Clinical Evidence Handbook

A Publication of BMJ Publishing Group

Sinusitis (Acute)



FREE PREVIEW Log in or buy this issue to read the full article. AAFP members and paid subscribers get free access to all articles. Subscribe now.


FREE PREVIEW Subscribe or buy this issue. AAFP members and paid subscribers get free access to all articles.

Am Fam Physician. 2009 Feb 15;79(4):320-321.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See CME Quiz on page 267.

Acute sinusitis is defined pathologically as transient inflammation of the mucosal lining of the paranasal sinuses that lasts less than four weeks.

  • Clinically, it is characterized by nasal congestion; rhinorrhea; facial pain; hyposmia; sneezing; and, if more severe, additional malaise and fever.

  • Acute sinusitis affects 1 to 5 percent of the adult population in Europe each year.

In clinically, radiologically, or bacteriologically diagnosed acute sinusitis, corticosteroids (intranasal spray) may reduce symptoms compared with placebo.

In clinically diagnosed acute sinusitis, there is currently little evidence from randomized controlled trials (RCTs) to support the use of amoxicillin, co-amoxiclav (amoxicillin/clavulanate), or doxycycline over placebo in terms of clinical cure rate.

  • We found no RCTs on the effects of cephalosporins or macrolides compared with placebo in clinically diagnosed acute sinusitis.

In persons with acute sinusitis that has been radiologically or bacteriologically confirmed as caused by a bacterial infection, antibiotics seem to be effective.

  • Amoxicillin and co-amoxiclav improve early clinical cure rates, but are associated with adverse gastrointestinal effects.

  • Cephalosporins and macrolides also seem to be as effective as amoxicillin, and have fewer adverse effects.

  • We found insufficient evidence to judge the effectiveness of doxycycline.

  • Long-term antibiotic regimens (six- to 10-day courses) do not seem more effective than short-term treatments (three- to five-day courses), but they seem to produce more adverse effects.

  • We found insufficient evidence to draw a conclusion about which is the most effective dosage regimen for antibiotics.

  • Caution: Since the last update of this review, the acute sinusitis indication for telithromycin has been withdrawn by the U.S. Food and Drug Administration because the risks/benefits ratio is no longer favorable (February 12, 2007).

We found no studies examining the effectiveness of antihistamines, decongestants, steam inhalation, or saline nasal washes for sinusitis diagnosed clinically, radiologically, or bacteriologically.

Clinical Questions

What are the effects of treatments in persons with clinically diagnosed acute sinusitis?

Likely to be beneficial

Corticosteroids (intranasal)

Unknown effectiveness

Antihistamines

Decongestants*

Saline nasal washes

Steam inhalation

Unlikely to be beneficial

Antibiotics†

What are the effects of treatments in persons with radiologically or bacteriologically confirmed acute sinusitis?

Likely to be beneficial

Cephalosporins or macrolides (fewer adverse effects than amoxicillin or co-amoxiclav)

Corticosteroids (intranasal)

Trade-off between benefits and harms

Amoxicillin or co-amoxiclav (more adverse effects than cephalosporins or macrolides)

Unknown effectiveness

Antihistamines

Decongestants*

Different dosages of antibiotics†

Doxycycline

Long-course antibiotic† regimens (no more effective than short-course regimens, and more adverse effects)

Saline nasal washes

Steam inhalation


*— Xylometazoline, phenylephrine, pseudoephedrine.

†— Amoxicillin, co-amoxiclav, doxycycline, cephalosporins, macrolides.

Clinical Questions

View Table

Clinical Questions

What are the effects of treatments in persons with clinically diagnosed acute sinusitis?

Likely to be beneficial

Corticosteroids (intranasal)

Unknown effectiveness

Antihistamines

Decongestants*

Saline nasal washes

Steam inhalation

Unlikely to be beneficial

Antibiotics†

What are the effects of treatments in persons with radiologically or bacteriologically confirmed acute sinusitis?

