Practice Guidelines

Guidelines for the Diagnosis and Management of Rhinosinusitis in Adults



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Am Fam Physician. 2007 Dec 1;76(11):1718-1724.

  Related Editorial

Guideline source: American Academy of Otolaryngology—Head and Neck Surgery

Literature search described? Yes

Evidence rating system used? Yes

Published source: Otolaryngology—Head and Neck Surgery, September 2007 (supplement)

Available at: http://journals.elsevierhealth.com/periodicals/ymhn/issues/contents (subscription required)

Each year in the United States, 31 million persons are diagnosed with sinusitis, the fifth most common condition for which antibiotics are prescribed in the United States. Despite the condition's prevalence, the diagnosis and management of rhinosinusitis is highly variable. New guidelines from the American Academy of Otolaryngology—Head and Neck Surgery are aimed at assisting physicians in diagnosing and treating patients 18 years and older with uncomplicated rhinosinusitis (the term rhinosinusitis is preferred because sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa). Uncomplicated rhinosinusitis is illness without clinically evident inflammation outside the paranasal sinuses and nasal cavity at the time of diagnosis (e.g., no neurologic, ophthalmologic, or soft tissue involvement). Table 1 summarizes the recommendations.

Table 1

Summary of Recommendations for Rhinosinusitis

Acute viral rhinosinusitis

Acute viral rhinosinusitis should be diagnosed in patients with typical symptoms of rhinosinusitis for less than 10 days and in whom symptoms are not worsening (Strong recommendation)

Do not obtain radiographic imaging for acute rhinosinusitis unless a complication or alternative diagnosis is suspected (Recommendation)

Symptomatic relief may be prescribed (Option)

Acute bacterial rhinosinusitis

Management should include pain assessment (Strong recommendation)

Symptomatic relief may be prescribed (Option)

Observation without antibiotic treatment is an option for some patients with mild, uncomplicated illness (Option)

If antibiotic treatment is initiated, amoxicillin should be the first-line therapy (Recommendation)

If the patient does not improve with initial management within seven days of diagnosis, reassess the diagnosis and management options; initiate or change antibiotic therapy (Recommendation)

Chronic and recurrent acute rhinosinusitis

Chronic and recurrent acute rhinosinusitis should be distinguished from other illnesses (Recommendation)

Patients should be assessed for factors that modify management such as allergic rhinitis, cystic fibrosis, immunocompromised state, ciliary dyskinesia, anatomic variations (Recommendation)

Diagnosis should be corroborated and/or underlying causes should be identified (Recommendation)

Nasal endoscopy may be performed during evaluation or diagnosis (Option)

Computed tomography of the paranasal sinuses should be performed during evaluation or diagnosis (Recommendation)

Allergy or immune testing may be performed during evaluation (Option)

Patients should be educated about preventive measures (Recommendation)


note: Strong recommendation = physicians should follow the recommendation unless a clear and compelling rationale for an alternative approach is present; Recommendation = physicians should generally follow the recommendation but should remain alert to new information and sensitive to patient preferences; Option = physicians should be flexible in their decision making about appropriate practices, although they may set bounds on alternatives; patient preferences should have a substantial influence.

Information from Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137(3 suppl):S6.

Table 1   Summary of Recommendations for Rhinosinusitis

View Table

Table 1

Summary of Recommendations for Rhinosinusitis

Acute viral rhinosinusitis

Acute viral rhinosinusitis should be diagnosed in patients with typical symptoms of rhinosinusitis for less than 10 days and in whom symptoms are not worsening (Strong recommendation)

Do not obtain radiographic imaging for acute rhinosinusitis unless a complication or alternative diagnosis is suspected (Recommendation)

Symptomatic relief may be prescribed (Option)

Acute bacterial rhinosinusitis

Management should include pain assessment (Strong recommendation)

Symptomatic relief may be prescribed (Option)

Observation without antibiotic treatment is an option for some patients with mild, uncomplicated illness (Option)

If antibiotic treatment is initiated, amoxicillin should be the first-line therapy (Recommendation)

If the patient does not improve with initial management within seven days of diagnosis, reassess the diagnosis and management options; initiate or change antibiotic therapy (Recommendation)

Chronic and recurrent acute rhinosinusitis

Chronic and recurrent acute rhinosinusitis should be distinguished from other illnesses (Recommendation)

Patients should be assessed for factors that modify management such as allergic rhinitis, cystic fibrosis, immunocompromised state, ciliary dyskinesia, anatomic variations (Recommendation)

Diagnosis should be corroborated and/or underlying causes should be identified (Recommendation)

Nasal endoscopy may be performed during evaluation or diagnosis (Option)

Computed tomography of the paranasal sinuses should be performed during evaluation or diagnosis (Recommendation)

Allergy or immune testing may be performed during evaluation (Option)

Patients should be educated about preventive measures (Recommendation)


note: Strong recommendation = physicians should follow the recommendation unless a clear and compelling rationale for an alternative approach is present; Recommendation = physicians should generally follow the recommendation but should remain alert to new information and sensitive to patient preferences; Option = physicians should be flexible in their decision making about appropriate practices, although they may set bounds on alternatives; patient preferences should have a substantial influence.

