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ABSTRACT: Rhinosinusitis can be divided among four subtypes: acute, recurrent acute, subacute and chronic, based on patient history and a limited physical examination. In most instances, therapy is initiated based on this classification. Antibiotic therapy, supplemented by hydration and decongestants, is indicated for seven to 14 days in patients with acute, recurrent acute or subacute bacterial rhinosinusitis. For patients with chronic disease, the same treatment regimen is indicated for an additional four weeks or more, and a nasal steroid may also be prescribed if inhalant allergies are known or suspected. Nasal endoscopy and computed tomography of the sinuses are reserved for circumstances that include a failure to respond to therapy as expected, spread of infection outside the sinuses, a question of diagnosis and when surgery is being considered. Laboratory tests are infrequently necessary and are reserved for patients with suspected allergies, cystic fibrosis, immune deficiencies, mucociliary disorders and similar disease states. Findings on endoscopically guided microswab culture obtained from the middle meatus correlate 80 to 85 percent of the time with results from the more painful antral puncture technique and is performed in patients who fail to respond to the initial antibiotic selection. Surgery is indicated for extranasal spread of infection, evidence of mucocele or pyocele, fungal sinusitis or obstructive nasal polyposis, and is often performed in patients with recurrent or persistent infection not resolved by drug therapy.
ABSTRACT: Sinusitis is one of the most common diseases treated by primary care physicians. Uncomplicated sinusitis does not require radiologic imagery. However, when symptoms are recurrent or refractory despite adequate treatment, further diagnostic evaluations may be indicated. Plain radiography has a limited role in the management of sinusitis. Although air-fluid levels and complete opacification of a sinus are more specific for sinusitis, they are only seen in 60 percent of cases. Noncontrast coronal computed tomographic (CT) images can define the nasal anatomy much more precisely. Mucosal thickening, polyps, and other sinus abnormalities can be seen in 40 percent of symptomatic adults; however, clinical correlation is needed to avoid overdiagnosis of sinusitis because of nonspecific CT findings. Use of CT is typically reserved for difficult cases or to define anatomy prior to sinus surgery. Magnetic resonance imaging (MRI) cannot define bony anatomy as well as CT. MRI is only used to differentiate soft-tissue structures, such as in cases of suspected fungal infection or neoplasm. Referral will occasionally be needed in unusual or complicated cases. Immunocompromised persons and smokers are at increased risk for serious sinusitis complications.
ABSTRACT: Acute rhinosinusitis is one of the most common conditions that physicians treat in ambulatory practice. Although often caused by viruses, it sometimes is caused by bacteria, a condition that is called acute bacterial rhinosinusitis. The signs and symptoms of acute bacterial rhinosinusitis and prolonged viral upper respiratory infection are similar, which makes accurate clinical diagnosis difficult. Because two thirds of patients with acute bacterial rhinosinusitis improve without antibiotic treatment and most patients with viral upper respiratory infection improve within seven d antibiotic therapy should be reserved for use in patients who have had symptoms for more than seven days and meet clinical criteria. Four signs and symptoms are the most helpful in predicting acute bacterial rhinosinusitis: purulent nasal discharge, maxillary tooth or facial pain (especially unilateral), unilateral maxillary sinus tenderness, and worsening symptoms after initial improvement. Sinus radiography and ultrasonography are not recommended in the diagnosis of uncomplicated acute bacterial rhinosinusitis, although computed tomography has a role in the care of patients with recurrent or chronic symptoms.
Principles of Appropriate Antibiotic Use: Part III. Acute Rhinosinusitis - Practice Guidelines
AAP Issues Recommendations for the Management of Sinusitis in Children - Practice Guidelines
Sinusitis and Renal Failure in an Elderly Patient - Photo Quiz
Sinus and Allergy Health Partnership Releases Report on Adult Chronic Rhinosinusitis - Practice Guidelines
Rhinosinusitis: What Is the Desired Outcome? - Editorials
ABSTRACT: Although most cases of acute rhinosinusitis are caused by viruses, acute bacterial rhinosinusitis is a fairly common complication. Even though most patients with acute rhinosinusitis recover promptly without it, antibiotic therapy should be considered in patients with prolonged or more severe symptoms. To avoid the emergence and spread of antibiotic-resistant bacteria, narrow-spectrum antibiotics such as amoxicillin should be used for 10 to 14 days. In patients with mild disease who have beta-lactam allergy, trimethoprim/sulfamethoxazole or doxycycline are options. Second-line antibiotics should be considered if the patient has moderate disease, recent antibiotic use (past six weeks), or no response to treatment within 72 hours. Amoxicillin-clavulanate potassium and fluoroquinolones have the best coverage for Haemophilus influenzae and Streptococcus pneumoniae. In patients with beta-lactam hypersensitivity who have moderate disease, a fluoroquinolone should be prescribed. The evidence supporting the use of ancillary treatments is limited. Decongestants often are recommended, and there is some evidence to support their use, although topical decongestants should not be used for more than three days to avoid rebound congestion. Topical ipratropium and the sedating antihistamines have anticholinergic effects that maybe beneficial, but there are no clinical studies supporting this possibility. Nasal irrigation with hypertonic and normal saline has been beneficial in chronic sinusitis and has no serious adverse effects. Nasal corticosteroids also may be beneficial in treating chronic sinusitis. Mist, zinc salt lozenges, echinacea extract, and vitamin C have no proven benefit in the treatment of acute bacterial rhinosinusitis.