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Home , Influenza, Nasal congestion, Nasal mucosa, Sinusitis, Sinus (anatomy)

Jennifer F. Wilson Science Writer Darren Taichman, MD,PhD Sankey Williams,MD Barbara J.Turner MD,MSED Section Editors For This original article has in theclinic version, CME Questions Practice Improvement Treatment Diagnosis Risk Factors PIER assistance ofsciencewritersandphysicianwriters.Editorialconsultantsfrom the ACP’s MedicalEducationandPublishingDivisionwiththe © 2010 AmericanCollegeofPhysicians judgment. cal The informationcontainedhereinshould neverbeusedasasubstituteforclini- treatment ofacutesinusitis. CME Objective:To reviewcurrentevidencefortheriskfactors,diagnosis,and mksap/15/?pr31, andotherresources referencedineachissueof http://pier.acponline.org, http://www.acponline.org/products_services/ interested intheseprimaryresourcesformoredetailcanconsult editors developIntheClinic Knowledge andSelf-AssessmentProgram).AnnalsofInternalMedicine PIER education resourcesoftheAmericanCollegePhysicians The contentofIntheClinic been and (Physicians’ InformationandEducationResource) click corrected. MKSAP "Original provide expertreviewofthecontent.Readerswhoare The Full specific is drawnfromtheclinicalinformationand from theseprimarysourcesincollaborationwith Text (PDF)" correction in column appears 2 page ITC3-16 page ITC3-13 MKSAP (ACP), including page ITC3-8 page ITC3-4 page ITC3-3 of on In theClinic. the the (Medical article last page at www.annals.org. of this document. in the clinic cute sinusitis affects millions of persons in the United States every year and is among the most common reasons for physician visits, Aprompting over 3 million visits annually (1). The more accurate term for this condition is acute rhinosinusitis, because symptoms involve both the and the sinuses. For simplicity, this review uses the term “sinusi- tis” for rhinosinusitis. There are 4 pairs of air-filled : the frontal, maxillary, ethmoid, and sphenoid sinuses. Acute sinusitis typically oc- curs in the maxillary sinuses (Figure). Sinusitis is characterized as acute when the duration of symptoms is shorter than 4 weeks, subacute when the dura- tion is from 4 weeks to 12 weeks, and chronic when the duration is more than 12 weeks. Sinusitis seems to be due to congestion and blockage of the nasal passages, usually in response to viral or allergic but oc- casionally to other stimuli. The paranasal sinuses become inflamed, and mu- cus cannot drain properly, providing an environment where , or rarely , can thrive. Persons with chronic , and particularly those with and , may be more prone to developing acute si- nusitis, but it can affect anyone. Suggestive symptoms include , con- gestion, facial , , and , all of which can be disruptive to usual activities but are rarely severe. The diagnosis is usually based on clinical . Radiologic tests are not recommended initially and, to make the diagnosis from culture, primary care physicians do not typically perform anterior rhinoscopy or antral puncture with aspiration. Evidence is lacking regarding optimum pre- vention and treatment. It is well known that physicians grossly overprescribe for presumed acute bacterial sinusitis despite a high prevalence of viral infection–causing symptoms. Moreover, 4 of 5 persons recover within 2 weeks without treatment (2). Overprescription of antibiotics probably reflects difficulty in establishing the diagnosis of sinusitis and in distinguishing viral from bacterial acute sinusitis. The risk for bacterial sinusitis is low until the symptoms persist for at least 7 to 10 days. A Cochrane review of 57 random- ized, controlled trials (RCTs) from 1950 to 2007 of antibiotics in the treat- ment of acute bacterial sinusitis reported that treatment reduced the risk for clinical failure at 7 to 15 days but was associated with significant side effects (2). When treatment is ineffective and sinusitis persists, or when symptoms are severe, puncture, imaging, and other diagnostic tests may be helpful in guiding management. In these cases, evaluation by a specialist may be warranted.

1. Anand VK. Epidemiol- ogy and economic impact of rhinosinusi- tis. Ann Otol Rhinol Laryngol Suppl. 2004;193:3-5. [PMID: 15174752] 2. Ahovuo-Saloranta A, Borisenko OV, Kova- nen N, et al. Antibi- otics for acute maxil- lary sinusitis. Cochrane Database Syst Rev. 2008:CD000243. [PMID: 18425861] 3. Mahakit P, Pumhirun P. A preliminary study of nasal in smokers, sinusitis and patients. Asian Pac J Im- Figure. Diffuse pansinusitis with mucosal thickening and polyposis in the munol. 1995;13:119- 21. [PMID: 8703239] anterior sinuses.

© 2010 American College of Physicians ITC3-2 In the Clinic Annals of Internal Medicine 7 September 2010 Risk Factors

What factors increase the risk for maxillary rhinosinusitis (4). How- acute sinusitis? ever, persons with asthma are more Most persons with acute sinusitis prone to chronic sinusitis, as are have had a recent upper respiratory persons with a condition known as viral infection, but acute sinusitis can Samter Triad or the ASA Triad, also occur with allergies or exposure which is characterized by asthma, to local irritants. These last 2 causes nasal polyps, and intolerance. are generally characterized by more In addition, persons with a deviated recurrent or chronic symptoms. Im- may also have an in- munocompromised persons are at creased risk for both acute and increased risk for fungal infection. chronic sinusitis.

