacking regarding optimum pre-vention and treatment. It is well known that physicians grossly overprescribeantibiotics for presumed acute bacterial sinusitis despite a high prevalence ofviral infection–causing symptoms. Moreover, 4 of 5 persons recover within 2weeks without treatment (2). Overprescription of antibiotics probably reflectsdifficulty in establishing the diagnosis of sinusitis and in distinguishing viralfrom bacterial acute sinusitis. The risk for bacterial sinusitis is low until thesymptoms persist for at least 7 to 10 days. A Cochrane review of 57 random-ized, controlled trials (RCTs) from 1950 to 2007 of antibiotics in the treat-ment of acute bacterial sinusitis reported that antibiotic treatment reducedthe risk for clinical failure at 7 to 15 days but was associated with significantside effects (2). When treatment is ineffective and sinusitis persists, or whensymptoms are severe, sinus puncture, imaging, and other diagnostic tests maybe helpful in guiding management. In these cases, evaluation by a specialistmay be warranted.

Figure. Diffuse pansinusitis with mucosal thickening and polyposis in the anterior sinuses.

© 2010 American College of PhysiciansITC3-3In the ClinicAnnals of Internal Medicine7 September 2010

What factors increase the risk foracute sinusitis?Most persons with acute sinusitishave had a recent upper respiratoryviral infection, but acute sinusitis canalso occur with allergies or exposureto local irritants. These last 2 causesare generally characterized by morerecurrent or chronic symptoms. Im-munocompromised persons are atincreased risk for fungal infection.

AgeOlder persons have more compro-mised immune systems and agreater prevalence of serious upperrespiratory tract infections, both ofwhich increase their risk for thecomplication of acute sinusitis.They also tend to have weakenedcartilage and dryness in the nasalpassages that can promote infec-tion. Because young children havemore colds and smaller nasal andsinus passages, they face an in-creased risk for sinusitis as well.

Smoke and other air pollutantsCigarette and cigar smoke and otherforms of air pollution, such as indus-trial chemicals, increase the risk forsinusitis. Air pollution can damagethe cilia responsible for moving mu-cus out of the sinuses (3).

Air travel and changes in atmosphericpressureAir travel as well as other situationsthat involve changes in atmosphericpressure, such as deep sea diving orclimbing to high altitude, increase therisk for sinus blockage and sinusitis.

SwimmingIn frequent swimmers, the chlorinein pools can irritate the lining ofthe nose and sinuses and can leadto sinusitis.

Asthma and allergiesAsthma and respiratory allergiesincrease sinus inflammation, whichcan increase the risk for infection.Allergic rhinitis may contribute to up to 30% of cases of acute

maxillary rhinosinusitis (4). How-ever, persons with asthma are moreprone to chronic sinusitis, as arepersons with a condition known asSamter Triad or the ASA Triad,which is characterized by asthma,nasal polyps, and aspirin intolerance.In addition, persons with a deviatednasal septum may also have an in-creased risk for both acute andchronic sinusitis.

Dental diseaseInfections from dental disease,such as dental abscesses and peri-odontal infection, or procedures,such as sinus perforations duringtooth extraction, can precipitatesinusitis. Patients with dental painmay indeed have sinusitis, espe-cially involving the upper teethand commonly the wisdom teeth.According to one review, odonto-genic sinusitis accounts for about10% to 12% of maxillary sinusitiscases (5). In such cases, the un-derlying dental condition may beasymptomatic or only mildlysymptomatic. Intervention isneeded to stop the disease pro-gression and to avoid excess an-tibiotic treatment.

Other medical conditionsMedical conditions that cause in-flammation in the airways or createpersistent thickened stagnant mucuscan increase the risk for recurrentacute or chronic sinusitis, such as di-abetes and other disorders of the im-mune system. AIDS and poorly con-trolled diabetes particularly increasethe risk for acute invasive fungal si-nusitis, which is called mucormyco-sis, zygomycosis, or fulminant inva-sive sinusitis (6). Pregnancy can alsocause temporary congestion andsymptoms of sinusitis.

An autoimmune disease, Wegenergranulomatosis, causes long-termswelling and tumor-like masses inair passages and predisposes toacute as well as chronic sinusitis.

4. Small CB, Bachert C,Lund VJ, et al. Judi-cious antibiotic useand intranasal corti-costeroids in acuterhinosinusitis. Am JMed. 2007;120:289-94. [PMID: 17398218]

5. Brook I. Sinusitis ofodontogenic origin.Otolaryngol HeadNeck Surg.2006;135:349-55.[PMID: 16949963]

6. Deshazo RD. Syn-dromes of invasivefungal sinusitis. MedMycol. 2009;47 Suppl1:S309-14.[PMID: 18654920]

Risk Factors


Persons with abnormalities in cil-iary function or mucous produc-tion, such as cystic fibrosis or theKartagener syndrome (triad ofbronchiectasis, sinusitis, and dex-trocardia), are also more likely tohave sinusitis. Structural abnormal-ities or facial injuries that impedemucus drainage from the sinuses,such as a deviated septum or nasalpolyps, increase the risk as well.

HospitalizationHospitalized patients face a higherrisk for sinusitis, particularly patientswith head injuries or conditions re-quiring insertion of tubes throughthe nose, antibiotics, or steroid treat-ment. Mechanical ventilators signif-icantly increase the risk for sinusitisin the maxillary sinuses.

How can patients decrease theirrisk for acute sinusitis?No method is scientifically provento prevent sinusitis, but variousmeasures may decrease this risk. Inparticular, patients should followfrequent hand-washing guidelinesand avoid persons with the com-mon cold or influenza. Nasal irriga-tion may help reduce congestion

and remove pathogens from the si-nuses (Box). Using saline irrigationand steam inhalation can help keepthe nose moist and the sinusesclear. A humidifier can moisten airin dry indoor environments.

Patients should avoid exposure to al-lergens. If exposure is unavoidable,then use nasal corticosteroids, whichare more effective than antihista-mines at preventing recurrent sinusi-tis in the allergic person. Im-munotherapy (or allergy shots) mayalso reduce sinusitis due to allergies.

Environmental irritants should alsobe avoided, especially tobaccosmoke, but also chemicals withstrong odors. Limit time swimmingin chlorine-treated pools and div-ing, which can force water into thesinuses from the nasal passages.

Air travel poses a problem for pa-tients with acute or chronic sinusi-tis. With air pressure changes in aplane, pressure can build up in thehead, blocking sinuses or the eu-stachian tubes in the ears. Usingdecongestant nose drops before aflight can help reduce this problem.

How to Perform Nasal IrrigationMake a salt-water solution by

combining 1/2 tsp ofnoniodinated salt and 1/2 tspbaking soda in an 8-ounce glassof warm water.

Place the solution in a neti pot,bulb syringe, or other appropriatedelivery device.

Lean over the sink with your headdown and chin up.

Pour or gently squeeze water intothe upper nostril. Water will drainout of other nostril.

Repeat on other side.

because it is painful, risks complica-tions, and requires expertise.

The history needs to focus on theduration of symptoms, because per-sons who have had less than 7 to10 days of symptoms are unlikelyto have a bacterial infection. Thehistory should also include ques-tions about allergic rhinitis, sys-temic diseases, trauma, airplanetravel, tobacco use, exposure to

What is the role of the medicalhistory and physical examinationin the diagnosis of acute sinusitis?In most cases, acute sinusitis is diag-nosed on the basis of the history andphysical examination, because thereis no accepted office-based test foracute bacterial sinusitis. The gold-standard test for the diagnosis ofacute bacterial sinusitis is culture ofthe aspirate from an antral puncture,but this should not be done routinely

Risk Factors... Because the most common cause of acute sinusitis is viral infec-tion, patients need to remember frequent hand washing and should avoid personswith the common cold or influenza. Smokers should be helped to quit. Personswith chronic allergic rhinitis many benefit from treatment to reduce congestion.

