- ACRONYMS AND DEFINITIONS
- AAP - American Academy of Pediatrics
- AAO-HNS - American Academy of Otolaryngology-Head and Neck Surgery
- IDSA- Infectious Diseases Society of America
- RCT - Randomized controlled trial
- PATHOLOGY
- Sinuses are hollow cavities in the bones around the nose (see sinus illustration). The cavities have ostia which are openings that continuously drain mucus into the nasal cavity. Ethmoid and maxillary sinuses are present at birth, but they are very small. As a person grows, they gradually enlarge and reach their full size in the teenage years. Frontal sinuses do not develop until around the age of 7 years, and they are not visible radiographically until the age of 12. The sphenoid sinus does not appear until adolescence.
- Sinusitis occurs when inflammation from an upper respiratory pathogen, allergies, or some other irritant causes the nasal mucosa to swell. The swollen mucosa blocks the ostia that drain the sinus cavities, and this leads to mucous retention and infection. The maxillary and ethmoid sinuses are most commonly affected.
- Viruses are by far the most common cause of sinusitis. About 0.5% - 2% of viral sinusitis infections will be complicated by bacterial sinusitis. The most common pathogens seen in acute bacterial sinusitis are Strep pneumoniae and Haemophilus influenzae.
- Sinusitis is one of the most common diagnoses in primary care, and it accounts for about 17 million antibiotic prescriptions each year in the U.S alone [1,2,9]
- RISK FACTORS
- Viral infections
- Allergic rhinitis
- Anatomical abnormalities - (ex. deviated septum, enlarged nasal tissue, etc.)
- Cigarette smoking
- Diabetes
- Swimming and diving
- High altitude climbing
- Dental infections and procedures
- SYMPTOMS
- Nasal obstruction or congestion
- Loss of sense of smell and taste
- Facial pain and tenderness
- Facial pain or pressure that is worse when leaning over
- Nasal drainage (anterior and/or posterior)
- NOTE: Nasal purulence or colored nasal discharge does not indicate a bacterial infection. Purulence and/or color are indicative of inflammation and the presence of neutrophils and are not specific for bacteria.
- Fever
- Toothache (upper teeth) [1,2,7]
- DIAGNOSIS
- The diagnosis of sinusitis is typically made based on clinical symptoms
- Diagnostic studies can be performed (see imaging below), but they are not generally performed in most clinical settings
- BACTERIAL VS VIRAL SINUSITIS
- Overview
- There is no single symptom or physical finding that can distinguish bacterial sinusitis from viral sinusitis
- The IDSA and the AAO-HNS guidelines give the following recommendations for distinguishing viral from bacterial sinusitis
- IDSA guidelines state the following characteristics may be more consistent with bacterial sinusitis:
- Persistent symptoms lasting ≥ 10 days without evidence of improvement
- Onset with severe symptoms or signs of high fever (102°F) and purulent nasal discharge or facial pain lasting for at least 3 – 4 consecutive days at the beginning of illness
- Onset with worsening symptoms or signs characterized by the new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted 5–6 days and was initially improving. [3]
- AAO-HNS guidelines state that bacterial sinusitis should be diagnosed when:
- Symptoms or signs of acute rhinosinusitis (purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms; OR
- Symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement (double worsening) [7]
- IMAGING
- Overview
- Imaging studies are not indicated in acute, uncomplicated sinusitis
- Imaging studies cannot distinguish between bacterial and viral sinusitis
- Imaging studies
- Sinus X-ray - X-rays may show sinus opacities, air-fluid levels, or marked mucosal thickening
- Sinus CT scan - CT scans provide a detailed view of the paranasal sinuses. One limitation of sinus CT scans is that there is a high frequency of abnormal scans in asymptomatic patients. [2]
- TREATMENT
- Sinusitis without signs of bacterial infection
- Treatment is symptomatic. See symptomatic treatment below
- Sinusitis with signs of bacterial infection
- The IDSA recommendations for antibiotic therapy in adults with symptoms of bacterial sinusitis (see bacterial vs viral) are outlined in the table below. The use of antibiotics in the treatment of sinusitis is controversial and largely unsupported by randomized controlled trials (see studies below).