Age Dental Older persons have more compro- from dental disease, mised immune systems and a such as dental and peri- greater prevalence of serious upper odontal infection, or procedures, infections, both of such as sinus perforations during which increase their risk for the tooth extraction, can precipitate of acute sinusitis. sinusitis. Patients with dental pain They also tend to have weakened may indeed have sinusitis, espe- cartilage and dryness in the nasal cially involving the upper teeth passages that can promote infec- and commonly the wisdom teeth. tion. Because young children have According to one review, odonto- more colds and smaller nasal and genic sinusitis accounts for about sinus passages, they face an in- 10% to 12% of maxillary sinusitis creased risk for sinusitis as well. cases (5). In such cases, the un- Smoke and other air pollutants derlying dental condition may be or only mildly Cigarette and cigar smoke and other symptomatic. Intervention is forms of , such as indus- needed to stop the disease pro- trial chemicals, increase the risk for gression and to avoid excess an- sinusitis. Air pollution can damage tibiotic treatment. the cilia responsible for moving mu- cus out of the sinuses (3). Other medical conditions Air travel and changes in atmospheric Medical conditions that cause in- pressure flammation in the airways or create Air travel as well as other situations persistent thickened stagnant that involve changes in atmospheric can increase the risk for recurrent pressure, such as deep sea diving or acute or chronic sinusitis, such as di- climbing to high altitude, increase the abetes and other disorders of the im- risk for sinus blockage and sinusitis. mune system. AIDS and poorly con- trolled particularly increase 4. Small CB, Bachert C, Lund VJ, et al. Judi- Swimming the risk for acute invasive fungal si- cious antibiotic use In frequent swimmers, the chlorine nusitis, which is called mucormyco- and intranasal corti- costeroids in acute in pools can irritate the lining of sis, zygomycosis, or fulminant inva- rhinosinusitis. Am J sive sinusitis (6). Pregnancy can also Med. 2007;120:289- the nose and sinuses and can lead 94. [PMID: 17398218] to sinusitis. cause temporary congestion and 5. Brook I. Sinusitis of odontogenic origin. symptoms of sinusitis. Otolaryngol Head Asthma and allergies Surg. 2006;135:349-55. Asthma and respiratory allergies An autoimmune disease, Wegener [PMID: 16949963] increase sinus , which granulomatosis, causes long-term 6. Deshazo RD. Syn- dromes of invasive can increase the risk for infection. swelling and tumor-like masses in . Med Allergic rhinitis may contribute air passages and predisposes to Mycol. 2009;47 Suppl 1:S309-14. to up to 30% of cases of acute acute as well as chronic sinusitis. [PMID: 18654920]

7 September 2010 Annals of Internal Medicine In the Clinic ITC3-3 © 2010 American College of Physicians Persons with abnormalities in cil- and remove from the si- In most cases, acute iary function or mucous produc- nuses (Box). Using irrigation sinusitis is diagnosed tion, such as or the and steam inhalation can help keep Kartagener syndrome (triad of the nose moist and the sinuses based on the history and , sinusitis, and dex- clear. A humidifier can moisten air trocardia), are also more likely to in dry indoor environments. physical examination have sinusitis. Structural abnormal- ities or facial injuries that impede Patients should avoid exposure to al- mucus drainage from the sinuses, lergens. If exposure is unavoidable, such as a deviated septum or nasal then use nasal , which How to Perform polyps, increase the risk as well. are more effective than antihista- Make a salt-water solution by mines at preventing recurrent sinusi- combining 1/2 tsp of Hospitalization tis in the allergic person. Im- noniodinated salt and 1/2 tsp baking soda in an 8-ounce glass Hospitalized patients face a higher munotherapy (or allergy shots) may of warm water. risk for sinusitis, particularly patients also reduce sinusitis due to allergies. Place the solution in a neti pot, with head injuries or conditions re- bulb syringe, or other appropriate quiring insertion of tubes through Environmental irritants should also delivery device. the nose, antibiotics, or steroid treat- be avoided, especially tobacco Lean over the sink with your head ment. Mechanical ventilators signif- smoke, but also chemicals with down and chin up. strong odors. Limit time swimming Pour or gently squeeze water into icantly increase the risk for sinusitis the upper . Water will drain in the maxillary sinuses. in chlorine-treated pools and div- out of other nostril. ing, which can force water into the Repeat on other side. How can patients decrease their sinuses from the nasal passages. risk for acute sinusitis? No method is scientifically proven Air travel poses a problem for pa- to prevent sinusitis, but various tients with acute or chronic sinusi- measures may decrease this risk. In tis. With air pressure changes in a particular, patients should follow plane, pressure can build up in the frequent hand-washing guidelines head, blocking sinuses or the eu- and avoid persons with the com- stachian tubes in the ears. Using mon cold or . Nasal irriga- nose drops before a tion may help reduce congestion flight can help reduce this problem.

Risk Factors... Because the most common cause of acute sinusitis is viral infec- tion, patients need to remember frequent and should avoid persons with the or influenza. Smokers should be helped to quit. Persons with chronic allergic rhinitis many benefit from treatment to reduce congestion.

CLINICAL BOTTOM LINE

Diagnosis

What is the role of the medical because it is painful, risks complica- 7. Rosenfeld RM, Andes history and physical examination tions, and requires expertise. D, Bhattacharyya N, in the diagnosis of acute sinusitis? et al. Clinical practice guideline: adult si- In most cases, acute sinusitis is diag- The history needs to focus on the nusitis. Otolaryngol duration of symptoms, because per- Head Neck Surg. nosed on the basis of the history and 2007;137:S1-31. physical examination, because there sons who have had less than 7 to [PMID: 17761281] 8. Williams JW Jr, Simel is no accepted office-based test for 10 days of symptoms are unlikely DL, Roberts L, et al. to have a bacterial infection. The Clinical evaluation for acute bacterial sinusitis. The gold- sinusitis. Making the standard test for the diagnosis of history should also include ques- diagnosis by history and physical exami- acute bacterial sinusitis is culture of tions about allergic rhinitis, sys- nation. Ann Intern the aspirate from an antral puncture, temic , trauma, airplane Med. 1992;117:705- 10. [PMID: 1416571] but this should not be done routinely travel, tobacco use, exposure to