CLINICAL BOTTOM LINE

Diagnosis

7. Rosenfeld RM, AndesD, Bhattacharyya N,et al. Clinical practiceguideline: adult si-nusitis. OtolaryngolHead Neck Surg.2007;137:S1-31.[PMID: 17761281]

8. Williams JW Jr, SimelDL, Roberts L, et al.Clinical evaluation forsinusitis. Making thediagnosis by historyand physical exami-nation. Ann InternMed. 1992;117:705-10. [PMID: 1416571]

In most cases, acute

sinusitis is diagnosed

based on the history and

physical examination

9. Snow V, Mottur-PilsonC, Gonzales R; Ameri-can Academy of Fam-ily Physicians. Princi-ples of appropriateantibiotic use fortreatment of acutebronchitis in adults.Ann Intern Med.2001;134:518-20.[PMID: 11255531]

10. Blomgren K, AlhoOP, Ertama L, et al;Finnish Society ofOtorhinolaryngolo-gy committee. Acutesinusitis: Finnish clin-ical practice guide-lines. Scand J InfectDis. 2005;37:245-50.[PMID: 15871161]


environmental toxins, and anatomi-cal abnormalities.

According to a multidisciplinaryexpert panel, the diagnosis ofacute sinusitis should be based on2 primary symptoms: purulentrhinitis and facial pain (7). Sepa-rately, these symptoms and physi-cal findings for the diagnosis ofacute sinusitis only have fair per-formance characteristics, but thecombination is better in makingthe diagnosis. Purulent rhinorrheahas a sensitivity of 72% and aspecificity of 52%, facial pressureor pain has a sensitivity of 52%and a specificity of 48%, and nasalobstruction has a sensitivity of41% and a specificity of 80% (8).Other symptoms are commonlyfound (Box). Patients may also de-scribe worsening symptoms afterinitial improvement (9). Never-theless, the absence of these spe-cific symptoms does not excludethe disease (10). Patients shouldalso be asked about allergies andprevious episodes of similar symp-toms and seasonal patterns.

The physical examination shouldfocus on checking for swollenturbinates, purulent rhinorrhea,nasal polyps, and local sinus painwhen bending over. Pain inducedwith sinus percussion is a less re-liable finding than focal painwhen bending over. An oropha-ryngeal red streak also may alsobe useful for diagnosing acute sinusitis.

In a study of 60 patients at a Veterans Af-fairs urgent care center (54 men; meanage, 51 years) who had nasal symptomslasting 4 or more weeks, patients weregiven a structured history and physicalexamination and then sinus computedtomography (CT ). Sinusitis was diag-nosed in 27 patients. The presence oforopharyngeal red streak had a sensitivi-ty of 70% and a specificity of 67% (11).The generalizability of this finding is un-clear. The authors recommended includ-ing the sign in future studies of acute si-nusitis clinical diagnostic criteria.

Why is it important to distinguishacute sinusitis from chronicsinusitis?Establishing the duration of symp-toms is necessary to guide propertreatment and management. Theduration of symptoms is the maindistinguishing feature, with acute si-nusitis occurring from 1 week to lessthan 4 weeks after onset of symp-toms, whereas subacute or chronicsinusitis lasts longer. Acute sinusitisusually starts as a viral respiratoryinfection, but chronic sinusitis ismore often caused by inflammationand blockage due to allergies or aphysical obstruction, such as a devi-ated septum, nasal polyps, mal-formed bone or cartilage structures,tumors, or foreign objects. Thesymptoms of acute sinusitis are typi-cally more severe than those ofchronic sinusitis but, in the latterdisease, symptoms often last formany months or even years and areoften associated with a persistentcough and nasal congestion.

Chronic sinusitis responds poorly toconventional antibiotic therapy andtypically requires a longer durationof treatment. Surgery may be war-ranted for patients with anatomicobstruction whose sinusitis is refrac-tory to medical treatment. Predis-posing factors that may further hin-der cure include severe respiratoryallergies or structural changes causedby chronic sinusitis itself or by previ-ous surgery for symptoms. Acute ex-acerbations can frequently compli-cate chronic sinusitis.

What noninfectious conditionsshould clinicians consider whenevaluating a patient for acutesinusitis?A key distinguishing feature ofacute sinusitis is the duration ofsymptoms. Symptoms lasting morethan 12 weeks represent chronic si-nusitis, which has a different differ-ential than acute sinusitis. The Boxlists conditions that cliniciansshould consider among the differ-ential diagnoses for acute sinusitis.

Common Signs and SymptomsAssociated With AcuteRhinosinusitis• Rhinorrhea (frequently purulent,

occasionally blood tinged)• Facial pain• Nasal congestion or obstruction• Postnasal drainage• Hyposmia or anosmia• Ear pressure• Cough

Differential Diagnosis of AcuteRhinosinusitis• Allergic rhinitis• Drug-induced rhinitis (such as

decongestant abuse more than 5 days, cocaine)

• Recurrent viral upper respiratoryinfections

• Dental pain• Occupational rhinosinusitis (12)• Gastroesophageal reflux (13)• Migraine or tension headache (14)• Nasal polyps (obstruction)

The duration of symptoms

is the main distinguishing

feature, with acute sinusitis

occurring from 1 week to

less than 4 weeks after

onset of symptoms, where-

as subacute or chronic

sinusitis lasts longer

11. Thomas C, Aizin V.Brief report: a redstreak in the lateralrecess of theoropharynx predictsacute sinusitis. J GenIntern Med.2006;21:986-8.[PMID: 16918746]

12. Hellgren J. Occupa-tional rhinosinusitis.Curr Allergy AsthmaRep. 2008;8:234-9.[PMID: 18589842]

13. Saleh H. Rhinosinusi-tis, laryngopharyn-geal reflux andcough: an ENT view-point. Pulm Pharma-col Ther.2009;22:127-9.[PMID: 19480077]

14. Silberstein SD.Headaches due tonasal and paranasalsinus disease. NeurolClin. 2004;22:1-19, v.[PMID: 15062525]

15. Meltzer EO, HamilosDL, Hadley JA, et al;American Academyof Allergy, Asthmaand Immunology(AAAAI). Rhinosinusi-tis: establishing defi-nitions for clinical re-search and patientcare. J Allergy ClinImmunol.2004;114:155-212.[PMID: 15577865]

16. Evidence Report: Di-agnosis and Treat-ment of Acute Bac-terial Sinusitis.Boston: New Eng-land Medical Center,Evidence-basedPractice Center;1998.

17. Varonen H, MäkeläM, Savolainen S, etal. Comparison of ul-trasound, radiogra-phy, and clinical ex-amination in thediagnosis of acutemaxillary sinusitis: asystematic review. JClin Epidemiol.2000;53:940-8.[PMID: 11004420]

18. Engels EA, Terrin N,Barza M, et al. Meta-analysis of diagnos-tic tests for acute si-nusitis. J ClinEpidemiol.2000;53:852-62.[PMID: 10942869]


These conditions may produce sim-ilar signs and symptoms but requiredifferent treatment.

What is the role of imaging in thediagnosis of acute sinusitis?The history and physical examina-tion establishes the diagnosis formost patients (15). Radiologic evi-dence of “sinusitis” exists in 87% ofviral upper respiratory infections;however, less than 3% of these infec-tions progress to bacterial infection.Imaging should only be consideredfor persons with rhinosinusitis symp-toms lasting at least 7 to 10 dayswho have a history of recurrentsymptoms or nonresponse to multi-ple courses of antibiotics in the past.A lower threshold for imaging maybe used for patients at risk for seri-ous complications, such as immuno-compromised persons.