- AAP recommendations for antibiotics in children with sinusitis are also presented below
ADULTS (2012 IDSA) |
---|
Standard
High-dose therapy
|
ADULTS (PENICILLIN ALLERGIC) |
|
CHILDREN (2014 AAP) |
---|
Standard
High-dose therapy - recommended in communities with a high prevalence of nonsusceptible S. pneumoniae (>10%, including intermediate- and high-level resistance)
Moderate-to-severe illness - defined as the presence of one of the following: < 2 years old; attending child care; recently been treated with an antimicrobial
|
CHILDREN (PENICILLIN ALLERGIC) |
Young children (< 2 years old)
|
- Symptomatic treatments
- Analgesics - medications like NSAIDs (e.g. ibuprofen, naproxen) and acetaminophen can be used for pain and fever
- Intranasal steroids (e.g. Flonase, Nasonex) - intranasal steroids help relieve facial pain and nasal congestion. In one study, intranasal steroid was superior to amoxicillin and placebo for symptom relief [PMID 16337461]. A Cochrane meta-analysis also found that intranasal steroids were effective in relieving symptoms of sinusitis. [PMID 24293353] Contrarily, a randomized controlled trial detailed below (see studies) found no effect.
- Sinus rinses (e.g. NeilMed, Neti Pot) - sinus rinses with either isotonic or hypertonic saline may help relieve symptoms of congestion, particularly in patients with recurrent sinusitis
- Oral decongestants (e.g. Sudafed) - oral decongestants can help alleviate congestive symptoms
- Topical decongestants (e.g. Afrin) - topical decongestants can help alleviate congestive symptoms. Limit use to 3 - 5 days to prevent rebound congestion.
- Oral antihistamines (e.g. Claritin, Allegra, Zyrtec) - oral antihistamines may decrease secretions and suppress sneezing
- Guaifenesin (expectorant) and dextromethorphan (cough suppressant) (e.g. Mucinex DM, Robitussin DM) - can suppress cough and loosen chest congestion
- Systemic steroids
- Systemic steroids (e.g. prednisone) are sometimes used to treat sinusitis. A Cochrane review of systemic steroids for acute sinusitis found that they may improve symptoms in the short-term (3 - 14 days). [PMID 24664368] The analysis was limited by the fact that 4 of the 5 trials used antibiotics in addition to steroids. The one trial (see studies below) that compared steroid monotherapy to placebo found no significant effect. The study used a lower dose of prednisolone (30 mg) which may have limited its effectiveness. [8]
- CHRONIC SINUSITIS
- Definition
- Acute sinusitis: < 4 weeks
- Subacute sinusitis: 4 - 12 weeks
- Chronic sinusitis: > 12 weeks
- Diagnosis
- The AAO-HNS 2015 sinusitis guidelines give two criteria for diagnosing chronic sinusitis
- Both criteria must be met to make a diagnosis
- Criteria 1: ≥ 12 weeks of ≥ 2 of the following signs or symptoms:
- Mucopurulent drainage (anterior, posterior, or both)
- Nasal obstruction (congestion)
- Facial pain, pressure, or fullness
- Decreased sense of smell
- Criteria 2: Inflammation documented by ≥ 1 of the following findings:
- Purulent (not clear) mucus or edema in the middle meatus or anterior ethmoid region
- Polyps in nasal cavity or the middle meatus
- Radiographic imaging (CT scan is preferred) showing inflammation of the paranasal sinuses
- Special considerations:
- Allergy testing - allergic rhinitis is present in 40 - 84% of patients with chronic sinusitis
- Immune function testing - immune deficiencies associated with chronic sinusitis include selective IgA deficiency, common variable immunodeficiency, and specific antibody deficiency which features normal IgG levels but a defective response to polysaccharide vaccines. Recommended immune testing may include quantitative immunoglobulin measurements (IgG, IgA, and IgM), preimmunization- and postimmunization-specific antibody responses to tetanus toxoid and pneumococcal polysaccharide vaccines, CH50, and measurement of T-cell number and function (delayed hypersensitivity skin tests and flow cytometric enumeration of T cells) [7]
- Treatment
- One or both of the following
- Daily intranasal steroids (e.g. Flonase, Nasonex)
- Daily saline nasal irrigation (e.g. NeilMed, Neti Pot)
- ANTIBIOTIC STUDIES
- A study published in the JAMA enrolled 166 patients with acute sinusitis
