Sinusitis Practice Guideline Aims to Improve Diagnosis, Cut Antibiotic Use

By News Staff
9/21/2007

Sinusitis affects one in seven adults in the United States and is responsible for more than one in five antibiotics prescribed for adults, according to the authors of a clinical practice guideline recently released by the American Academy of Otolaryngology-Head and Neck Surgery, or AAO-HNS. The guideline, developed by a multidisciplinary panel that included two family physicians, presents evidence-based recommendations to aid physicians and other health care professionals in diagnosing and managing this condition.

The guideline defines rhinosinusitis as "symptomatic inflammation of the paranasal sinuses and nasal cavity," further noting that use of the term rhinosinusitis is preferred because "sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa." It also explicitly defines acute rhinosinusitis in terms of specific symptoms (i.e., purulent nasal drainage accompanied by nasal obstruction; facial pain, pressure or fullness; or both) and length of time (up to four weeks) those symptoms have been present.

The guideline is intended to reduce inappropriate use of antibiotics and radiographic imaging, as well as improve diagnostic accuracy and promote appropriate use of nasal endoscopy, CT, and testing for allergies and immune function. The guideline panel included experts in the fields of family medicine, allergy, emergency medicine, immunology, infectious disease, internal medicine and nursing. Theodore Ganiats, M.D., of La Jolla, Calif., and Martin Mahoney, M.D., of Buffalo, N.Y., both family physicians with extensive experience in guideline development, participated on the panel.

What's Recommended

The guideline incorporates three levels of evidence-based practice statements: "strong recommendations," "recommendations" and "options." Strong recommendations included in the guideline are:

Health care professionals should be careful to distinguish acute bacterial rhinosinusitis from rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions.
Acute bacterial rhinosinusitis should be diagnosed when acute rhinosinusitis signs or symptoms are present 10 or more days after onset of upper respiratory symptoms or worsen within 10 days after initial improvement.
Any clinician managing a patient with acute bacterial rhinosinusitis should assess the patient's pain and recommend or prescribe appropriate analgesic treatment.

Recommendations include the following:

Radiographic imaging should not be used in patients who meet diagnostic criteria for acute rhinosinusitis unless a complication or alternative diagnosis is suspected.
If antibiotics are required to treat acute bacterial rhinosinusitis, amoxicillin is considered the first-line treatment for most adults.
If a patient's symptoms worsen or fail to improve with first-line therapy by seven days after the diagnosis is made, the health care professional should reassess the patient to confirm the diagnosis of acute bacterial rhinosinusitis, exclude other causes of symptoms and detect complications.
Clinicians should distinguish chronic rhinosinusitis (lasting 12 weeks or longer) and recurrent acute rhinosinusitis (four episodes per year with no intervening symptoms) from isolated episodes of acute bacterial rhinosinusitis and other causes of such symptoms.
If a patient has chronic rhinosinusitis or recurrent acute rhinosinusitis, the health care professional should assess him or her for factors that may modify treatment, including allergic rhinitis, cystic fibrosis, immunocompromised state, ciliary dyskinesia and anatomic variation.
Health care professionals should corroborate a diagnosis of chronic rhinosinusitis or recurrent acute rhinosinusitis and/or investigate for underlying causes.
CT of the paranasal sinuses should be used when diagnosing or evaluating a patient who has chronic or recurrent acute rhinosinusitis.
Clinicians should educate patients with chronic or recurrent acute rhinosinusitis about control measures (e.g., smoking cessation, saline nasal irrigation).

The guideline also offers the following practice options:

Symptomatic relief for viral rhinosinusitis and acute bacterial rhinosinusitis may be prescribed.
Observation without prescribing antibiotics is a safe and effective option for managing acute bacterial rhinosinusitis in selected adults who have mild illness (i.e., mild pain, temperature <101˚F), with appropriate follow-up.
Nasal endoscopy is an option for diagnosing or evaluating a patient who has chronic or recurrent acute rhinosinusitis.
Health care professionals may want to obtain testing for allergies or immune function when evaluating a patient with chronic or recurrent acute rhinosinusitis.

The guideline notes that acute rhinosinusitis may take as long as seven days after diagnosis to improve, regardless of whether the initial therapy is observation or antibiotics. It also points out that X-rays are not recommended to diagnose acute rhinosinusitis in most patients.

Getting the Guidelines

"Clinical Practice Guideline: Adult Sinusitis" (31-page PDF; About PDFs) is posted online at the AAO-HNS Web site and appears as a supplement to the September 2007 issue of Otolaryngology — Head and Neck Surgery, the journal of the AAO-HNS and the American Academy of Otolaryngic Allergy.

Printer-friendly version

Email this page