Information from Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137(3 suppl):S6.

Diagnosis

Rhinosinusitis is classified as acute (bacterial or viral), chronic, or recurrent acute. Table 2 presents definitions of the different types of rhinosinusitis.

Table 2

Definitions of Rhinosinusitis Types

Type Definition

Acute rhinosinusitis

Up to four weeks of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction; facial pain, pressure, or fullness; or both

Purulent nasal discharge is cloudy or colored (opposed to clear secretions that typically accompany viral upper respiratory infection) and may be reported by the patient or seen during physical examination

Nasal obstruction may be reported by the patient as nasal obstruction, congestion, blockage, or stuffiness, or it may be diagnosed on physical examination

Facial pain, pressure, or fullness may involve the anterior face or periorbital region or may manifest with localized or diffuse headache

Viral rhinosinusitis

Acute rhinosinusitis that is presumed to be caused by viral infection; physicians should diagnose viral rhinosinusitis when symptoms or signs of acute rhinosinusitis are present for less than 10 days and symptoms are not worsening

Acute bacterial rhinosinusitis

Acute rhinosinusitis that is presumed to be caused by bacterial infection; physicians should diagnose acute bacterial rhinosinusitis when:

Symptoms or signs of acute rhinosinusitis are present 10 days or more after onset of upper respiratory symptoms

or

Symptoms or signs of acute rhinosinusitis worsen within 10 days of initial improvement (i.e., double worsening)

Chronic rhinosinusitis

Two or more of the following signs and symptoms lasting 12 weeks or more:

Mucopurulent drainage (anterior, posterior, or both)

Nasal obstruction (congestion)

Facial pain, pressure, or fullness

Decreased sense of smell

and

Inflammation documented by one or more of the following findings:

Purulent mucus or edema in the middle meatus or ethmoid region

Polyps in the nasal cavity or middle meatus

Radiographic imaging shows inflammation of the paranasal sinuses

Recurrent acute rhinosinusitis

Four or more episodes per year of acute bacterial rhinosinusitis without signs or symptoms of rhinosinusitis between episodes

Each episode should meet the diagnostic criteria for acute bacterial rhinosinusitis


Adapted with permission from Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137(3 suppl):S7, S18.

Table 2   Definitions of Rhinosinusitis Types

View Table

Table 2

Definitions of Rhinosinusitis Types

Type Definition

Acute rhinosinusitis

Up to four weeks of purulent nasal drainage (anterior, posterior, or both) accompanied by nasal obstruction; facial pain, pressure, or fullness; or both

Purulent nasal discharge is cloudy or colored (opposed to clear secretions that typically accompany viral upper respiratory infection) and may be reported by the patient or seen during physical examination

Nasal obstruction may be reported by the patient as nasal obstruction, congestion, blockage, or stuffiness, or it may be diagnosed on physical examination

Facial pain, pressure, or fullness may involve the anterior face or periorbital region or may manifest with localized or diffuse headache

Viral rhinosinusitis

Acute rhinosinusitis that is presumed to be caused by viral infection; physicians should diagnose viral rhinosinusitis when symptoms or signs of acute rhinosinusitis are present for less than 10 days and symptoms are not worsening

Acute bacterial rhinosinusitis

Acute rhinosinusitis that is presumed to be caused by bacterial infection; physicians should diagnose acute bacterial rhinosinusitis when:

Symptoms or signs of acute rhinosinusitis are present 10 days or more after onset of upper respiratory symptoms

or

Symptoms or signs of acute rhinosinusitis worsen within 10 days of initial improvement (i.e., double worsening)

Chronic rhinosinusitis

Two or more of the following signs and symptoms lasting 12 weeks or more:

Mucopurulent drainage (anterior, posterior, or both)

Nasal obstruction (congestion)

Facial pain, pressure, or fullness

Decreased sense of smell

and

Inflammation documented by one or more of the following findings:

Purulent mucus or edema in the middle meatus or ethmoid region

Polyps in the nasal cavity or middle meatus

Radiographic imaging shows inflammation of the paranasal sinuses

Recurrent acute rhinosinusitis

Four or more episodes per year of acute bacterial rhinosinusitis without signs or symptoms of rhinosinusitis between episodes

Each episode should meet the diagnostic criteria for acute bacterial rhinosinusitis


Adapted with permission from Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137(3 suppl):S7, S18.