Sinus radiographyRegardless of the prevalence of bac-terial sinusitis in the patient popula-tion or the individual’s likelihood ofbacterial sinusitis, sinus radiographyis not typically required in the rou-tine management of uncomplicatedsinusitis (16). Plain sinus radiogra-phy has reasonable diagnostic per-formance, with a sensitivity of 87%and a specificity of 89%; ultrasono-graphy has poorer performance (10).However, neither test is cost-effective compared with sympto-matic treatment or the use of clinicalcriteria to guide antibiotic therapy.Acute viral sinusitis resembles acutebacterial sinusitis on radiographs.

When other conditions are beingseriously considered in the differen-tial of acute sinusitis, sinus radiogra-phy may be warranted. Radiologicstudies are also useful in patientswith predisposing factors for atypi-cal microbial causes, such asPseudomonas aeruginosa, or fungal in-fection in immunocompromised pa-tients or in those in whom empiricaltherapy has failed. The occipitomen-tal view (also known as the Watersview) is the standard radiographic

view for visualizing the paranasal si-nuses, especially the maxillary sinus-es. A series of 3 or 4 radiographs isoften ordered. A common criterionfor positive radiography is sinus flu-id or opacity. Some studies also con-sider mucous membrane thickeninggreater than 50%, which increasesthe sensitivity of radiography butdecreases its specificity.

A systematic review of methods for diagnos-ing acute maxillary sinusitis analyzed 11 eli-gible studies and determined that radiogra-phy was more accurate than sinus punctureand that ultrasonography was slightly lessaccurate than radiography (17). Only 2 stud-ies compared clinical examination and si-nus puncture, and both found that the clini-cal examination was unreliable, regardlessof clinician expertise. On the basis of thisweak evidence, the authors concluded thatusing radiography or ultrasonography im-proved diagnostic accuracy.

A meta-analysis of published studies com-paring diagnostic tests for acute sinusitis in-cluded 13 studies and found that radiogra-phy and clinical evaluation provided usefuldiagnostic information, whereas ultrasono-graphy performance varied substantially (18).

Role of CT and magnetic resonanceimagingEvidence to support the role of sinusCT and magnetic resonance imaging(MRI) in diagnosing acute bacterialsinusitis is limited. One study foundCT was more sensitive than x-raysfor showing radiographic changesconsistent with acute sinusitis (19).Use of new low-dose scanners re-duces radiation exposure comparedwith traditional CT. However, likeplain sinus film x-rays, CT and MRIscans also have high false-positiverates in acute sinusitis.

Several studies using CT or MRI have re-ported sinus mucosal abnormalities in upto 49% of apparently healthy persons withno symptoms of sinusitis (20, 21). The clini-cal importance of these chance findings isuncertain. Asymptomatic patients withabnormalities on imaging studies do notrequire treatment.

Given problematic current evidencesupporting the use of CT or MRI,

19. Burke TF, Guertler AT,Timmons JH. Com-parison of sinus x-rays with computedtomography scans inacute sinusitis. AcadEmerg Med.1994;1:235-9.[PMID: 7621202]

20. Havas TE, MotbeyJA, Gullane PJ. Preva-lence of incidentalabnormalities oncomputed tomo-graphic scans of theparanasal sinuses.Arch OtolaryngolHead Neck Surg.1988;114:856-9.[PMID: 3390327]

21. Patel K, Chavda SV,Violaris N, et al. Inci-dental paranasal si-nus inflammatorychanges in a Britishpopulation. J Laryn-gol Otol.1996;110:649-51.[PMID: 8759538]

22. Stewart MG, John-son RF. Chronic si-nusitis: symptomsversus CT scan find-ings. Curr Opin Oto-laryngol Head NeckSurg. 2004;12:27-9.[PMID: 14712116]

23. Benninger MS,Payne SC, FergusonBJ, et al. Endoscopi-cally directed middlemeatal cultures ver-sus maxillary sinustaps in acute bacter-ial maxillary rhinosi-nusitis: a meta-analysis. OtolaryngolHead Neck Surg.2006;134:3-9.[PMID: 16399172]

24. Gwaltney JM Jr.Acute community-acquired sinusitis.Clin Infect Dis.1996;23:1209-23;quiz 1224-5.[PMID: 8953061]

25. Brook I. Microbiolo-gy and antimicrobialmanagement of si-nusitis. J LaryngolOtol. 2005;119:251-8.[PMID: 15949076]

26. Taxy JB, El-Zayaty S,Langerman A. AcuteFungal Sinusitis Nat-ural History and theRole of Frozen Sec-tion. Am J ClinPathol. 2009;132:86-93. [PMID: 19864238]


they should be reserved for investi-gation of symptoms or signs of lo-cal spread or intracranial complica-tions (22). In addition, whensinusitis symptoms persist for morethan 3 weeks despite treatment, orare recurrent, CT may be useful forreassessing diagnosis and determin-ing the need for referral.

What is the role of laboratorytesting in the diagnosis of acutesinusitis?Usually, no laboratory tests areneeded to diagnose acute sinusitis.In cases that do not respond totreatment or that get worse, tissuecultures may help pinpoint the spe-cific cause. The sinus puncture isconsidered the gold standard fordiagnosing sinusitis, because it isthe most accurate way to identifythe organism responsible for sinusi-tis. In this test, an otolaryngologistadministers local anesthesia thenuses a large-bore needle to with-draw small amounts of fluid fromthe maxillary sinus to culture. Be-cause this test is invasive and car-ries the risk for complications, suchas increased pain, bleeding,swelling, and false passage, it isusually reserved for cases requiringmicrobial identification, such aswhen antibiotic therapy has failed.Transnasal endoscopic culture rep-resents a reasonable alternative toantral puncture. It is also per-formed in the otolaryngologist’s of-fice with the use of a topical anes-thetic but is less invasive. In ameta-analysis of studies of endo-scopic versus antral culture, the for-mer had a sensitivity of 80.9%,specificity of 90.5%, positive pre-dictive value of 82.6%, and negativepredictive value of 89.4%, (23). Onthe other hand, nasal culture speci-mens obtained from a direct swabthrough the nose do not correlatewell with sinus pathogens found ina sinus puncture, because of con-tamination of the swab with nor-mal nasal flora. Other laboratorytests depend on the clinical situa-tion, such as a complete blood

count test with differential, thyroidfunction tests for fatigue; and chlo-ride testing to rule out cystic fibro-sis. Consider referral to an allergistor immunologist for evaluation ofthe role of allergy or an immunedeficiency contributing to recurrentor persistent sinusitis.

What organisms can cause acutesinusitis?The predominant isolates fromacute bacterial sinusitis have longbeen Streptococcus pneumonia andHaemophilus influenzae. One earlystudy estimated that these organ-isms accounted for more than 50%of acute bacterial sinusitis (24).With recent pneumococcal vaccina-tion, there seems to be a relative in-crease in H. influenzae. Studies inmore recent years have also shownmore Moraxella catarrhalis, especiallyin children and young adults, andmore Streptococcus pyogenes.About one third of H. influenzae iso-lates and most isolates of M. ca-tarrhalis produce β-lactamases andare resistant to penicillin and amoxi-cillin. These organisms become re-sistant to penicillins either throughthe production of β-lactamase (H. influenzae, M. catarrhalis, Staphylo-coccus aureus, Fusobacterium spp., andPrevotella spp.) or through changesin the penicillin-binding protein(Streptococcus pneumoniae) (25). In pa-tients who harbor more resistantbacteria, antimicrobial therapy di-rected against all pathogens in mixedinfections is often required.

Less commonly, acute sinusitis iscaused by a fungal infection. Sinusfungal infections usually occur in im-munocompromised persons but havebeen known to occur in persons whoare immunocompetent. Acute fungalsinusitis is most commonly causedby either the Aspergillus or Mucorspecies (26). Fulminant invasive dis-ease has a high mortality if not treat-ed early and aggressively. Treatmentusually involves removal of the fun-gus via nasal surgery.