© 2010 American College of Physicians ITC3-4 In the Clinic Annals of Internal Medicine 7 September 2010 environmental toxins, and anatomi- Why is it important to distinguish cal abnormalities. acute sinusitis from chronic The duration of symptoms sinusitis? is the main distinguishing According to a multidisciplinary Establishing the duration of symp- expert panel, the diagnosis of toms is necessary to guide proper feature, with acute sinusitis acute sinusitis should be based on treatment and management. The 2 primary symptoms: purulent duration of symptoms is the main occurring from 1 week to rhinitis and facial pain (7). Sepa- distinguishing feature, with acute si- less than 4 weeks after rately, these symptoms and physi- nusitis occurring from 1 week to less cal findings for the diagnosis of than 4 weeks after onset of symp- onset of symptoms, where- acute sinusitis only have fair per- toms, whereas subacute or chronic formance characteristics, but the sinusitis lasts longer. Acute sinusitis as subacute or chronic combination is better in making usually starts as a viral respiratory sinusitis lasts longer the diagnosis. Purulent infection, but chronic sinusitis is has a sensitivity of 72% and a more often caused by inflammation specificity of 52%, facial pressure and blockage due to allergies or a Common Signs and Symptoms or pain has a sensitivity of 52% physical obstruction, such as a devi- Associated With Acute and a specificity of 48%, and nasal ated septum, nasal polyps, mal- Rhinosinusitis obstruction has a sensitivity of formed bone or cartilage structures, • Rhinorrhea (frequently purulent, 41% and a specificity of 80% (8). tumors, or foreign objects. The occasionally blood tinged) Other symptoms are commonly symptoms of acute sinusitis are typi- • Facial pain found (Box). Patients may also de- cally more severe than those of • Nasal congestion or obstruction scribe worsening symptoms after chronic sinusitis but, in the latter • Postnasal drainage initial improvement (9). Never- disease, symptoms often last for • or theless, the absence of these spe- many months or even years and are • Ear pressure cific symptoms does not exclude often associated with a persistent • Cough the disease (10). Patients should cough and nasal congestion. also be asked about allergies and previous episodes of similar symp- Chronic sinusitis responds poorly to of Acute toms and seasonal patterns. conventional antibiotic and Rhinosinusitis typically requires a longer duration • Allergic rhinitis The physical examination should of treatment. Surgery may be war- • Drug-induced rhinitis (such as focus on checking for swollen ranted for patients with anatomic decongestant abuse more than 5 days, ) obstruction whose sinusitis is refrac- turbinates, purulent rhinorrhea, • Recurrent viral upper respiratory nasal polyps, and local sinus pain tory to medical treatment. Predis- infections when bending over. Pain induced posing factors that may further hin- • Dental pain with sinus percussion is a less re- der cure include severe respiratory • Occupational rhinosinusitis (12) liable finding than focal pain allergies or structural changes caused • Gastroesophageal reflux (13) when bending over. An oropha- by chronic sinusitis itself or by previ- • or tension headache (14) ryngeal red streak also may also ous surgery for symptoms. Acute ex- • Nasal polyps (obstruction) be useful for diagnosing acute acerbations can frequently compli- sinusitis. cate chronic sinusitis.

In a study of 60 patients at a Veterans Af- What noninfectious conditions 9. Snow V, Mottur-Pilson C, Gonzales R; Ameri- fairs urgent care center (54 men; mean should clinicians consider when can Academy of Fam- age, 51 years) who had nasal symptoms ily Physicians. Princi- evaluating a patient for acute ples of appropriate lasting 4 or more weeks, patients were sinusitis? antibiotic use for given a structured history and physical treatment of acute A key distinguishing feature of in adults. examination and then sinus computed acute sinusitis is the duration of Ann Intern Med. tomography (CT). Sinusitis was diag- 2001;134:518-20. symptoms. Symptoms lasting more [PMID: 11255531] nosed in 27 patients. The presence of 10. Blomgren K, Alho oropharyngeal red streak had a sensitivi- than 12 weeks represent chronic si- OP, Ertama L, et al; nusitis, which has a different differ- Finnish Society of ty of 70% and a specificity of 67% (11). Otorhinolaryngolo- The generalizability of this finding is un- ential than acute sinusitis. The Box gy committee. Acute sinusitis: Finnish clin- clear. The authors recommended includ- lists conditions that clinicians ical practice guide- ing the sign in future studies of acute si- should consider among the differ- lines. Scand J Infect Dis. 2005;37:245-50. nusitis clinical diagnostic criteria. ential diagnoses for acute sinusitis. [PMID: 15871161]