Likely to be beneficial

Cephalosporins or macrolides (fewer adverse effects than amoxicillin or co-amoxiclav)

Corticosteroids (intranasal)

Trade-off between benefits and harms

Amoxicillin or co-amoxiclav (more adverse effects than cephalosporins or macrolides)

Unknown effectiveness

Antihistamines

Decongestants*

Different dosages of antibiotics†

Doxycycline

Long-course antibiotic† regimens (no more effective than short-course regimens, and more adverse effects)

Saline nasal washes

Steam inhalation


*— Xylometazoline, phenylephrine, pseudoephedrine.

†— Amoxicillin, co-amoxiclav, doxycycline, cephalosporins, macrolides.

Definition

Acute sinusitis is defined pathologically as transient inflammation of the mucosal lining of the paranasal sinuses lasting less than four weeks. Clinically, it is characterized by nasal congestion; rhinorrhea; facial pain; hyposmia; sneezing; and, if more severe, by additional malaise and fever. The diagnosis is usually made clinically (on the basis of history and examination, but without radiological or bacteriological investigation). Clinically diagnosed acute sinusitis is less likely to be caused by bacterial infection than acute sinusitis confirmed by radiological or bacteriological investigation. In this review, we have excluded studies of children, persons with symptoms lasting longer than four weeks (chronic sinusitis), and persons with symptoms after facial trauma. We have made it clear in each section whether we are discussing clinically diagnosed acute sinusitis or acute sinusitis with clinical symptoms that have also been confirmed by bacteriological or radiological investigation, because the effects of treatment may be different in these groups.

Incidence/Prevalence

Each year in Europe, 1 to 5 percent of adults are diagnosed with acute sinusitis by their general physicians. Extrapolated to the British population, this is estimated to cause 6 million restricted working days per year. Most persons with acute sinusitis are assessed and treated in a primary care setting. The prevalence varies according to whether diagnosis is made on clinical grounds or on the basis of radiological or bacteriological investigation.

Etiology/Risk Factors

One systematic review (search date: 1998) reported that approximately 50 percent of persons with a clinical diagnosis of acute sinusitis have a bacterial sinus infection. The usual pathogens in acute bacterial sinusitis are Streptococcus pneumoniae and Haemophilus influenzae, with occasional infection with Moraxella catarrhalis. A preceding viral upper respiratory tract infection is often the trigger for acute bacterial sinusitis, with approximately 0.5 percent of common colds becoming complicated by the development of acute sinusitis.

Prognosis

One meta-analysis of RCTs found that up to two thirds of persons with acute sinusitis had spontaneous resolution of symptoms without active treatment. One nonsystematic review reported that persons with acute sinusitis are at risk of chronic sinusitis and irreversible damage to the normal mucociliary mucosal surface. One further nonsystematic review reported rare life-threatening complications, such as orbital cellulitis and meningitis, after acute sinusitis. However, we found no reliable data to measure these risks.

Author disclosure: Kim Ah-See has been reimbursed by Schering-Plough, manufacturer of Nasonex, for attending a conference and for delivering educational talks to medical and paramedical staff.

editor’s note: Xylometazoline is no longer available in the United States.

search date: August 2007.

Adapted with permission from Ah-See K. Sinusitis (acute). Clin Evid Handbook. June 2008:203–205. Please visit http://www.clinicalevidence.bmj.com for full text and references.

 

This is one in a series of chapters excerpted from the Clinical Evidence Handbook, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of the Clinical Evidence Handbook, as well as online at http://www.clinicalevidence.bmj.com (subscription required). Those who receive a complimentary print copy of the Clinical Evidence Handbook from United Health Foundation can gain complimentary online access by registering on the Web site using the ISBN number of their book.


Want to use this article elsewhere? Get Permissions


Article Tools

  • Print page
  • Share this page
  • AFP CME Quiz

Information From Industry

Navigate this Article