27. Kassel JC, King D,Spurling GK. Salinenasal irrigation foracute upper respira-tory tract infections.Cochrane DatabaseSyst Rev.2010;3:CD006821.[PMID: 20238351]

28. Anzai Y, Jarvik JG,Sullivan SD, et al. Thecost-effectiveness ofthe management ofacute sinusitis. Am JRhinol. 2007;21:444-51. [PMID: 17882914]

29. Arroll B, Kenealy T.Antibiotics for thecommon cold andacute purulent rhini-tis. Cochrane Data-base Syst Rev.2005:CD000247.[PMID: 16034850]

30. Williamson IG,Rumsby K, Benge S,et al. Antibiotics andtopical nasal steroidfor treatment ofacute maxillary si-nusitis: a random-ized controlled trial.JAMA.2007;298:2487-96.[PMID: 18056902]


pathogens. Furthermore, restricteduse of antibiotics avoids drug sideeffects, particularly gastrointestinaleffects. A Markov disease simula-tion model found that empiricalantibiotic treatment was cost-effec-tive from a societal perspective butthat drug resistance would eventu-ally lead to increased costs and re-duced efficacy (28).

A Cochrane review of 5 RCTscomparing antibiotics with placeboand 51 RCTs comparing antibioticsfrom different classes for the treat-ment of acute maxillary sinusitis inadults reported a statistically signif-icant difference in favor of antibi-otics compared with placebo(pooled relative risk [RR], 0.66[95% CI, 0.44 to 0.98]) (2). Thereview considered trials with clini-cally diagnosed acute sinusitis butdid not require confirmation by ra-diography or bacterial culture.Overall, the meta-analysis found a34% reduction (CI, 2% to 56%) inthe RR for resolution at 7 to 15days, but the authors deemed thisevidence as “equivocal” because80% of the control group hadsymptoms resolve versus 90% ofthe antibiotic treatment group. Theauthors concluded that antibioticshave a small beneficial effect in pa-tients with uncomplicated acute sinusitis.

What nondrug measures arehelpful in the treatment ofpatients with acute sinusitis?No well-designed, randomizedstudies have addressed the efficacyof nondrug therapies. Steam in-halation, hydration, and sinus irri-gation are often recommended.These measures can help thin mu-cus and aid sinus draining. Sinus ir-rigation, such as with a saline nasalirrigation or neti pot, can increasemucosal moisture and remove in-flammatory debris and bacteria.According to a Cochrane review,nasal saline irrigation abbreviatedsymptoms by a nonsignificant 0.3day (out of 8 days) in 1 study,whereas, in a second study, irriga-tion was associated with less timeoff work, but minor discomfort wasnot uncommon (27).

How should clinicians decidewhether to use antibiotics to treatacute sinusitis?Most cases of suspected sinusitiswill resolve without antibiotic ther-apy, so this treatment should be re-served for persons who have hadsymptoms for at least 7 to 10 daysand who have received conservativetreatment. Widespread prescribingof antibiotics has serious ramifica-tions, including increased costs ofcare and promotion of drug-resist-ant strains of common respiratory

Diagnosis... Most cases of acute sinusitis are diagnosed by history and physicalexamination. Key findings are purulent rhinitis and facial pain. Other symptomsthat may be indicative of acute sinusitis include unilateral facial pressure or pain,facial pressure that is worse when bending forward, general headache, olfactorydisturbance, fever, halitosis, maxillary toothache, cough, and the presence of anoropharyngeal red streak. Establishing the duration of symptoms is important be-cause, when the duration is less than 7 to 10 days, the condition is more likely tobe a viral infection, whereas bacterial infection generally only appears after atleast 1 week of symptoms. Chronic sinusitis (symptoms longer than 30 days),nasal polyps, upper respiratory infection, migraine, and dental abscess may pro-duce signs and symptoms similar to acute sinusitis. Imaging should be reservedfor cases that are resistant to treatment or when a complication or alternativeconditions is likely. Similarly, laboratory tests are usually unnecessary except fortreatment failure. Bacterial pathogens Streptococcus pneumoniae, H. influenzae,and M. catarrhalis account for most cases of acute bacterial sinusitis.


Treatment

31. Arroll B, Kenealy T.Are antibiotics effec-tive for acute puru-lent rhinitis? System-atic review andmeta-analysis ofplacebo controlledrandomised trials.BMJ. 2006;333:279.[PMID: 16861253]

32. Young J, De Sutter A,Merenstein D, et al.Antibiotics for adultswith clinically diag-nosed acute rhinosi-nusitis: a meta-analysis of individualpatient data. Lancet.2008;371:908-14.[PMID: 18342685]

33. Snow V, Mottur-Pil-son C, Hickner JM;American Academyof Family Physicians.Principles of appro-priate antibiotic usefor acute sinusitis inadults. Ann InternMed. 2001;134:495-7. [PMID: 11255527]


Another Cochrane review of 6RCTs comparing antibiotic therapyagainst placebo in persons with acuteupper respiratory tract infections andless than 7 days of symptoms or lessthan 10 days of acute purulent rhini-tis found that persons receiving an-tibiotics did no better than those re-ceiving placebo (29). The antibioticsdid not improve the cure rate or thepersistence of symptoms (in terms oflack of cure or symptom persistence,RR, 0.89, [CI, 0.77 to 1.04]).

Other recent studies and analyseshave reported similarly unclearfindings.

One RCT of 240 adults with acute nonrecur-rent sinusitis in the primary care settingfound that an antibiotic did not provide ef-fective treatment for acute sinusitis. Not onlydid 7 days of antibiotic amoxicillin (500 mg 3times daily) prove ineffective, but so did thisantibiotic combined with budesonide (200µg once daily in each nostril), or 10 days ofbudesonide alone (30).

One review of 7 studies concluded thatmost patients will get better without an-tibiotics, with the benefit of avoiding an-tibiotic-related adverse effects (31). The au-thors calculated that patients treated withantibiotics for 5 to 8 days for persistent pu-rulent rhinitis had a 1.18 pooled RR for ben-efit (CI, 1.05 to 1.33) but a 1.46 RR for ad-verse effects from antibiotics (CI, 1.10 to1.94) They concluded that antibiotics areprobably effective for acute purulent rhini-tis but supported a no antibiotic as firstline” strategy.

A meta-analysis of 9 randomized trials as-sessing whether common signs and symp-toms can be used to identify patients whobenefit from antibiotics determined that an-tibiotics would have to be given to 15 pa-tients with rhinosinusitis-like symptoms be-fore an additional patient was cured (95% CINNT[benefit] 7 to NNT[harm] 190) (32). Pa-tients with purulent discharge in the phar-ynx took longer to cure; 8 patients with pu-rulent discharge in the pharynx would needto be treated with antibiotics before 1 addi-tional patient was cured (95% CI NNT[bene-fit] 4 to NNT[harm] 47). Older patients orthose whose symptoms were more severe orlonger-lasting were no more likely than oth-er patients to benefit from antibiotics. Theauthors concluded that common clinical

signs and symptoms could not accuratelyidentify patients with rhinosinusitis, evenwhen a patient reported symptoms lastinglonger than 7 to 10 days.

Because the signs and symptoms ofacute bacterial sinusitis and of pro-longed viral upper respiratory tractinfections are similar, misclassifica-tion is common (33). The decisionto use antibiotic therapy should bebased on the probability of bacterialsinusitis (Box). Antibiotic therapyis appropriate for patients with ahigh likelihood of bacterial sinusi-tis, or if symptomatic therapy failsin low-probability cases. In patientswith less severe symptoms whohave had no improvement after 7to 10 days of symptomatic therapy,antibiotic therapy may be added.