7 September 2010 Annals of Internal Medicine In the Clinic ITC3-5 © 2010 American College of Physicians These conditions may produce sim- view for visualizing the paranasal si- ilar signs and symptoms but require nuses, especially the - different treatment. es. A series of 3 or 4 radiographs is often ordered. A common criterion What is the role of imaging in the for positive is sinus flu- diagnosis of acute sinusitis? id or opacity. Some studies also con- The history and physical examina- sider thickening tion establishes the diagnosis for greater than 50%, which increases most patients (15). Radiologic evi- the sensitivity of radiography but dence of “sinusitis” exists in 87% of decreases its specificity. viral upper respiratory infections; however, less than 3% of these infec- A systematic review of methods for diagnos- tions progress to bacterial infection. ing acute maxillary sinusitis analyzed 11 eli- 11. Thomas C, Aizin V. Imaging should only be considered gible studies and determined that radiogra- Brief report: a red phy was more accurate than sinus puncture streak in the lateral for persons with rhinosinusitis symp- recess of the and that ultrasonography was slightly less oropharynx predicts toms lasting at least 7 to 10 days accurate than radiography (17). Only 2 stud- acute sinusitis. J Gen Intern Med. who have a history of recurrent ies compared clinical examination and si- 2006;21:986-8. symptoms or nonresponse to multi- nus puncture, and both found that the clini- [PMID: 16918746] 12. Hellgren J. Occupa- ple courses of antibiotics in the past. cal examination was unreliable, regardless tional rhinosinusitis. A lower threshold for imaging may of clinician expertise. On the basis of this Curr Allergy Asthma Rep. 2008;8:234-9. be used for patients at risk for seri- weak evidence, the authors concluded that [PMID: 18589842] 13. Saleh H. Rhinosinusi- ous complications, such as immuno- using radiography or ultrasonography im- tis, laryngopharyn- compromised persons. proved diagnostic accuracy. geal reflux and cough: an ENT view- point. Pulm Pharma- Sinus radiography A meta-analysis of published studies com- col Ther. Regardless of the prevalence of bac- paring diagnostic tests for acute sinusitis in- 2009;22:127-9. cluded 13 studies and found that radiogra- [PMID: 19480077] terial sinusitis in the patient popula- 14. Silberstein SD. phy and clinical evaluation provided useful due to tion or the individual’s likelihood of nasal and paranasal diagnostic information, whereas ultrasono- sinus disease. Neurol bacterial sinusitis, sinus radiography graphy performance varied substantially (18). Clin. 2004;22:1-19, v. [PMID: 15062525] is not typically required in the rou- 15. Meltzer EO, Hamilos tine management of uncomplicated Role of CT and magnetic resonance DL, Hadley JA, et al; American Academy sinusitis (16). Plain sinus radiogra- imaging of Allergy, Asthma phy has reasonable diagnostic per- Evidence to support the role of sinus and Immunology (AAAAI). Rhinosinusi- formance, with a sensitivity of 87% CT and magnetic resonance imaging tis: establishing defi- nitions for clinical re- and a specificity of 89%; ultrasono- (MRI) in diagnosing acute bacterial search and patient graphy has poorer performance (10). sinusitis is limited. One study found care. J Allergy Clin Immunol. However, neither test is cost- CT was more sensitive than x-rays 2004;114:155-212. [PMID: 15577865] effective compared with sympto- for showing radiographic changes 16. Evidence Report: Di- matic treatment or the use of clinical consistent with acute sinusitis (19). agnosis and Treat- ment of Acute Bac- criteria to guide antibiotic therapy. Use of new low-dose scanners re- terial Sinusitis. Boston: New Eng- Acute viral sinusitis resembles acute duces radiation exposure compared land Medical Center, bacterial sinusitis on radiographs. with traditional CT. However, like Evidence-based Practice Center; plain sinus film x-rays, CT and MRI 1998. When other conditions are being 17. Varonen H, Mäkelä scans also have high false-positive M, Savolainen S, et seriously considered in the differen- rates in acute sinusitis. al. Comparison of ul- tial of acute sinusitis, sinus radiogra- trasound, radiogra- phy, and clinical ex- phy may be warranted. Radiologic Several studies using CT or MRI have re- amination in the ported sinus mucosal abnormalities in up diagnosis of acute studies are also useful in patients maxillary sinusitis: a with predisposing factors for atypi- to 49% of apparently healthy persons with systematic review. J no symptoms of sinusitis (20, 21). The clini- Clin Epidemiol. cal microbial causes, such as 2000;53:940-8. cal importance of these chance findings is [PMID: 11004420] Pseudomonas aeruginosa, or fungal in- uncertain. Asymptomatic patients with 18. Engels EA, Terrin N, fection in immunocompromised pa- Barza M, et al. Meta- abnormalities on imaging studies do not analysis of diagnos- tients or in those in whom empirical require treatment. tic tests for acute si- nusitis. J Clin therapy has failed. The occipitomen- Epidemiol. tal view (also known as the Waters Given problematic current evidence 2000;53:852-62. [PMID: 10942869] view) is the standard radiographic supporting the use of CT or MRI,

© 2010 American College of Physicians ITC3-6 In the Clinic Annals of Internal Medicine 7 September 2010 they should be reserved for investi- count test with differential, thyroid gation of symptoms or signs of lo- function tests for fatigue; and chlo- cal spread or intracranial complica- ride testing to rule out cystic fibro- tions (22). In addition, when sis. Consider referral to an allergist sinusitis symptoms persist for more or immunologist for evaluation of than 3 weeks despite treatment, or the role of allergy or an immune are recurrent, CT may be useful for deficiency contributing to recurrent reassessing diagnosis and determin- or persistent sinusitis. ing the need for referral. What organisms can cause acute What is the role of laboratory sinusitis? testing in the diagnosis of acute The predominant isolates from sinusitis? acute bacterial sinusitis have long 19. Burke TF, Guertler AT, Usually, no laboratory tests are Timmons JH. Com- been and parison of sinus x- needed to diagnose acute sinusitis. . One early rays with computed tomography scans in In cases that do not respond to study estimated that these - acute sinusitis. Acad treatment or that get worse, tissue Emerg Med. isms accounted for more than 50% 1994;1:235-9. cultures may help pinpoint the spe- of acute bacterial sinusitis (24). [PMID: 7621202] 20. Havas TE, Motbey cific cause. The sinus puncture is With recent pneumococcal vaccina- JA, Gullane PJ. Preva- considered the gold standard for tion, there seems to be a relative in- lence of incidental abnormalities on diagnosing sinusitis, because it is crease in H. influenzae. Studies in computed tomo- the most accurate way to identify graphic scans of the more recent years have also shown paranasal sinuses. the organism responsible for sinusi- more catarrhalis, especially Arch Otolaryngol Head Neck Surg. tis. In this test, an otolaryngologist in children and young adults, and 1988;114:856-9. administers local anesthesia then [PMID: 3390327] more Streptococcus pyogenes. 21. Patel K, Chavda SV, uses a large-bore needle to with- Violaris N, et al. Inci- dental paranasal si- draw small amounts of fluid from About one third of H. influenzae iso- nus inflammatory the maxillary sinus to culture. Be- lates and most isolates of M. ca- changes in a British β population. J Laryn- cause this test is invasive and car- tarrhalis produce -lactamases and gol Otol. 1996;110:649-51. ries the risk for complications, such are resistant to and amoxi- [PMID: 8759538] as increased pain, bleeding, cillin. These organisms become re- 22. Stewart MG, John- son RF. Chronic si- swelling, and false passage, it is sistant to either through nusitis: symptoms usually reserved for cases requiring the production of β-lactamase versus CT scan find- ings. Curr Opin Oto- microbial identification, such as (H. influenzae, M. catarrhalis, Staphylo- laryngol Head Neck Surg. 2004;12:27-9. when antibiotic therapy has failed. coccus aureus, Fusobacterium spp., and [PMID: 14712116] Transnasal endoscopic culture rep- Prevotella spp.) or through changes 23. Benninger MS, Payne SC, Ferguson resents a reasonable alternative to in the penicillin-binding protein BJ, et al. Endoscopi- cally directed middle antral puncture. It is also per- () (25). In pa- meatal cultures ver- formed in the otolaryngologist’s of- tients who harbor more resistant sus maxillary sinus taps in acute bacter- fice with the use of a topical anes- bacteria, antimicrobial therapy di- ial maxillary rhinosi- thetic but is less invasive. In a nusitis: a meta- rected against all pathogens in mixed analysis. Otolaryngol meta-analysis of studies of endo- infections is often required. Head Neck Surg. 2006;134:3-9. scopic versus antral culture, the for- [PMID: 16399172] mer had a sensitivity of 80.9%, Less commonly, acute sinusitis is 24. Gwaltney JM Jr. Acute community- specificity of 90.5%, positive pre- caused by a fungal infection. Sinus acquired sinusitis. fungal infections usually occur in im- Clin Infect Dis. dictive value of 82.6%, and negative 1996;23:1209-23; predictive value of 89.4%, (23). On munocompromised persons but have quiz 1224-5. [PMID: 8953061] the other hand, nasal culture speci- been known to occur in persons who 25. Brook I. Microbiolo- are immunocompetent. Acute fungal gy and antimicrobial mens obtained from a direct swab management of si- through the nose do not correlate sinusitis is most commonly caused nusitis. J Laryngol Otol. 2005;119:251-8. well with sinus pathogens found in by either the or Mucor [PMID: 15949076] a sinus puncture, because of con- (26). Fulminant invasive dis- 26. Taxy JB, El-Zayaty S, Langerman A. Acute tamination of the swab with nor- ease has a high mortality if not treat- Fungal Sinusitis Nat- ural History and the mal nasal flora. Other laboratory ed early and aggressively. Treatment Role of Frozen Sec- tests depend on the clinical situa- usually involves removal of the fun- tion. Am J Clin Pathol. 2009;132:86- tion, such as a complete blood gus via nasal surgery. 93. [PMID: 19864238]

