Duke Internal Medicine Residency Curriculum
Acute Sinusitis
Author: Marie Carson, MD
Editor: Amy Shaheen, MD, Assistant Professor
of Clinical Medicine
Duke University Medical Center
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Acute Sinusitis: Overview and Epidemiology
• The diagnosis is common, as it is one of the top 10
most common diagnoses in ambulatory practice, and
5th most common diagnosis for which an antibiotic is
prescribed
• Usually due to secondary infection from preceding URI,
though only 0.2% to 2% of viral URIs are complicated
by bacterial rhinosinusitis; bacterial sinusitis rarely
presents before 7 days of illness
• Viral pathogens include rhinovirus, parainfluenza,
influenza, RSV, adenovirus
• Common bacterial pathogens include Strep pneumo,
H flu, Moraxella
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Acute Sinusitis: Diagnosis
• The gold standard is sinus puncture and drainage, though this is
seldom performed in primary care; this limits the quality of the
evidence related to diagnostic testing
• How good are symptoms and signs?
Symptom or Sign
Positive LR
Negative LR
Maxillary toothache
2.5
0.9
Purulent secretion
2.1
0.7
Poor response to
decongestants
2.1
0.7
Abnormal
transillunination
1.6
0.5
Hx of colored nasal
discharge
1.5
0.5
Williams et al. Ann Int Med 1992 (117): 705-710 (note that this study compared clinical signs/symptoms to plain films)
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Acute Sinusitis: How good are symptoms & signs (cont.)
• If there are 4 or more signs, the positive LR is
6.4, 3 signs yield LR 2.6, 2 signs yield LR 1.1,
1 sign yields LR 0.5, no signs yield LR 0.1.
• Physician assessment is just as good: an
impression that sinusitis was “definitely or most
likely present” generated a LR of 4.7
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Acute Sinusitis: What about radiographic studies?
• A single Waters view (maxillary) is the best studied,
with sensitivity of about 80% (compared to puncture); it
correlates well to standard 4 view sinus series
• There is minimal data on CT; probably highly sensitive,
but lacks specificity (about 80% of pts with viral URI
may have evidence of sinusitis on CT). Its true value
may be in diagnosing recurrent or chronic sinusitis with
impacted secretions, anatomical abnormalities, etc.
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Acute Sinusitis: Radiographic studies
Sinus
radiography
vs. culture.
Sensitivity
Specificity
Pos LR
Neg LR
Fluid level or
opacification
73%
80%
3.7
0.3
Fluid level,
opacity or
mucosal
thickening
90%
61%
2.9
0.2
http://www.ahcpr.gov/clinic/sinussum.htm
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Acute Sinusitis: Diagnosis – Bottom Line
The bottom line for diagnosis: A
combination of clinical signs and symptoms
is adequate; radiology doesn’t add anything
to diagnosing uncomplicated rhinosinusitis
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Acute Sinusitis: Treatment
• There are no RCTs of antibiotic treatment using pre and post
cultures of sinus aspirates
• Most utilize “clinical failure” as negative outcome, “clinical
improvement” as positive outcome at 10-14 days
• Patients who receive antibiotics tend to get better and get better
somewhat faster; HOWEVER:
• Most pts who receive placebo ALSO get better—by 2 weeks,
symptoms improved or resolved in 70%; antibiotic therapy (any)
pushed the resolution rate to 74-90%
• In none of the treatment trials reviewed in 2 recent meta-analyses
did a patient have a complication of untreated sinusitis (abscess,
etc)
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Acute Sinusitis: Treatment
A Cochrane systematic review in 1999 found no difference between penicillin,
amoxicillin, amox-clav, macrolides, cephalosporins in cure rates or relapse of sinusitis
Comparison
Any Abx. vs.
placebo
Amox. vs.
other abx.
TMP-SMX vs.
other
N of trials
Failure rates
RRR
NNT
6
16% vs. 31%
46%
7
14
9% vs. 11%
NS
NS
9
13% vs. 11%
NS
NS
From AHCPR meta-analysis March 1999:
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Acute Sinusitis: Adjunctive Therapies
• Are there any adjunctive therapies that have
been proven to work?
– The CAFFS trial in 2001 looked at recurrent and
chronic sinusitis and suggests that adding Flonase
to Ceftin shortened duration of illness and improved
response at 8 weeks (74% response for antibiotic
plus decongestant v. 94% with the addition of nasal
fluticasone)
– Anti-histamines have not been proven to work
– Decongestants may provide symptomatic relief
– There is no data for nasal saline lavage or systemic
steroids
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Acute Sinusitis: Antibiotic Resistance and “Treatment Failure”, Treatment Length
• What about antibiotics resistance and
“treatment failure”?
– Not well studied. The recommendations are to
choose narrow spectrum antibiotics initially. For
treatment failures, recurrence, etc., referral to ENT
for sinus aspirate and culture should be considered.
• How long to treat?
– Controversial. Most studies done with therapy for
10 – 14 days.
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Acute Sinusitis: Treatment – The Bottom Line
Most patients, regardless of whether the
pathogen is viral or bacterial get better
spontaneously. It is reasonable to treat
symptomatically at first. Consider antibiotic
therapy
if severe or moderate symptoms present for more
than 7 days, and consider adjunct therapies such
as decongestants and intranasal steroids
(particularly if recurrent or if there is history of
atopy).