Antibiotic therapyThe choice of antibiotics dependson circumstances (Table). An in-crease in bacterial resistance mayneed to be taken into account whenprescribing antibiotics, but evidenceis lacking for better clinical out-comes by selecting antibiotics thatmight have a lower probability ofresistance. Pneumococcal resistanceto macrolides and other agents hasincreased, and trimethoprim–sulfamethoxazole is not a recom-mended second-line agent in chil-dren although it continues to be anacceptable first-line agent in adults.

Newer broad-spectrum agents are,however, more costly than most olderagents, and substantial concern existsabout promoting the development ofwidespread resistance among bacteriain the community and in the host.Evidence indicates that these broad-spectrum agents are usually unneces-sary in first-line treatment.

A Cochrane review of antibiotic use for acutesinusitis identified 51 studies that compareddifferent classes of antibiotics and foundthat the efficacy of these regimens was simi-lar, with the exception of a significantly low-er risk for clinical failure at 7 to 15 days fol-low-up for amoxicillin–clavulanate than forcephalosporins, but this benefit disappearedwith longer follow-up. However, adverse

Probability of Bacterial SinusitisHigh probability (>50%) when at

least 2 of the following arepresent: upper respiratoryinfection >7 days, facial pain, andpurulent discharge (nasal,pharyngeal, or both).

Low probability (<25%) when only1 of the following are present:upper respiratory infection >7days, facial pain, or purulentdischarge.

34. Williams JW Jr,Aguilar C, Cornell J,et al. Antibiotics foracute maxillary si-nusitis. CochraneDatabase Syst Rev.2003:CD000243.[PMID: 12804392]

35. Guillemot D, CarbonC, Balkau B, et al.Low dosage andlong treatment du-ration of beta-lac-tam: risk factors forcarriage of penicillin-resistant Streptococ-cus pneumoniae.JAMA. 1998;279:365-70. [PMID: 9459469]


effects were greater for the amoxicillin–clavulanate group compared with themacrolide and cephalosporin groups (29).Therefore, little evidence supports using moreexpensive, broad-spectrum antibiotics foracute sinusitis.

A review of 49 studies determined that foracute maxillary sinusitis confirmed radi-ographically or by aspiration, the current lim-ited evidence supports the use of penicillin oramoxicillin for 7 to 14 days (34). The authorsnote, however, that the moderate benefits ofantibiotic treatment need to be weighedagainst the potential adverse effects.

AmoxicillinAmoxicillin is generally recommend-ed as a first-line agent. Traditionally,courses of 7 to 14 days have beenused in clinical practice and in mostrandomized trials. Data are limited

on the optimum duration of anti-biotic treatment for acute sinusitis,and it is unclear whether such longcourses are necessary. A recentCochrane review on the use of an-tibiotics for acute sinusitis found noappropriately designed studies to ad-dress the duration of therapy (2).Unfortunately, lengthy courses of an-tibiotic treatment increase the riskfor resistance (35, 36).

A patient who responds only par-tially to initial amoxicillin therapymay benefit from extending therapyby an additional 7 to 10 days, for atotal of 3 weeks (37). In cases of si-nusitis that do not improve after 3to 5 days of antibiotic treatment, analternative antibiotic may be con-sidered.

Table. Drug Treatment for Sinusitis, by Highest Level of Evidence*Agent Notes

Nasal steriods (e.g., fluticasone, 2 puffs Reduces mucosal inflammation. May cause local irritation.intranasally [200 µg] daily)

Oral corticosteroids For severe disease, reduces pain.Antibiotics Only prescribe after 5 days of symptoms and treat for at least 7 to 10 days. Or treat for 7

days after the resolution of symptoms.First-line: Amoxicillin, 1.5 to 3.5 g/d divided Potential adverse effects: rash, hypersensitivity reaction (rare), gastrointestinal symptoms.

2 or 3 times daily)Trimethoprim–sulfamethoxazole Consider in patients allergic to penicillin. Potential adverse effects: hematologic (rare),

(800/160 mg twice daily) rash, gastrointestinal symptoms, toxic epidermal necrolysis (rare). Pneumococcal resistance is high.

Second-line: Amoxicillin–clavulanate Same as first-line amoxicillin.(500/125 mg 3 times daily)

Second- or third-generation cephalosporins Caution in patients allergic to penicillin. Side effects include gastrointestinal upset, (e.g., cefuroxime, 250 or 500 mg twice daily, headache, rash, blood dyscrasias.or cefaclor, 250 or 500 mg 3 times daily)

Doxycycline (200 mg on first day then 100 mg Potential adverse effects: gastrointestinal upset, photosensitivity, neutropenia. twice daily for 2 to 10 days) Not recommended in children aged ≤8 y.

Macrolides (e.g., clarithromycin, 500 mg twice daily, Consider in patients allergic to both penicillin and trimethoprim–sulfamethoxazole. or azithromycin, 500 mg daily for 5 days) For 5 d of azithromycin, stop for 5 d, then may have to repeat. Potential adverse effects:

gastrointenstinal upset, allergic reactions (e.g., angioedema), liver dysfunction.Fluoroquinolones (e.g., ciprofloxacin, Side effects: gastrointestinal upset, diarrhea, headache, confusion. Concern about

500 twice a day, levofloxacin, 500 mg once daily) antibiotic resistance.†Oral antihistamines (e.g., loratadine, 10 mg daily) Inhibits inflammatory pathways, helpful especially with history of allergic rhinitis.Nasal decongestant (e.g., xylometazoline Reduces mucosal inflammation, improves ostial drainage by vasoconstriction.

intranasally, 2 to 3 sprays every 8 to 10 h) Avoid use for more than 3 to 5 days because of the risk for rebound congestion.Systemic decongestants (e.g., pseudoephedrine Use caution with underlying cardiovascular disease, poorly controlled hypertension,

short-acting, 60 mg every 4 to 6 h, or hyperthyroidism, or diabetes mellitus.long-acting, 120 mg every 12 h)

Mucolytic agents (e.g., guaifenesin, 1200 mg twice Reduces viscosity of nasal secretions. May cause gastrointestinal symptoms.daily, not to exceed 2400 mg per 24 h)

* Thomas M, Yawn BP, Price D, et al; European Position Paper on Rhinosinusitis and Nasal Polyps Group. EPOS Primary Care Guidelines: European PositionPaper on the Primary Care Diagnosis and Management of Rhinosinusitis and Nasal Polyps 2007 - a summary. Prim Care Respir J. 2008;17:79-89.[PMID: 18438594]

† Le Saux N. The treatment of acute bacterial sinusitis: no change is good medicine. CMAJ. 2008;178:865-6. [PMID: 18362382]

36. Hay AD, Thomas M,Montgomery A, etal. The relationshipbetween primarycare antibiotic pre-scribing and bacteri-al resistance inadults in the com-munity: a controlledobservational studyusing individual pa-tient data. J Antimi-crob Chemother.2005;56:146-53.[PMID: 15928011]

37. University of Michi-gan Health System.Acute rhinosinusitisin adults. Ann Arbor,MI: Univ MichiganHealth System; 2007

38. de Bock GH, DekkerFW, Stolk J, et al. An-timicrobial treat-ment in acute maxil-lary sinusitis: ameta-analysis. J ClinEpidemiol.1997;50:881-90.[PMID: 9291872]

39. Jenkins SG, BrownSD, Farrell DJ. Trendsin antibacterial re-sistance amongStreptococcus pneu-moniae isolated inthe USA: updatefrom PROTEKT USYears 1-4. Ann ClinMicrobiol Antimi-crob. 2008;7:1.[PMID: 18190701]

40. de Ferranti SD, Ioan-nidis JP, Lau J, et al.Are amoxycillin andfolate inhibitors aseffective as other an-tibiotics for acute si-nusitis? A meta-analysis. BMJ.1998;317:632-7.[PMID: 9727991]

41. Zalmanovici A,Yaphe J. Intranasalsteroids for acute si-nusitis. CochraneDatabase Syst Rev.2009:CD005149.[PMID: 19821340]

42. Braun JJ, Alabert JP,Michel FB, et al. Ad-junct effect of lorata-dine in the treat-ment of acutesinusitis in patientswith allergic rhinitis.Allergy. 1997;52:650-5. [PMID: 9226059]


DoxycyclineFor patients who are allergic topenicillin or who have persistentsymptoms, consider alternativeantibiotics, such as doxycycline or trimethoprim–sulfamethoxa-zole in adults and doxycycline in older children. Cure rates are similar for doxycycline andamoxicillin (38).