7 September 2010 Annals of Internal Medicine In the Clinic ITC3-7 © 2010 American College of Physicians Diagnosis... Most cases of acute sinusitis are diagnosed by history and physical examination. Key findings are purulent rhinitis and facial pain. Other symptoms that may be indicative of acute sinusitis include unilateral facial pressure or pain, facial pressure that is worse when bending forward, general headache, olfactory disturbance, , halitosis, maxillary , cough, and the presence of an oropharyngeal red streak. Establishing the duration of symptoms is important be- cause, when the duration is less than 7 to 10 days, the condition is more likely to be a viral infection, whereas bacterial infection generally only appears after at least 1 week of symptoms. Chronic sinusitis (symptoms longer than 30 days), nasal polyps, upper respiratory infection, migraine, and dental may pro- duce signs and symptoms similar to acute sinusitis. Imaging should be reserved for cases that are resistant to treatment or when a complication or alternative conditions is likely. Similarly, laboratory tests are usually unnecessary except for treatment failure. Bacterial pathogens Streptococcus pneumoniae, H. influenzae, and M. catarrhalis account for most cases of acute bacterial sinusitis.

CLINICAL BOTTOM LINE Treatment What nondrug measures are pathogens. Furthermore, restricted helpful in the treatment of use of antibiotics avoids drug side patients with acute sinusitis? effects, particularly gastrointestinal No well-designed, randomized effects. A Markov disease simula- studies have addressed the efficacy tion model found that empirical of nondrug . Steam in- antibiotic treatment was cost-effec- halation, hydration, and sinus irri- tive from a societal perspective but gation are often recommended. that drug resistance would eventu- These measures can help thin mu- ally lead to increased costs and re- cus and aid sinus draining. Sinus ir- duced efficacy (28). rigation, such as with a saline nasal irrigation or neti pot, can increase A Cochrane review of 5 RCTs mucosal moisture and remove in- comparing antibiotics with flammatory debris and bacteria. and 51 RCTs comparing antibiotics According to a Cochrane review, from different classes for the treat- 27. Kassel JC, King D, nasal saline irrigation abbreviated ment of acute maxillary sinusitis in Spurling GK. Saline adults reported a statistically signif- nasal irrigation for symptoms by a nonsignificant 0.3 acute upper respira- day (out of 8 days) in 1 study, icant difference in favor of antibi- tory tract infections. Cochrane Database whereas, in a second study, irriga- otics compared with placebo Syst Rev. (pooled relative risk [RR], 0.66 2010;3:CD006821. tion was associated with less time [PMID: 20238351] off work, but minor discomfort was [95% CI, 0.44 to 0.98]) (2). The 28. Anzai Y, Jarvik JG, review considered trials with clini- Sullivan SD, et al. The not uncommon (27). cost-effectiveness of cally diagnosed acute sinusitis but the management of acute sinusitis. Am J How should clinicians decide did not require confirmation by ra- Rhinol. 2007;21:444- whether to use antibiotics to treat diography or bacterial culture. 51. [PMID: 17882914] 29. Arroll B, Kenealy T. acute sinusitis? Overall, the meta-analysis found a Antibiotics for the common cold and Most cases of suspected sinusitis 34% reduction (CI, 2% to 56%) in acute purulent rhini- will resolve without antibiotic ther- the RR for resolution at 7 to 15 tis. Cochrane Data- base Syst Rev. apy, so this treatment should be re- days, but the authors deemed this 2005:CD000247. [PMID: 16034850] served for persons who have had evidence as “equivocal” because 30. Williamson IG, symptoms for at least 7 to 10 days 80% of the control group had Rumsby K, Benge S, et al. Antibiotics and and who have received conservative symptoms resolve versus 90% of topical nasal steroid treatment. Widespread prescribing the antibiotic treatment group. The for treatment of acute maxillary si- of antibiotics has serious ramifica- authors concluded that antibiotics nusitis: a random- ized controlled trial. tions, including increased costs of have a small beneficial effect in pa- JAMA. care and promotion of drug-resist- tients with uncomplicated acute 2007;298:2487-96. [PMID: 18056902] ant strains of common respiratory sinusitis.