Main inclusion criteria
- All of the following must be present: history of maxillary pain or tenderness in the face or teeth, purulent nasal secretions, rhinosinusitis symptoms for ≥ 7 days that were not improving or rhinosinusitis symptoms for < 7 days that had worsened after initial improvement
Main exclusion criteria
- Antibiotic treatment within 4 weeks
- Patients who rated symptoms as very mild or mild
Baseline characteristics
- Median age 32 years
- History of sinus disease - 73%
- Using daily intranasal steroid - 6%
- Average number of days with symptoms - 11
- Baseline SNOT-16 score - 1.71
Randomized treatment groups
- Group 1 (85 patients) - Amoxicillin 500 mg 3 times a day for 10 days
- Group 2 (81 patients) - Placebo for 10 days
- All patients also received guaifenesin, dextromethorphan, pseudoephedrine, and saline nasal spray
Primary outcome: Change in disease-specific quality of life after 3 to 4 days of treatment assessed with the Sinonasal Outcome
Test-16 (SNOT-16) (average of 16 sinus-related symptoms rated from 0 - 3 where 0=no problem and 3=severe problem)
Results
Duration: 10 days | |||
Outcome | Amoxicillin | Placebo | Comparisons |
---|---|---|---|
Primary outcome (Day 3) | 0.59 | 0.54 | p=0.69 |
Primary outcome (Day 7) | 1.06 | 0.86 | p=0.02 |
Primary outcome (Day 10) | 1.23 | 1.20 | p=0.85 |
|
Findings: Among patients with acute rhinosinusitis, a 10-day course of amoxicillin compared with placebo did not reduce symptoms at day 3 of treatment
- A study published in the JAMA enrolled 240 patients with acute sinusitis
Main inclusion criteria
- Two or more of the following: purulent nasal discharge predominantly on one side, sinus pain predominantly on one side, purulent nasal discharge on both sides and pus on inspection inside the nose
Main exclusion criteria
- History of recurrent sinusitis (≥ 2 attacks in previous 12 months)
- History of allergies
Baseline characteristics
- Average age 42 years
- History of previous sinusitis - 80%
- Median length of symptoms - 7 days
Randomized treatment groups
- Group 1 (53 patients) - Amoxicillin 500 mg 3 times a day for 7 days and nasal steroid for 10 days
- Group 2 (60 patients) - Amoxicillin 500 mg 3 times a day for 7 days and placebo spray
- Group 3 (64 patients) - Placebo and nasal steroid for 10 days
- Group 4 (63 patients) - Double placebo
Primary outcome: Proportion clinically cured at day 10 using patient symptom diaries and the duration and severity of symptoms. Patient
diaries included 11 symptom variables assessed on 7-point Likert scales.
Results
Duration: 10 days |
|
Findings: Neither an antibiotic nor a topical steroid alone or in combination was
effective as a treatment for acute sinusitis in the primary care setting.
- A study published in the Lancet enrolled 214 patients with maxillary sinusitis confirmed on X-ray
Main inclusion criteria
- Sinusitis symptoms (acute onset of a common cold with sickness, headache, nose obstruction, discharge, and tapping pain of the maxillary sinus) and a positive sinus X-ray that showed mucosal swelling of more than 5 mm, complete shadowing, or a fluid level
Main exclusion criteria
- Current episode > 3 months
- Antibiotics during previous month
Baseline characteristics
- Average age 34 years
- Average length of symptoms - 2.2 weeks
Randomized treatment groups
- Group 1 (108 patients) - Amoxicillin 750 mg three times a day for 7 days
- Group 2 (106 patients) - Placebo for 7 days
Primary outcome: Cure rate (defined as being symptom-free) after 2 weeks and symptom scores after 1 and 2 weeks
Results
Duration: 2 weeks | |||
Outcome | Amoxicillin | Placebo | Comparisons |
---|---|---|---|
Cure rate (2 weeks) | 65% | 52% | p=0.06 |
Greatly decreased symptoms (2 weeks) | 83% | 77% | p=0.20 |
Adverse events (mostly GI symptoms and rash) | 28% | 9% | p<0.001 |
Relapse within 1 year | 21% | 17% | p=0.42 |
|
Findings: Antibiotic treatment did not improve the clinical course of acute maxillary sinusitis presenting to
general practice. For these patients, an initial radiographic examination is not necessary and initial management can be limited to symptomatic treatment. Whether antibiotics
are necessary in more severe cases warrants further study.