Doxycycline has a broader spec-trum than amoxicillin; it also coversβ-lactamase–producing strains ofH. influenzae and M. catarrhalis. Itsuse should satisfy concerns aboutantimicrobial resistance when pro-viding treatment for acute sinusitis.

Trimethoprim–sulfamethoxazoleTrimethoprim–sulfamethoxazoleis another good option for patients with penicillin allergiesor persistent symptoms. However,pneumococcal resistance rates to trimethoprim–sulfamethoxa-zole have increased to at least24% (39). For patients who arenot allergic to sulfamethoxazole,trimethoprim–sulfamethoxazoleis an effective drug for most patients, but because of resistanceconcerns, failure to respond after approximately 5 days should prompt reconsideration of therapy.

CephalosporinsFirst-generation cephalosporinshave minimal efficacy againstStreptococcus pneumoniae and H. influenzae. Second-generationcephalosporins, such as cefpo-doxime, are considered second-line agents for acute sinusitis.

Minor side effects, mostly gastro-intestinal, occurred in 10% to20% of patients in most reportsand as many as half in some tri-als. In most cases, side effects re-solved once antibiotic treatmentwas stopped. The withdrawal ratein randomized trials averaged between 4% and 6% with amoxi-cillin, folate inhibitors, or doxycycline (38, 40).

How should clinicians decidewhether to use other drugs totreat acute sinusitis?A range of nonantibiotic drugs arecommonly used to try to restore nor-mal sinus environment and function(Table). In patients with a low prob-ability of bacterial disease, these oth-er drugs may be used as initial thera-py. They can also relieve symptomsin patients who have been prescribedantibiotics. Efficacy seems to vary,and evidence is limited, but availableresearch indicates that these ancillarydrug therapies are generally benefi-cial, particularly for people with lesssevere symptoms. In particular, in-tranasal steroids have received somerecent attention.

In a Cochrane meta-analysis, 3 trials foundthat intranasal steroids for acute sinusitisincreased resolution or improvement ofsymptoms compared with control partici-pants (73% versus 66.4%; risk ratio, 1.11 [CI,1.04 to 1.18]). Mometasone furoate(MFNS), 400 µg versus 200 µg, was associ-ated with greater improvement (risk ratio,1.10 [CI, 1.02 to 1.18]) with no significantadverse events reported at either dose (41).

In a double-blind, placebo-controlled trialin 139 patients aged 15 to 65 years with al-lergies and acute rhinosinusitis confirmedby rhinoscopy and sinus radiograph, par-ticipants received antibiotics, steroids, andeither loratadine or placebo. The groupwith adjunctive loratadine had significant-ly greater improvement in sneezing (P =0.003) after 14 days, and in nasal obstruc-tion (P = 0.002) after 28 days comparedwith patients who received placebo (42).

Over-the-counter pain medicationsmay also be used to reduce sinusitis-related congestion and discomfort.

Evidence on the effect of herbalremedies is very limited. A reviewof RCTs testing the effect of anyherbal medicine as sole or adjunc-tive treatment for sinusitis foundlimited evidence that any are bene-ficial (43).

What are the complications ofacute sinusitis?Serious complications of acute bacterial sinusitis are rare when the

43. Guo R, Canter PH,Ernst E. Herbal medi-cines for the treat-ment of rhinosinusi-tis: a systematicreview. OtolaryngolHead Neck Surg.2006;135:496-506.[PMID: 17011407]

44. National AmbulatoryMedical Care Survey.National HospitalDischarge Survey.National Center forHealth Statistics. Se-ries 13. 1993-1995.

45. Cabrera CE, DeutschES, Eppes S, et al. In-creased incidence ofhead and neck ab-scesses in children.Otolaryngol HeadNeck Surg.2007;136:176-81.[PMID: 17275535]

46. Bayonne E, Kania R,Tran P, et al. Intracra-nial complications ofrhinosinusitis. A re-view, typical imag-ing data and algo-rithm ofmanagement. Rhi-nology. 2009;47:59-65. [PMID: 19382497]


infection is managed properly. An-tibiotic treatment can usually resolveeven severe episodes. However, clini-cians need to be aware of clinicalalerts signifying more serious infec-tion or complications (Box). Becauseof the proximity of the sinuses to thebrain, the infection can become lifethreatening if it spreads. Intracranialcomplications occur if the infectionpasses through the layer of bone sepa-rating the sinuses from the tissue andfluid that lines the brain. In severecases of this complication, infectionspreads to the brain and causes an ab-scess. Based on data from the early1990s, approximately 1000 cases ofbrain abscesses per year are sinusitis-related, translating to an attack rate of1 in 3000 in patients seen for acutesinusitis (44). A retrospective reviewof the incidence of head and neck ab-scesses in children admitted to a terti-ary care pediatric hospital during thefirst quarters of 2000 through 2003found increasing incidence of compli-cations of acute sinusitis (45).

In a French series of 25 cases of intracranialcomplications from sinusitis, most weremen aged 10 to 20 years who had no riskfactors. Frontal and sphenoid sinuses werethe most commonly involved. Diffuseheadache evolving to altered mental sta-tus was indicative of meningitis and brainabscess (46).

Infection can also spread from thesinuses to the orbit and can cause in-flammation of the eyelid, abscesses,and blindness. Orbital cellulitis is di-agnosed on the basis of orbitalswelling, redness of the conjunctiva,and limitation of extraocular move-ments. Periorbital and orbital celluli-tis are seen mainly in children.When sinusitis becomes chronic anderodes the bony areas around the si-nuses, it makes the infection moredifficult to treat and increases therisk for intracranial and intraorbitalcomplications. Other potential com-plications include an aneurysm orblood clot that can be triggered if the infection spreads from thesphenoid sinus cavity to the carotidartery or cavernous sinus. This

complication can also be fatal. Nervedamage from a sinus infection maycause permanent loss of sense ofsmell or taste. When either oph-thalmic or neurologic symptoms orsigns are present, the patient shouldbe referred for consultation by a spe-cialist. Appropriate diagnostic imag-ing, such as CT, may be required.

In addition to these serious but rarecomplications, sinusitis may exacer-bate asthma; therefore, treating thesinus condition will improve asthmasymptoms. Gastroesophageal refluxcan also exacerbate sinusitis when itis sufficiently severe to be associatedwith laryngopharyngeal reflux; pa-tients may respond to treatment withgastric acid suppression and otherbehavioral changes, such as avoidinglate or spicy meals (13).

When should clinicians considerconsultation from a specialist?In patients with uncomplicated si-nusitis, consultation increases thecosts of care without added diagnosticor clinical benefits. It should be re-served for complicated cases or forpatients whose symptoms are severeor do not respond to initial therapy.Otolaryngologists can provide spe-cialized care when patients with pre-sumed acute sinusitis do not respondto initial treatment or have recurrentor chronic sinus infections, or if ananatomical abnormality is suspected.An allergist should be consultedwhen underlying atopic disease ispresent, especially in persons with re-current episodes or persistent symp-toms. Patients with other underlyingdisease may require referral to otherspecialists.