© 2010 American College of Physicians ITC3-8 In the Clinic Annals of Internal Medicine 7 September 2010 Another Cochrane review of 6 signs and symptoms could not accurately RCTs comparing antibiotic therapy identify patients with rhinosinusitis, even Probability of Bacterial Sinusitis against placebo in persons with acute when a patient reported symptoms lasting High probability (>50%) when at longer than 7 to 10 days. least 2 of the following are upper respiratory tract infections and present: upper respiratory less than 7 days of symptoms or less Because the signs and symptoms of infection >7 days, facial pain, and than 10 days of acute purulent rhini- purulent discharge (nasal, acute bacterial sinusitis and of pro- pharyngeal, or both). tis found that persons receiving an- longed viral upper respiratory tract tibiotics did no better than those re- Low probability (<25%) when only infections are similar, misclassifica- 1 of the following are present: ceiving placebo (29). The antibiotics tion is common (33). The decision upper respiratory infection >7 did not improve the cure rate or the days, facial pain, or purulent to use antibiotic therapy should be discharge. persistence of symptoms (in terms of based on the probability of bacterial lack of cure or symptom persistence, sinusitis (Box). Antibiotic therapy RR, 0.89, [CI, 0.77 to 1.04]). is appropriate for patients with a Other recent studies and analyses high likelihood of bacterial sinusi- have reported similarly unclear tis, or if symptomatic therapy fails findings. in low-probability cases. In patients with less severe symptoms who One RCT of 240 adults with acute nonrecur- have had no improvement after 7 rent sinusitis in the primary care setting to 10 days of symptomatic therapy, found that an antibiotic did not provide ef- antibiotic therapy may be added. fective treatment for acute sinusitis. Not only did 7 days of antibiotic (500 mg 3 Antibiotic therapy times daily) prove ineffective, but so did this The choice of antibiotics depends antibiotic combined with budesonide (200 on circumstances (Table). An in- µg once daily in each nostril), or 10 days of crease in bacterial resistance may budesonide alone (30). need to be taken into account when One review of 7 studies concluded that prescribing antibiotics, but evidence most patients will get better without an- is lacking for better clinical out- tibiotics, with the benefit of avoiding an- comes by selecting antibiotics that tibiotic-related adverse effects (31). The au- might have a lower probability of thors calculated that patients treated with resistance. Pneumococcal resistance antibiotics for 5 to 8 days for persistent pu- to and other agents has rulent rhinitis had a 1.18 pooled RR for ben- increased, and trimethoprim– efit (CI, 1.05 to 1.33) but a 1.46 RR for ad- sulfamethoxazole is not a recom- verse effects from antibiotics (CI, 1.10 to mended second-line agent in chil- 1.94) They concluded that antibiotics are dren although it continues to be an probably effective for acute purulent rhini- acceptable first-line agent in adults. tis but supported a no antibiotic as first line” strategy. 31. Arroll B, Kenealy T. Newer broad-spectrum agents are, Are antibiotics effec- tive for acute puru- A meta-analysis of 9 randomized trials as- however, more costly than most older lent rhinitis? System- atic review and sessing whether common signs and symp- agents, and substantial concern exists meta-analysis of toms can be used to identify patients who about promoting the development of placebo controlled randomised trials. benefit from antibiotics determined that an- widespread resistance among bacteria BMJ. 2006;333:279. tibiotics would have to be given to 15 pa- [PMID: 16861253] in the community and in the . 32. Young J, De Sutter A, tients with rhinosinusitis-like symptoms be- Evidence indicates that these broad- Merenstein D, et al. fore an additional patient was cured (95% CI Antibiotics for adults spectrum agents are usually unneces- with clinically diag- NNT[benefit] 7 to NNT[harm] 190) (32). Pa- sary in first-line treatment. nosed acute rhinosi- tients with purulent discharge in the phar- nusitis: a meta- analysis of individual ynx took longer to cure; 8 patients with pu- A Cochrane review of antibiotic use for acute patient data. Lancet. rulent discharge in the would need sinusitis identified 51 studies that compared 2008;371:908-14. [PMID: 18342685] to be treated with antibiotics before 1 addi- different classes of antibiotics and found 33. Snow V, Mottur-Pil- tional patient was cured (95% CI NNT[bene- that the efficacy of these regimens was simi- son C, Hickner JM; American Academy fit] 4 to NNT[harm] 47). Older patients or lar, with the exception of a significantly low- of Family Physicians. those whose symptoms were more severe or er risk for clinical failure at 7 to 15 days fol- Principles of appro- priate antibiotic use longer-lasting were no more likely than oth- low-up for amoxicillin–clavulanate than for for acute sinusitis in er patients to benefit from antibiotics. The cephalosporins, but this benefit disappeared adults. Ann Intern Med. 2001;134:495- authors concluded that common clinical with longer follow-up. However, adverse 7. [PMID: 11255527]