- A study published in the Archives of Internal Medicine enrolled 252 patients with acute sinusitis
Main inclusion criteria
- All of the following: history of repeated purulent nasal discharge, unilateral or bilateral maxillary or frontal sinus pain for ≥ 48 hours, presence of pus under rhinoscopy
Main exclusion criteria
- Symptoms > 1 month
- Antibiotics during previous 4 weeks
- Upper respiratory infection
Baseline characteristics
- Average age 37 years
- Median length of symptoms - 4.5 days
Randomized treatment groups
- Group 1 (125 patients) - Augmentin 875/125 twice a day for 6 days
- Group 2 (127 patients) - Placebo for 6 days
Primary outcome: Time to cure. Cure was defined as no activity restrictions due to symptoms at work or home.
Patients were evaluated on days 7 and 14.
Results
Duration: 14 days | |||
Outcome | Augmentin | Placebo | Comparisons |
---|---|---|---|
Primary outcome (Day 7) | 29.8% | 30.7% | p>0.05 |
Primary outcome (Day 14) | 76.6% | 74% | p>0.05 |
|
Findings: Adult patients in general practice with clinically diagnosed acute rhinosinusitis experience no advantage
with antibiotic treatment with augmentin and are more likely to experience adverse effects
- STEROID STUDIES
- A study published in the CMAJ enrolled 185 patients with acute sinusitis
Main inclusion criteria
- Symptoms for at least 5 days
- At least 2 of the following: nasal discharge (posterior or anterior) or nasal congestion, facial pressure or pain, pain when chewing
Main exclusion criteria
- Symptoms > 12 weeks
- Recurrent sinusitis (≥ 2 episodes in previous year
- Use of intranasal or oral corticosteroids in the previous 4 weeks
Baseline characteristics
- Average age 43 years
- Median length of symptoms - 13 days
- History of allergic rhinitis - 19%
Randomized treatment groups
- Group 1 (93 patients) - Prednisolone 30 mg/day for 7 days
- Group 2 (92 patients) - Placebo for 7 days
- Patients were allowed to use acetaminophen and xylometazoline 0.1% nasal spray
- Family physicians were allowed to prescribe antibiotics or intranasal corticosteroid treatment but were advised to refrain from doing so as much as possible during the first week of study
Primary outcome: Resolution of facial pain or pressure on day 7 as recorded in a patient diary
Results
Duration: 7 days | |||
Outcome | Prednisolone | Placebo | Comparisons |
---|---|---|---|
Primary outcome | 62.5% | 55.8% | Diff 6.7%, 95%CI [-7.9 to 21.2%] |
|
Findings: Systemic corticosteroid monotherapy had no clinically relevant beneficial effects among patients with clinically diagnosed
acute rhinosinusitis.
- BIBLIOGRAPHY
- 1 - PMID 17303885 - BMJ review
- 2 - PMID 15329428 - NEJM review
- 3 - PMID 22438350 - IDSA guidelines
- 4 - PMID 23796742 - AAP sinusitis GL
- 5 - Manufacturer's PI for listed drug
- 6 - PMID 27431306 Neti pot study
- 7 - PMID 25832968 - AAO-HNS Clinical Practice Guideline (Update): Adult Sinusitis (2015)
- 8 - PMID 24664368 - Systemic corticosteroids for acute sinusitis, Cochrane Database Syst Rev (2014)
- 9 - Acute sinusitis, Medscape