Am Fam Physician. 2002;65(4):558-560
to the editor: Having just put together a lecture on acute rhinosinusitis, I eagerly opened the January 1, 2001 issue of American Family Physician to read “Adult Rhinosinusitis: Diagnosis and Management.”1 I was hoping to find validation of the conclusions I had drawn from my own weeks of study and synthesis on the subject. I also hoped to find new insights from an experienced author on the difficult issue of how we should approach patients with signs and symptoms that may be either viral or bacterial.
However, I was disappointed to find a review that relied heavily on the ear, nose, and throat and allergy literature and nearly ignored the research that has fueled multiple meta-analyses and new general practice studies of acute rhinosinusitis during the past few years.
To be specific, Dr. Osguthorpe's discussion of the acute variety of rhinosinusitis fails to recognize studies that have reported which signs and symptoms have statistically significant correlations with bacterial infection and which do not.2–4 He also fails to define which radiologic or computed tomographic (CT) features have validity in the diagnosis and which do not. This information has been well reported in the general practice literature, too.3,5,6 In addition, he perpetuates what is probably a myth that untreated acute bacterial sinusitis leads to chronic sinusitis or spreads to the orbit or meninges (none of the studies cited in the meta-analyses has found any incidence of these complications). Finally, he extrapolates a dose of amoxicillin advocated for acute otitis in the pediatric literature to adults with no evidence of increased efficacy or lack of increased side effects. The dose he suggests would amount to approximately 6 g a day for a 70-kg adult.
In this era of increasing recognition of the harm caused by misuse of antibiotics, it is important to use what research we do have to better differentiate the population that may benefit from antibiotics from those who should have symptomatic management until the natural resolution of the illness. There are good data showing that the combination of at least three of the following clinical findings (unilaterally predominant pain, history of purulent secretions, presence of purulent secretions, “double sickening”) has fair sensitivity and specificity for bacterial infection.2–4 The predictive value can be enhanced with finding an elevated erythrocyte sedimentation rate, which is also associated with pyogenic infection.3,4 Until better studies are conducted, we should avoid using less specific clinical criteria and limit the use of radiologic studies since findings other than opacity and air/fluid levels are not specific to bacterial sinusitis.
in reply: Rather than ignoring multi-analyses of the diagnosis and treatment of rhinosinusitis, most of my article, such as the treatment flow diagram, was directly based on the most comprehensive analysis to date, which is a detailed review of over 7,000 articles by the Agency for Healthcare Research and Quality (AHRQ).1 Four medical specialty societies, including the American Academy of Family Physicians, participated in this review. Most investigators in the otolaryngology and neuroradiology communities believe that radiographic studies should usually not be the sole diagnostic criteria for rhinosinusitis. For this reason, specifying which changes on radiograph or computed tomographic (CT) scan have unequivocal diagnostic validity is a bit tricky, but the best analyses to date are in the AHRQ document1 and in articles on paranasal disease by Dr. Zinreich.2
On the question of whether rhinosinusitis can spread to the orbit or meninges, a MED-LINE search for “sinusitis and cellulitis” reveals a dozen citations in 2000–01 alone, one of which is referenced here.3 It is true that, with “watchful waiting,” 69 percent of patients with acute bacterial rhinosinusitis will have their symptoms resolve, or at least improve, without antibiotic treatment.1 However, given the loss of productivity, pain/suffering, and the small but important incidence of acute bacterial sinusitis progressing to chronic rhinosinusitis or more serious problems,1,3 data gathered by the AHRQ suggest that clinical criteria-guided treatment with amoxicillin or folate inhibitors is the most effective and cost-effective strategy for managing uncomplicated acute bacterial rhinosinusitis at prevalence rates encountered in most primary care practices.1 Selection of the dose of amoxicillin or of a folate inhibitor is left to the treating physician, but the efficacy of high-dose amoxicillin on otitis media in children is noted.
For persons who wish to pursue the topic further, I highly recommend a published synopsis of antimicrobial treatments for acute bacterial rhinosinusitis,4 which represents the “best guess” of representatives from many medical specialties as well as the Centers for Disease Control and Prevention (CDC) and the U.S. Food and Drug Administration (FDA).