7 September 2010 Annals of Internal Medicine In the Clinic ITC3-9 © 2010 American College of Physicians Table. Drug Treatment for Sinusitis, by Highest Level of Evidence* Agent Notes Nasal steriods (e.g., fluticasone, 2 puffs Reduces mucosal inflammation. May cause local irritation. intranasally [200 µg] daily) Oral corticosteroids For severe disease, reduces pain. Antibiotics Only prescribe after 5 days of symptoms and treat for at least 7 to 10 days. Or treat for 7 days after the resolution of symptoms. First-line: Amoxicillin, 1.5 to 3.5 g/d divided Potential adverse effects: rash, hypersensitivity reaction (rare), gastrointestinal symptoms. 2 or 3 times daily) Trimethoprim–sulfamethoxazole Consider in patients allergic to penicillin. Potential adverse effects: hematologic (rare), (800/160 mg twice daily) rash, gastrointestinal symptoms, toxic epidermal necrolysis (rare). Pneumococcal resistance is high. Second-line: Amoxicillin–clavulanate Same as first-line amoxicillin. (500/125 mg 3 times daily) Second- or third-generation cephalosporins Caution in patients allergic to penicillin. Side effects include gastrointestinal upset, (e.g., cefuroxime, 250 or 500 mg twice daily, headache, rash, blood dyscrasias. or cefaclor, 250 or 500 mg 3 times daily) (200 mg on first day then 100 mg Potential adverse effects: gastrointestinal upset, photosensitivity, . twice daily for 2 to 10 days) Not recommended in children aged ≤8 y. Macrolides (e.g., , 500 mg twice daily, Consider in patients allergic to both penicillin and trimethoprim–sulfamethoxazole. or , 500 mg daily for 5 days) For 5 d of azithromycin, stop for 5 d, then may have to repeat. Potential adverse effects: gastrointenstinal upset, allergic reactions (e.g., angioedema), liver dysfunction. Fluoroquinolones (e.g., , Side effects: gastrointestinal upset, diarrhea, headache, confusion. Concern about 500 twice a day, , 500 mg once daily) antibiotic resistance.† Oral (e.g., loratadine, 10 mg daily) Inhibits inflammatory pathways, helpful especially with history of allergic rhinitis. Nasal decongestant (e.g., Reduces mucosal inflammation, improves ostial drainage by vasoconstriction. intranasally, 2 to 3 sprays every 8 to 10 h) Avoid use for more than 3 to 5 days because of the risk for rebound congestion. Systemic (e.g., Use caution with underlying , poorly controlled hypertension, short-acting, 60 mg every 4 to 6 h, or hyperthyroidism, or diabetes mellitus. long-acting, 120 mg every 12 h) Mucolytic agents (e.g., guaifenesin, 1200 mg twice Reduces viscosity of nasal secretions. May cause gastrointestinal symptoms. daily, not to exceed 2400 mg per 24 h)

* Thomas M, Yawn BP, Price D, et al; European Position Paper on Rhinosinusitis and Nasal Polyps Group. EPOS Primary Care Guidelines: European Position Paper on the Primary Care Diagnosis and Management of Rhinosinusitis and Nasal Polyps 2007 - a summary. Prim Care Respir J. 2008;17:79-89. [PMID: 18438594] † Le Saux N. The treatment of acute bacterial sinusitis: no change is good medicine. CMAJ. 2008;178:865-6. [PMID: 18362382]

effects were greater for the amoxicillin– on the optimum duration of anti- clavulanate group compared with the biotic treatment for acute sinusitis, and cephalosporin groups (29). and it is unclear whether such long Therefore, little evidence supports using more courses are necessary. A recent expensive, broad-spectrum antibiotics for Cochrane review on the use of an- acute sinusitis. tibiotics for acute sinusitis found no A review of 49 studies determined that for appropriately designed studies to ad- acute maxillary sinusitis confirmed radi- dress the duration of therapy (2). ographically or by aspiration, the current lim- Unfortunately, lengthy courses of an- 34. Williams JW Jr, ited evidence supports the use of penicillin or tibiotic treatment increase the risk Aguilar C, Cornell J, et al. Antibiotics for amoxicillin for 7 to 14 days (34). The authors for resistance (35, 36). acute maxillary si- nusitis. Cochrane note, however, that the moderate benefits of Database Syst Rev. antibiotic treatment need to be weighed A patient who responds only par- 2003:CD000243. [PMID: 12804392] against the potential adverse effects. tially to initial amoxicillin therapy 35. Guillemot D, Carbon may benefit from extending therapy C, Balkau B, et al. Low dosage and Amoxicillin by an additional 7 to 10 days, for a long treatment du- Amoxicillin is generally recommend- total of 3 weeks (37). In cases of si- ration of beta-lac- tam: risk factors for ed as a first-line agent. Traditionally, nusitis that do not improve after 3 carriage of penicillin- resistant Streptococ- courses of 7 to 14 days have been to 5 days of antibiotic treatment, an cus pneumoniae. used in clinical practice and in most alternative antibiotic may be con- JAMA. 1998;279:365- 70. [PMID: 9459469] randomized trials. Data are limited sidered.