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Acute Sinusitis: Recommendations
• Sinus radiography is not recommended for
diagnosis of uncomplicated sinusitis
• Acute bacterial sinusitis does not require
antibiotic treatment, especially if mild or
moderate
• Patients with severe or persistent moderate
symptoms and specific findings of bacterial
sinusitis that persist after 7 days should be
treated with antibiotics. Amoxicillin,
doxycycline, or TMP-SMX are favored
antibiotic choices.
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Acute Sinusitis: Review Question 1
43 yo woman presents with fatigue, rhinorrhea, left facial
pressure, mild pharyngitis, left maxillary toothache and
postnasal drip for the past 3 weeks. She has felt
feverish, but has not taken her temperature. She uses
an oral anti-histamine for allergic rhinitis. She has no
allergies to antibiotics.
On PE, she has an oral temp of 37.4C. There is
mucopurulent discharge from the left hostril, tenderness
over the left maxillary sinus, mildly erythematous
tympanic membranes, poor transillumination of the left
maxillary sinus, no cervical adenopathy and clear lungs.
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Acute Sinusitis: Review Question 1 - Rationale
Answer: E Amoxicillin
This pt has acute sinusitis, given symptoms > 1
week, unilateral or bilateral purulent rhinorrhea,
local pain and maxillary toothache. Acute sinusitis
is defined as having symptoms lasting up to 4
weeks, chronic sinusitis greater than 12 weeks
duration. Other therapy for rhinitis includes
administration of intranasal glucocorticoids and
intranasal decongestants. (cont. next slide)
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Acute Sinusitis: Review Question 1 – Rationale (cont.)
Patients can have multiple episodes of acute sinusitis. Allergic rhinitis may
predispose and should be addressed. Antihistamines should be continued for
the pt’s underlying allergic rhinitis, and the first choice of treatment is
antibiotics. Treatment with amoxicillin or TMP-SMX is successful in 90% of
patients and should be first line therapy. If antibiotics are used, choosing the
agent with narrower coverage is consistent with the need to avoid antibiotic
resistance. In pts with acute sinusitis, 69% had resolution or improvement
without antibiotics by 14 days. Recommendations on the duration of therapy
vary, with data showing that 3 days of therapy is as effective as 10 days for
acute maxillary sinusitis.
This patient does not have chronic sinusitis. Therefore, therapy with
amoxicillin-clavulanate is not appropriate. Regarding possible imaging studies,
plain films of the sinuses are not indicated; CT scan of the sinuses would be
the imaging test of choice, but it is reserved for patients who have sinusitis or
who have failed to respond to treatment.
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Acute Sinusitis: Review Question 2
A 27 yo man presents with 4 days of malaise, fatigue,
and yellow discharge from his right nostril, along with
sneezing, mild sore throat, congestion, dry cough, and
myalgias. He wants relief from his symptoms because
he must travel by plane in 3 days. He smokes one pack
of cigarettes per day.
On physical examination, his temperature is 37.4C.
There is no facial tenderness, and normal
transillumination of his sinuses, yellow rhinorrhea from
right nostril, mild pharyngeal erythema, no cervical
adenopathy and clear lungs.
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Acute Sinusitis: Review Question 1 - Rationale
Answer: B Pseudoephedrine therapy
This patient does not meet the criteria for sinusitis. His symptoms have lasted
less than 7 days, and he likely has a viral URI. Other than unilateral purulent
discharge, he does not have specific criteria for sinusitis. Systemic adrenergic
agonists may play a role, as may nasal glucocorticoids, guaifenesin, oral
hydration or nasal saline spray. Patients with controlled hypertension may use
short-term adrenergic agonists or decongestants. Smoking cessation should
also be stressed in this patient.
Antibiotics are over-prescribed for colds, URI and bronchitis. In one study,
more than 50% of patients who presented with any of these three conditions
was prescribed an antibiotic, even though antibiotics have little to no benefit in
these conditions.
Ipratropium bromide has been shown to decrease nasal discharge and
sneezing, but routine use of this medication is questioned because of cost and
because it does not releive many other symptoms related to the common cold.
Sinus radiography is not indicated win the evaluation of uncomplicated viral
URI.
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Acute Sinusitis: References
• Snow, V., et al. Principles of appropriate antibiotic use for acute
sinusitis in adults. Ann Int Med 2001 Mar 20; 134(6): 495-7.
• Lau, J., et al. Diagnosis and treatment of acute bacterial sinusitis.
www.ahcpr.gov/clinic/epcsums/sinussum.htm 1999
• Williams, J., et al. Antimicrobial therapy for acute maxillary
sinusitis. Cochrane Review, latest version 26 May 1999.
• Dolor, R., et al. Comparison of cefuroxime with or without
intranasal fluticasone for the treatment of rhinosinusitis. The
CAFFS Trial: a randomized controlled trial. JAMA. 2001 Dec 26;
286:3097-105.
• Williams, J., et al. Does this patient have sinusitis? The rational
clinical examination series. JAMA 1993. 270(10); 12421246.
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