Current Concepts in Adult Acute Rhinosinusitis

 

Am Fam Physician. 2016 Jul 15;94(2):97-105.

  Patient information: See related handout on acute sinusitis, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Acute rhinosinusitis is one of the most common conditions that physicians treat in ambulatory care. Most cases of acute rhinosinusitis are caused by viral upper respiratory infections. A meta-analysis based on individual patient data found that common clinical signs and symptoms were not effective for identifying patients with rhinosinusitis who would benefit from antibiotics. C-reactive protein and erythrocyte sedimentation rate are somewhat useful tests for confirming acute bacterial maxillary sinusitis. Four signs and symptoms that significantly increase the likelihood of a bacterial cause when present are double sickening, purulent rhinorrhea, erythrocyte sedimentation rate greater than 10 mm per hour, and purulent secretion in the nasal cavity. Although cutoffs vary depending on the guideline, antibiotic therapy should be considered when rhinosinusitis symptoms fail to improve within seven to 10 days or if they worsen at any time. First-line antibiotics include amoxicillin with or without clavulanate. Current guidelines support watchful waiting within the first seven to 10 days after upper respiratory symptoms first appear. Evidence on the use of analgesics, intranasal corticosteroids, and saline nasal irrigation for the treatment of acute rhinosinusitis is poor. Nonetheless, these therapies may be used to treat symptoms within the first 10 days of upper respiratory infection. Radiography is not recommended in the evaluation of uncomplicated acute rhinosinusitis. For patients who do not respond to treatment, computed tomography of the sinuses without contrast media is helpful to evaluate for possible complications or anatomic abnormalities. Referral to an otolaryngologist is indicated when symptoms persist after maximal medical therapy and if any rare complications are suspected.

Symptoms of acute rhinosinusitis manifest when the mucosal lining in the paranasal sinuses and nasal cavity becomes inflamed. Because the nasal mucosa is contiguous with mucosa of the paranasal sinuses, inflammation of the sinuses rarely occurs without inflammation of the nasal mucosa. Although this process is commonly called sinusitis, rhinosinusitis is the more accurate term. Each year in the United States, rhinosinusitis affects one in seven adults, resulting in more than 30 million annual diagnoses.1 Rhinosinusitis is the fifth most common diagnosis for which antibiotics are prescribed in the United States.13 The management of acute and chronic sinusitis has a direct cost of more than $11 billion per year, not including the economic impact of lost productivity due to illness.1

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BEST PRACTICES IN INFECTIOUS DISEASE – RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organizations

Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis.

American College of Emergency Physicians

Do not routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.

American Academy of Otolaryngology–Head and Neck Surgery

Do not routinely prescribe antibiotics for acute, mild to moderate sinusitis unless symptoms (which must include purulent nasal secretions and maxillary pain or facial and dental tenderness to percussion) last at least seven days or symptoms worsen after initial clinical improvement.

American Academy of Allergy, Asthma and Immunology

American Academy of Family Physicians

American Academy of Otolaryngology–Head and Neck Surgery


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN INFECTIOUS DISEASE – RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organizations

Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis.

American College of Emergency Physicians

Do not routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.

American Academy of Otolaryngology–Head and Neck Surgery

Do not routinely prescribe antibiotics for acute, mild to moderate sinusitis unless symptoms (which must include purulent nasal secretions and maxillary pain or facial and dental tenderness to percussion) last at least seven days or symptoms worsen after initial clinical improvement.

American Academy of Allergy, Asthma and Immunology

American Academy of Family Physicians

American Academy of Otolaryngology–Head and Neck Surgery


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

For patients with acute rhino

The Authors

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ANN M. ARING, MD, FAAFP, is associate residency director of the Riverside Family Medicine Residency Program at OhioHealth Riverside Methodist Hospital, Columbus; an adjunct assistant professor in the Department of Family Medicine at The Ohio State University College of Medicine, Columbus; and a clinical assistant professor at the University of Toledo (Ohio), Northeastern Ohio Universities College of Medicine, Rootstown, and Ohio University Heritage College of Osteopathic Medicine, Athens....

MIRIAM M. CHAN, PharmD, is director of research and evidence-based medicine at the Riverside Family Medicine Residency Program at Ohio-Health Riverside Methodist Hospital; an adjunct assistant professor in the College of Pharmacy and Department of Family Medicine at The Ohio State University College of Medicine; and a clinical assistant professor at Ohio University Heritage College of Osteopathic Medicine.

Address correspondence to Ann M. Aring, MD, FAAFP, OhioHealth Riverside Family Practice Center, 697 Thomas Ln., Columbus, OH 43214 (e-mail: Ann.Aring@ohiohealth.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 suppl):S1–S39....

2. Fokkens WJ, Lund VJ, Mullol J, et al. European position paper on rhinosinusitis and nasal polyps 2012. Rhinol Suppl. 2012;(23):1–298.

3. Chow AW, Benninger MS, Brook I, et al.; Infectious Diseases Society of America. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012;54(8):e72–e112.

4. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg. 1997;117(3 pt 2):S1–S7.

5. Sande MA, Gwaltney JM. Acute community-acquired bacterial sinusitis: continuing challenges and current management. Clin Infect Dis. 2004;39(suppl 3):S151–S158.

6. Ah-See KW, Evans AS. Sinusitis and its management. BMJ. 2007;334(7589):358–361.

7. Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines. Mayo Clin Proc. 2011;86(5):427–443.

8. Hansen JG, Schmidt H, Rosborg J, Lund E. Predicting acute maxillary sinusitis in a general practice population. BMJ. 1995;311(6999):233–236.

9. van Buchem L, Peeters M, Beaumont J, Knottnerus JA. Acute maxillary sinusitis in general practice: the relation between clinical picture and objective findings. Eur J Gen Pract. 1995;1(4):155–160.

10. Piccirillo JF. Clinical practice. Acute bacterial sinusitis. N Engl J Med. 2004;351(9):902–910.

11. Hwang PH. A 51-year-old woman with acute onset of facial pressure, rhinorrhea, and tooth pain: review of acute rhinosinusitis. JAMA. 2009;301(17):1798–1807.

12. Williams JW Jr, Simel DL, Roberts L, Samsa GP. Clinical evaluation for sinusitis. Making the diagnosis by history and physical examination. Ann Intern Med. 1992;117(9):705–710.

13. Berg O, Carenfelt C. Analysis of symptoms and clinical signs in the maxillary sinus empyema. Acta Otolaryngol. 1988;105(3–4):343–349.

14. Lindbaek M, Hjortdahl P, Johnsen UL. Use of symptoms, signs, and blood tests to diagnose acute sinus infections in primary care: comparison with computed tomography. Fam Med. 1996;28(3):183–188.

15. van den Broek MF, Gudden C, Kluijfhout WP, et al. No evidence for distinguishing bacterial from viral acute rhinosinusitis using symptom duration and purulent rhinorrhea: a systematic review of the evidence base. Otolaryngol Head Neck Surg. 2014;150(4):533–537.

16. Slavin RG, Spector SL, Bernstein IL, et al.; American Academy of Allergy, Asthma and Immunology; American College of Allergy, Asthma and Immunology; Joint Council of Allergy, Asthma and Immunology. The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol. 2005;116(6):S13–S47.

17. Meltzer EO, Hamilos DL, Hadley JA, et al.; American Academy of Allergy, Asthma and Immunology; American Academy of Otolaryngic Allergy; American Academy of Otolaryngology—Head and Neck Surgery; American College of Allergy, Asthma and Immunology; American Rhinologic Society. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol. 2004;114(6 suppl):155–212.

18. Hadley JA, Schaefer SD. Clinical evaluation of rhinosinusitis: history and physical examination. Otolaryngol Head Neck Surg. 1997;117(3 pt 2):S8–S11.

19. Cornelius RS, Martin J, Wippold FJ II, et al.; American College of Radiology. ACR appropriateness criteria sinonasal disease. J Am Coll Radiol. 2013;10(4):241–246.

20. Savolainen S, Pietola M, Kiukaanniemi H, Lappalainen E, Salminen M, Mikkonen P. An ultrasound device in the diagnosis of acute maxillary sinusitis. Acta Otolaryngol Suppl. 1997;529:148–152.

21. Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines. Mayo Clin Proc. 2011;86(5):427–443.

22. Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet. 2008;371(9616):908–914.

23. Falagas ME, Giannopoulou KP, Vardakas KZ, Dimopoulos G, Karageorgopoulos DE. Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis of randomised controlled trials. Lancet Infect Dis. 2008;8(9):543–552.

24. Lemiengre MB, van Driel ML, Merenstein D, Young J, De Sutter AI. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2012;(10):CD006089.

25. Desrosiers M, Evans GA, Keith PK, et al. Canadian clinical practice guidelines for acute and chronic rhinosinusitis. J Otolaryngol Head Neck Surg. 2011;40(suppl 2):S99–S193.

26. Rosenfeld RM, Singer M, Jones S. Systematic review of antimicrobial therapy in patients with acute rhinosinusitis. Otolaryngol Head Neck Surg. 2007;137(3 suppl):S32–S45.

27. Anon JB, Jacobs MR, Poole MD, et al.; Sinus And Allergy Health Partnership. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis [published correction appears in Otolaryngol Head Neck Surg. 2004; 130(6):794–796]. Otolaryngol Head Neck Surg. 2004;130(1 suppl):1–45.

28. Karageorgopoulos DE, Giannopoulou KP, Grammatikos AP, Dimopoulos G, Falagas ME. Fluoroquinolones compared with beta-lactam antibiotics for the treatment of acute bacterial sinusitis: a meta-analysis of randomized controlled trials. CMAJ. 2008;178(7):845–854.

29. U.S. Food and Drug Administration. FDA Drug Safety Communication: FDA advises restricting fluoroquinolone antibiotic use for certain uncomplicated infections; warns about disabling side effects that can occur together. http://www.fda.gov/Drugs/DrugSafety/ucm500143.htm. Accessed May 27, 2016.

30. Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials. Br J Clin Pharmacol. 2009;67(2):161–171.

31. Meltzer EO, Ratner PH, McGraw T. Oral phenylephrine HCl for nasal congestion in seasonal allergic rhinitis: a randomized, open-label, placebo-controlled study. J Allergy Clin Immunol Pract. 2015;3(5):702–708.

32. Hayward G, Heneghan C, Perera R, Thompson M. Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis. Ann Fam Med. 2012;10(3):241–249.

33. Zalmanovici Trestioreanu A, Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2013;(12):CD005149.

34. Inanli S, Oztürk O, Korkmaz M, Tutkun A, Batman C. The effects of topical agents of fluticasone propionate, oxymetazoline, and 3% and 0.9% sodium chloride solutions on mucociliary clearance in the therapy of acute bacterial rhinosinusitis in vivo. Laryngoscope. 2002;112(2):320–325.

35. Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R. Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. J Fam Pract. 2002;51(12):1049–1055.

36. Meltzer EO, Orgel HA, Backhaus JW, et al. Intranasal flunisolide spray as an adjunct to oral antibiotic therapy for sinusitis. J Allergy Clin Immunol. 1993;92(6):812–823.

37. Barlan IB, Erkan E, Bakir M, Berrak S, Başaran MM. Intranasal budesonide spray as an adjunct to oral antibiotic therapy for acute sinusitis in children. Ann Allergy Asthma Immunol. 1997;78(6):598–601.

38. Meltzer EO, Charous BL, Busse WW, Zinreich SJ, Lorber RR, Danzig MR; The Nasonex Sinusitis Group. Added relief in the treatment of acute recurrent sinusitis with adjunctive mometasone furoate nasal spray. J Allergy Clin Immunol. 2000;106(4):630–637.

39. Yilmaz G, Varan B, Yilmaz T, Gürakan B. Intranasal budesonide spray as an adjunct to oral antibiotic therapy for acute sinusitis in children. Eur Arch Otorhinolaryngol. 2000;257(5):256–259.

40. Dolor RJ, Witsell DL, Hellkamp AS, Williams JW Jr, Califf RM, Simel DL; Ceftin and Flonase for Sinusitis (CAFFS) Investigators. Comparison of cefuroxime with or without intranasal fluticasone for the treatment of rhinosinusitis. The CAFFS Trial: a randomized controlled trial [published correction appears in JAMA. 2004;292(14):1686]. JAMA. 2001;286(24):3097–3105.

41. Nayak AS, Settipane GA, Pedinoff A, et al.; Nasonex Sinusitis Group. Effective dose range of mometasone furoate nasal spray in the treatment of acute rhinosinusitis. Ann Allergy Asthma Immunol. 2002;89(3):271–278.

42. Meltzer EO, Bachert C, Staudinger H. Treating acute rhinosinusitis: comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo. J Allergy Clin Immunol. 2005;116(6):1289–1295.

43. Williamson IG, Rumsby K, Benge S, et al. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial. JAMA. 2007;298(21):2487–2496.

44. Keojampa BK, Nguyen MH, Ryan MW. Effects of buffered saline solution on nasal mucociliary clearance and nasal airway patency. Otolaryngol Head Neck Surg. 2004;131(5):679–682.

45. Hauptman G, Ryan MW. The effect of saline solutions on nasal patency and mucociliary clearance in rhinosinusitis patients. Otolaryngol Head Neck Surg. 2007;137(5):815–821.

46. King D, Mitchell B, Williams CP, Spurling GK. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst Rev. 2015;(4):CD006821.

47. Yoder JS, Straif-Bourgeois S, Roy SL, et al. Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clin Infect Dis. 2012;55(9):e79–e85.

48. Cope JR, Ratard RC, Hill VR, et al. The first association of a primary amebic meningoencephalitis death with culturable Naegleria fowleri in tap water from a US treated public drinking water system. Clin Infect Dis. 2015;60(8):e36–e42.

49. Taverner D, Danz C, Economos D. The effects of oral pseudoephedrine on nasal patency in the common cold: a double-blind single-dose placebo-controlled trial. Clin Otolaryngol Allied Sci. 1999;24(1):47–51.

50. Caenen M, Hamels K, Deron P, Clement P. Comparison of decongestive capacity of xylometazoline and pseudoephedrine with rhinomanometry and MRI. Rhinology. 2005;43(3):205–209.

51. Braun JJ, Alabert JP, Michel FB, et al. Adjunct effect of loratadine in the treatment of acute sinusitis in patients with allergic rhinitis. Allergy. 1997;52(6):650–655.

52. Turner JH, Reh DD. Incidence and survival in patients with sinonasal cancer: a historical analysis of population-based data. Head Neck. 2012;34(6):877–885.

53. Aring AM, Chan MM. Acute rhinosinusitis in adults. Am Fam Physician. 2011;83(9):1057–1063.


 

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