Acute rhinosinusitis is defined as up to four weeks of purulent nasal drainage plus nasal obstruction; facial pain, pressure, or fullness; or both. Radiographic imaging is not needed in patients who meet these diagnostic criteria, unless there is a complication (e.g., orbital, intracranial, or soft tissue involvement); certain comorbidities; or a suspected alternative diagnosis. After the diagnosis is made, physicians should further distinguish between a bacterial or viral cause, based on illness pattern and duration. A viral cause should be assumed unless patients have been symptomatic for 10 days or more or symptoms have worsened after initial improvement.

Chronic rhinosinusitis usually includes the presence of two or more signs or symptoms lasting more than 12 weeks, with or without acute exacerbations. However, the diagnosis requires that documented inflammation accompany the persistent symptoms. Recurrent acute rhinosinusitis, which is a distinct form of rhinosinusitis, is four or more episodes of acute bacterial rhinosinusitis per year.

Chronic and recurrent rhinosinusitis should be differentiated from other causes of illness. Nasal endoscopy and allergy and immunologic testing may be performed, and computed tomography of the paranasal sinuses should be performed when evaluating patients with chronic or recurrent rhinosinusitis.

Treatment

VIRAL RHINOSINUSITIS

Antibiotics are not recommended to treat viral rhinosinusitis because they are ineffective against viral illness and do not directly relieve symptoms. However, physicians may treat symptoms (e.g., prescribing analgesics for pain and antipyretics for fever). Topical or systemic decongestants may provide further relief, although their effects are limited to the nasal cavity. Topical decongestants are more effective than oral decongestants, but physicians usually stop therapy after three days because of the risk of rebound nasal congestion after discontinuation of therapy.

Systemic steroids have not been shown to be effective in patients with viral rhinosinusitis, and weak evidence supports the use of topical nasal steroids. Although antihistamines have been used, no studies have evaluated their effect on viral rhinosinusitis.

ACUTE BACTERIAL RHINOSINUSITIS

Management of acute bacterial rhinosinusitis focuses on pain assessment and may include therapy for pain relief, patient observation, or antibiotic therapy. If the patient fails to improve within seven days of diagnosis, or if symptoms worsen, antibiotic therapy should be initiated or changed.

Pain Relief. An important goal in treating patients with acute bacterial rhinosinusitis is pain relief, and an ongoing assessment of patient discomfort is essential. Severity can be assessed using a pain scale or simple visual analog scale, or by asking the patient to rate the discomfort as mild, moderate, or severe. Acetaminophen or nonsteroidal anti-inflammatory drugs, with or without opioids, are usually effective for mild or moderate discomfort. Oral administration is preferred because of cost and convenience.

Adjunctive treatments such as alpha-adrenergic decongestants, corticosteroids, saline irrigation, and mucolytics may be considered for symptomatic relief in patients with acute bacterial rhinosinusitis. Although the U.S. Food and Drug Administration has not approved these therapies for acute rhinosinusitis and few studies support their use, physicians may decide to use them based on the individual patient.

Patient Observation. Some randomized controlled trials have shown a high rate of improvement in patients taking placebo; and moderate, incremental benefits in patients taking antibiotics. Therefore, patient observation without antibiotics for up to seven days after diagnosis of acute bacterial rhinosinusitis is an option for patients with uncomplicated, mild illness (i.e., mild pain and a temperature of less than 101°F [38.3°C]); follow-up should be assured. Management is limited to symptom relief during observation. Although illness severity is the main consideration when deciding on observation, other factors include patient preference, age, general health, cardiopulmonary status, and comorbidities.

Antibiotic Therapy. If antibiotic treatment is initiated, amoxicillin should be the first-line therapy because of its safety, effectiveness, low cost, and narrow microbiologic spectrum. Folate inhibitors (e.g., trimethoprim/sulfamethoxazole [Bactrim/Septra]) and macrolide antibiotics are alternatives for patients who are allergic to penicillin.

Antibiotic use within the preceding four to six weeks increases the risk that an antibiotic-resistant bacterium is present. In this case, a different antibiotic, such as a fluoroquinolone or high-dose amoxicillin/clavulanate (Augmentin; 4 g/250 mg per day), should be used. Having a child in the household who attends day care increases the risk of penicillin-resistant Streptococcus pneumoniae infection, for which amoxicillin is an option.

Evidence does not show that longer courses of therapy are more effective than shorter courses. However, adherence rates are generally higher with once-daily dosing and a short duration of therapy.

CHRONIC OR RECURRENT ACUTE RHINOSINUSITIS

Although patients with chronic rhinosinusitis or recurrent acute rhinosinusitis cannot prevent disease onset, certain practices can reduce the risk of developing initial rhinosinusitis. These practices include good hygiene, such as hand washing, and abstinence from smoking. Secondary prevention, such as saline nasal irrigation and treatment of underlying conditions, can minimize symptoms and exacerbations. It is important for physicians to counsel patients about these measures to control chronic or recurrent acute rhinosinusitis.


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