Specialty referral is also advisedwhen serious complications, suchas periorbital cellulitis, venous si-nus thrombosis, an abscess ormeningeal spread of infection aresuspected. Consultation with anotolaryngologist, ophthalmolo-gist, neurosurgeon, infectious disease expert, or neurologist maybe appropriate, depending on

Clinical AlertsOrbital swelling, erythema of

conjunctiva, limited extraocularmovements

Focal neurologic signsAltered mental statusAbnormal culture on sinus punctureExacerbation of asthma

Serious complications of

acute bacterial sinusitis

are rare when the

infection is managed

properly.


symptoms. Patients should behospitalized if they have seriouscomplications of acute bacterialsinusitis, such as local extensionof the infection or orbital in-volvement, infection or thrombo-sis of the intracranial venous si-nuses, or metastatic spread to thecentral nervous system. Thesecomplications require a longcourse of parenteral antibioticsand close observation.

Do special considerations exist forclinical care of patients withrecurrent acute sinusitis?In patients with persistent symptoms, it can be difficult to determine whether the recurrencerepresents a relapse of previous in-fection or a de novo episode. Re-evaluation is warranted whensymptoms persist for several weeksor new or worsening symptoms develop, especially symptoms suggestive of serious complications.

Failure to improve may indicate antibiotic resistance, significant al-lergic inflammation, a fungal ratherthan bacterial infection, or thepresence of complications.

In cases where sinusitis persists orrecurs, a follow-up physical shouldinclude a check for persistent fever,sinus tenderness, purulent discharge,and changes in mental status or vi-sion. Clinicians should assess factorsthat could modify management, suchas allergic rhinitis, anatomic varia-tion, cystic fibrosis, ciliary dyskinesia,and immunocompromised state (7).

Imaging studies and bacterialcultures, such obtained fromnasal endoscopy, may help deter-mine the course of treatment andrule out complications. Patientswith recurrent episodes of acutesinusitis who have been evaluatedand found not to have anatomicanomalies may benefit from second-line antibiotic therapy.

Treatment... Steam inhalation, hydration, and sinus irrigation are frequently recom-mended nondrug measures for treating acute sinusitis. Nonantibiotic drugs, such asnasal steroids, antihistamines, and decongestants, can also help restore normal sinusenvironment and function. Expert opinions vary on the appropriate role of antibioticsin treating acute sinusitis. Many cases of suspected sinusitis will resolve without antibiotics. Antibiotic therapy is appropriate for patients with less severe symptomswith no improvement after 7 to 10 days, especially with adjunctive therapy. Anti-biotic therapy may be added in patients with a high likelihood of bacterial sinusitis.The choice of antibiotics depends on circumstances. Amoxicillin is generally recom-mended as a first-line agent for patients with no penicillin allergy. Serious complica-tions of acute bacterial sinusitis are rare when the infection is managed properly, butthere is potential for the infection to be life-threatening if it spreads. Specialty con-sultation or hospitalization may be needed for complicated cases or for patientswhose symptoms are severe or fail to respond to initial therapy.


Practice Improvementthat fungi are increasingly being rec-

ognized as a factor in chronic sinusi-tis, particularly in the southeast andsouthwest parts of the country.

In 2006, the American College ofChest Physicians (ACCP) ExpertPanel on the Diagnosis and Man-agement of Cough (URTI) recom-mended that, in patients with cough

Are there practice guidelinesrelevant to acute sinusitis?In 2005, the Joint Council of Allergy,Asthma, and Immunology updatedtheir 1998 guidelines on diagnosisand management of sinusitis (47).The guidelines incorporated newconcepts in diagnosis and manage-ment and new insights into patho-genesis. In particular, the authors note

47. Slavin RG, SpectorSL, Bernstein IL, et al;American Academyof Allergy, Asthmaand Immunology.The diagnosis andmanagement of si-nusitis: a practiceparameter update. JAllergy Clin Im-munol.2005;116:S13-47.[PMID: 16416688]

48. Pratter MR. Coughand the commoncold: ACCP evi-dence-based clinicalpractice guidelines.Chest. 2006;129:72S-74S.[PMID: 16428695]

49. Centre for ClinicalPractice. Respiratorytract infections—an-tibiotic prescribing.Prescribing of antibi-otics for self-limitingrespiratory tract in-fections in adultsand children in pri-mary care. London:National Institute forHealth and ClinicalExcellence; 2008.

50. Ip S, Fu L, Balk E, etal. Update on acutebacterial rhinosinusi-tis. Evid Rep TechnolAssess (Summ).2005;124:1-3.[PMID: 15989375]

inthe

c linicTool Kit

in the clinic

Acute Sinusitis

PIER Moduleshttp://pier.acponline.org/physicians/diseases/d096/d096.htmlAccess the PIER module on acute sinusitis from the American College of Physicians.PIER modules provide evidence-based, updated information on current diagnosis andtreatment in an electronic format designed for rapid access at the point of care.

Patient Informationhttp://pier.acponline.org/physicians/diseases/d096/d096-pi.htmlAccess the Patient Information material that appears on the following pages for dupli-cation and distribution to patients.www.aaaai.org/patients/publicedmat/tips/sinusitis.stmAccess a Tips to Remember: Sinusitis, a patient handout from the American Academy ofAllergy, Asthma & Immunology (AAAAI).www.nlm.nih.gov/medlineplus/sinusitis.htmlAccess MEDLINE Plus information about acute sinusitis for patients, including aninteractive tutorial available in both English and Spanish.

Clinical Guidelineswww.entnet.org/Practice/adultSinusitis.cfmClinical practice guidelines, released in 2007, from the American Academy of Oto-laryngology and Head and Neck Surgery Foundation on adult sinusitis.www.aaaai.org/professionals/resources/pdf/sinusitis2005.pdfPractice recommendations, issued in 2005, from the Joint Council of Allergy, Asthma,and Immunology on the diagnosis and management of sinusitis.http://chestjournal.chestpubs.org/content/129/1_suppl/1S.fullPractice recommendations, released in 2006, from the American College of ChestPhysicians (ACCP) Expert Panel on the diagnosis and management of cough (URTI).

Diagnostic Tests and Criteriawww.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=erta9&part=A13283Sensitivity and Specificity of a 4-Item Clinical Score for Diagnosing Acute BacterialSinusitis.

Quality of Care Guidelineswww.guideline.gov/content.aspx?id=12682&search=acute+sinusitisA 2007 update of an earlier guideline from the University of Michigan Health System

7 September 2010Annals of Internal MedicineIn the ClinicITC3-14© 2010 American College of Physicians

and acute upper respiratory tract in-fection, the diagnosis of bacterial si-nusitis should not be made duringthe first week of symptoms (48). Theauthors noted that the symptoms,signs, and sinus imaging abnormali-ties of an upper respiratory tract in-fection may be indistinguishablefrom acute bacterial sinusitis.

Guidelines released in 2007 fromthe American Academy of Oto-laryngology and Head and NeckSurgery Foundation recommendedthat clinicians should reevaluate thediagnosis and consider other causesof illness and possible complica-tions when symptoms worsen or donot improve by 7 days after diagno-sis and management (7). If the di-agnosis of acute bacterial sinusitis isconfirmed, the clinician should be-gin antibiotic therapy in patientsinitially managed with observationand should change the prescribedantibiotic in patients initially man-aged with an antibiotic.

Guidelines from the British NationalInstitute for Health and Clinical Ex-cellence recommend a “no antibioticor delayed antibiotic strategy” formost cases of sinusitis (49). Recom-mendations do, however, advise animmediate antibiotic prescription andfurther appropriate investigation andmanagement for patients who are sys-temically sick or who have symptomsand signs suggestive of serious illnessor complications; for patients whohave a preexisting comorbid condi-tion that increases risk for seriouscomplications; and for elderly patientswho have additional criteria that in-crease risk, such as diabetes or oralglucocorticoid use.

An evidence report sponsored by theAgency for Healthcare Research andQuality on the treatment of acutebacterial sinusitis noted that studiescomparing newer antibiotics witholder, less expensive ones like amoxi-cillin and trimethoprim–sulfamethox-azole are lacking (50).

In the ClinicAnnals of Internal Medicine

Pati

ent

Info

rmat

ion

THINGS YOU SHOULDKNOW ABOUT ACUTESINUSITIS

What is acute sinusitis?• Acute sinusitis, also known as a sinus infection or

rhinosinusitis, refers to inflammation and infectionin one or more of the paranasal sinuses.

• It often occurs after a cold, when mucus getstrapped in inflamed sinuses and does not drainproperly. This condition encourages bacterial growth,or rarely fungal growth, that can lead to infection.

• Sinusitis affects is one of the most common reasonspeople visit the doctor.

• It is acute when in the early stages, from 1 to 4 weeksafter symptoms start. Subacute or chronic sinusitis hassymptoms that last longer than 1 month.

Who gets it?• Anyone can get sinusitis, but it is more common in

very young people and elderly people.

• People with nasal allergies or asthma have anincreased risk for sinusitis.

• Smoking, swimming, air travel, and dental problemsare factors that increase risk for sinusitis.

What are the signs and symptoms?• Symptoms include a headache, congestion with pus

in the nose, facial pressure and pain, postnasal drip,cough, sore throat, and fatigue.

• A fever lasting more than 3 to 4 days is suggestiveof a bacterial infection.

What is the difference between a coldand acute sinusitis?• A cold is caused by a virus and usually lasts about 1

week. Persons with symptoms of acute sinusitis forless than 1 week are still usually only infected with avirus.

• Acute bacterial sinusitis generally occurs aftersymptoms have persisted for 7 to 10 days.

How do you know if you have acutesinusitis?• Your doctor will make the diagnosis based on your

symptoms and a physical examination.

• In complicated, severe, or persistent cases, x-rays orcomputed tomography may be needed. A sample ofsinus fluid may need to be obtained by a specialistto identify the exact strain of bacteria causing thesinusitis.

How is it treated?• Resting, drinking plenty of fluids, and using a saline

spray or neti pot can reduce symptoms.

• Decongestants, antihistamines, and other over-the-counter medications may also reduce symptoms.

• Antibiotics may be prescribed if your doctor believesyour symptoms and the duration of the diseasewarrant this treatment.

For More Informationhttps://aaaai.org/patients/topicofthemonth/1206/Sinusitis FAQs from the American Academy of Allergy, Asthma,

and Immunology.

www.entnet.org/HealthInformation/doIHaveSinusitis.cfmFact Sheet: Do I Have Sinusitis? From the American Academy of

Otolaryngology-Head and Neck Surgery.

http://www3.niaid.nih.gov/topics/sinusitis/Information on sinusitis from the National Institute of Allergy

and Infectious Disease.

5.

4.

3.

CME Questions

7 September 2010Annals of Internal MedicineIn the ClinicITC3-16© 2010 American College of Physicians

A 37-year-old woman is evaluated for a2-week history of sinus congestion. Sheinitially believed she had a cold and feltbetter after taking an over-the-countercombination of oral pseudoephedrine anddiphenhydramine; however, her symptomsreturned, and she began having low-gradefevers and increased nasal secretions. Shehas no drug allergies.

On physical examination, thetemperature is 37.4°C (99.4°F). There isright maxillary pressure when her head isdown, erythematous turbinates,yellowish-green nasal secretions and athickened postnasal drip and erythemaof the posterior pharynx.

Which is the most appropriatemanagement for this patient’s disorder?

A. Oral amoxicillinB. Oral nonsedating antihistamineC. Sinus radiographyD. Sinus computed tomography (CT)E. Oral amoxicillin–clavulanate

A 28-year-old man presents with 4 daysof upper respiratory congestion and sinuspain. The patient has had no significantmedical history. He notes that he mayhave initially had a mild fever but he hasnot been febrile in the past 48 hours. Hedescribes some yellowish nasaldischarge. On examination, he has fluidbehind his tympanic membranes andmoderate tenderness over his maxillarysinuses. He has taken acetaminophen forhis discomfort and an “herbal” drug forcolds.

What is the most appropriate initialmanagement?

A. Oral prednisone taperB. AmoxicillinC. Oral decongestantsD. Trimethoprim–sulfamethoxazoleE. Azithromycin

A 32-year-old man has a 5-day historyof persistent nasal congestion and painin the right forehead area associatedwith a clear nasal discharge and mildcough. The patient reports that he hashad similar episodes in the past thatwere helped by antibiotics. Medicalhistory is otherwise unremarkable, andhe currently takes no medications.

On physical examination, vital signs,including temperature, are normal. Mildright suborbital ridge tenderness ispresent. The nares are patent with aclear mucoid discharge. There is nopharyngeal erythema or exudate. Thelungs are clear to auscultation.

Which is the best initial management?

A. AmoxicillinB. CT of the sinusesC. Plain films of sinusesD. Symptomatic treatmentE. Trimethoprim–sulfamethoxazole

A 24-year-old man requests antibioticsduring an evaluation for symptoms hehas attributed to a sinus infection. Hereports sinus congestion and clear nasaldrainage that has persisted for 1 monthafter he developed a cold; he has nofever, sinus pain, purulent nasal drainage,sneezing, or nasal itching. Since theonset of his symptoms, he has beenusing a nasal decongestant spray withonly short-term symptomatic relief, buthe states that antibiotics have beeneffective in the past for treating hissinus infections. His history includesallergic rhinitis, but his primary allergensare not in season.

Nasal examination shows congestednasal mucosa with a profuse waterydischarge. The nasal septum seemsnormal, the turbinates are pale, andthere are no polyps. The remainder of thephysical examination is normal.

Which is the most likely reason for thispatient’s symptoms?

A. Allergic rhinitisB. Bacterial sinusitisC. Nonallergic rhinitisD. Rhinitis medicamentosaE. Viral upper respiratory infection

A 37-year-old man is evaluated forfrontal headaches, nasal congestion, andmucopurulent nasal drainage that havepersisted intermittently for several years.He also has fatigue, a nighttime cough,and decreased sense of smell. Over thepast 4 months, he has received 3successive courses of antibiotics forworsening symptoms—initially withweek-long courses of trimethoprim–sulfamethoxazole and doxycycline. Mostrecently, he completed a 3-week course ofamoxicillin–clavulanate in combinationwith a nasal steroid inhaler, nasal salineirrigation, and an oral decongestant. Thistreatment regimen provided only partialrelief. He has no history of allergic rhinitis,eczema, or drug allergy.

On physical examination, he is afebrile.The turbinates are edematous, withyellowish mucus between the rightmiddle turbinate and lateral nasal wall.The septum is deviated to the right butwith no nasal polyps. Percussion of hisright maxillary sinus elicits mildtenderness.

Which is the most appropriatemanagement for this patient’s condition?

A. Allergy testingB. Nasal swab culturesC. Sinus MRI D. Sinus CT E. Sinus radiography

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2.

Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP, accessed athttp://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/

to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.

Correction: Acute SinusitisIn the recent In the Clinic on acutesinusitis (1), the figure title on pageITC3-2 was incorrect. The correcttitle is: “Diffuse pansinusitis withmucosal thickening and polyposisin the anterior sinuses.”

Also, the sidebar “How to PerformNasal Irrigation” on page IT3-4

contained an error. The last lineshould be: “Repeat on the other side.”

These errors been corrected in theonline version.

Reference1. Wilson JF. In the clinic. Acute si-nusitis. Ann Intern Med. 2010;153:ITC3-1-15. [PMID: 20820036]

in the clinic acute sinusitis - american college of … the clinic in the clinic acute sinusitis...

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