© 2010 American College of Physicians ITC3-10 In the Clinic Annals of Internal Medicine 7 September 2010 Doxycycline How should clinicians decide For patients who are allergic to whether to use other drugs to penicillin or who have persistent treat acute sinusitis? symptoms, consider alternative A range of nonantibiotic drugs are antibiotics, such as doxycycline commonly used to try to restore nor- or trimethoprim–sulfamethoxa- mal sinus environment and function zole in adults and doxycycline (Table). In patients with a low prob- in older children. Cure rates ability of bacterial disease, these oth- are similar for doxycycline and er drugs may be used as initial thera- amoxicillin (38). py. They can also relieve symptoms in patients who have been prescribed Doxycycline has a broader spec- antibiotics. Efficacy seems to vary, trum than amoxicillin; it also covers and evidence is limited, but available β -lactamase–producing strains of research indicates that these ancillary H. influenzae and M. catarrhalis. Its drug therapies are generally benefi- 36. Hay AD, Thomas M, use should satisfy concerns about Montgomery A, et cial, particularly for people with less al. The relationship when pro- between primary severe symptoms. In particular, in- care antibiotic pre- viding treatment for acute sinusitis. tranasal steroids have received some scribing and bacteri- al resistance in Trimethoprim–sulfamethoxazole recent attention. adults in the com- munity: a controlled Trimethoprim–sulfamethoxazole In a Cochrane meta-analysis, 3 trials found observational study using individual pa- is another good option for that intranasal steroids for acute sinusitis tient data. J Antimi- patients with penicillin allergies increased resolution or improvement of crob Chemother. 2005;56:146-53. or persistent symptoms. However, symptoms compared with control partici- [PMID: 15928011] pants (73% versus 66.4%; risk ratio, 1.11 [CI, 37. University of Michi- pneumococcal resistance rates gan Health System. to trimethoprim–sulfamethoxa- 1.04 to 1.18]). furoate Acute rhinosinusitis (MFNS), 400 µg versus 200 µg, was associ- in adults. Ann Arbor, zole have increased to at least MI: Univ Michigan ated with greater improvement (risk ratio, 24% (39). For patients who are Health System; 2007 1.10 [CI, 1.02 to 1.18]) with no significant 38. de Bock GH, Dekker not allergic to sulfamethoxazole, FW, Stolk J, et al. An- adverse events reported at either dose (41). timicrobial treat- trimethoprim–sulfamethoxazole ment in acute maxil- is an effective drug for most In a double-blind, placebo-controlled trial lary sinusitis: a meta-analysis. J Clin patients, but because of resistance in 139 patients aged 15 to 65 years with al- Epidemiol. lergies and acute rhinosinusitis confirmed 1997;50:881-90. concerns, failure to respond [PMID: 9291872] after approximately 5 days by rhinoscopy and sinus radiograph, par- 39. Jenkins SG, Brown ticipants received antibiotics, steroids, and SD, Farrell DJ. Trends should prompt reconsideration in antibacterial re- of therapy. either loratadine or placebo. The group sistance among with adjunctive loratadine had significant- Streptococcus pneu- moniae isolated in Cephalosporins ly greater improvement in sneezing (P = the USA: update 0.003) after 14 days, and in nasal obstruc- from PROTEKT US First-generation cephalosporins Years 1-4. Ann Clin tion (P = 0.002) after 28 days compared have minimal efficacy against Microbiol Antimi- with patients who received placebo (42). crob. 2008;7:1. Streptococcus pneumoniae and [PMID: 18190701] 40. de Ferranti SD, Ioan- H. influenzae. Second-generation Over-the-counter pain nidis JP, Lau J, et al. Are amoxycillin and cephalosporins, such as cefpo- may also be used to reduce sinusitis- folate inhibitors as doxime, are considered second- effective as other an- related congestion and discomfort. tibiotics for acute si- line agents for acute sinusitis. nusitis? A meta- Evidence on the effect of herbal analysis. BMJ. 1998;317:632-7. Minor side effects, mostly gastro- remedies is very limited. A review [PMID: 9727991] intestinal, occurred in 10% to 41. Zalmanovici A, of RCTs testing the effect of any Yaphe J. Intranasal 20% of patients in most reports herbal medicine as sole or adjunc- steroids for acute si- nusitis. Cochrane and as many as half in some tri- tive treatment for sinusitis found Database Syst Rev. als. In most cases, side effects re- 2009:CD005149. limited evidence that any are bene- [PMID: 19821340] solved once antibiotic treatment ficial (43). 42. Braun JJ, Alabert JP, was stopped. The withdrawal rate Michel FB, et al. Ad- junct effect of lorata- in randomized trials averaged What are the complications of dine in the treat- ment of acute between 4% and 6% with amoxi- acute sinusitis? sinusitis in patients cillin, folate inhibitors, or Serious complications of acute with allergic rhinitis. Allergy. 1997;52:650- doxycycline (38, 40). bacterial sinusitis are rare when the 5. [PMID: 9226059]

7 September 2010 Annals of Internal Medicine In the Clinic ITC3-11 © 2010 American College of Physicians infection is managed properly. An- complication can also be fatal. Nerve Serious complications of tibiotic treatment can usually resolve damage from a sinus infection may acute bacterial sinusitis even severe episodes. However, clini- cause permanent loss of sense of cians need to be aware of clinical smell or taste. When either oph- are rare when the alerts signifying more serious infec- thalmic or neurologic symptoms or tion or complications (Box). Because signs are present, the patient should infection is managed of the proximity of the sinuses to the be referred for consultation by a spe- properly. brain, the infection can become cialist. Appropriate diagnostic imag- threatening if it spreads. Intracranial ing, such as CT, may be required. complications occur if the infection passes through the layer of bone sepa- In addition to these serious but rare Clinical Alerts rating the sinuses from the tissue and complications, sinusitis may exacer- bate asthma; therefore, treating the Orbital swelling, erythema of fluid that lines the brain. In severe , limited extraocular cases of this complication, infection sinus condition will improve asthma movements spreads to the brain and causes an ab- symptoms. Gastroesophageal reflux Focal neurologic signs scess. Based on data from the early can also exacerbate sinusitis when it Altered mental status 1990s, approximately 1000 cases of is sufficiently severe to be associated Abnormal culture on sinus puncture brain abscesses per year are sinusitis- with ; pa- Exacerbation of asthma related, translating to an attack rate of tients may respond to treatment with 1 in 3000 in patients seen for acute gastric acid suppression and other sinusitis (44). A retrospective review behavioral changes, such as avoiding of the incidence of head and neck ab- late or spicy meals (13). scesses in children admitted to a terti- ary care pediatric hospital during the When should clinicians consider first quarters of 2000 through 2003 consultation from a specialist? found increasing incidence of compli- In patients with uncomplicated si- cations of acute sinusitis (45). nusitis, consultation increases the costs of care without added diagnostic In a French series of 25 cases of intracranial or clinical benefits. It should be re- complications from sinusitis, most were served for complicated cases or for men aged 10 to 20 years who had no risk patients whose symptoms are severe factors. Frontal and sphenoid sinuses were or do not respond to initial therapy. the most commonly involved. Diffuse headache evolving to altered mental sta- Otolaryngologists can provide spe- tus was indicative of and brain cialized care when patients with pre- 43. Guo R, Canter PH, abscess (46). sumed acute sinusitis do not respond Ernst E. Herbal medi- to initial treatment or have recurrent cines for the treat- ment of rhinosinusi- Infection can also spread from the or chronic sinus infections, or if an tis: a systematic review. Otolaryngol sinuses to the and can cause in- anatomical abnormality is suspected. Head Neck Surg. flammation of the eyelid, abscesses, An allergist should be consulted 2006;135:496-506. [PMID: 17011407] and blindness. Orbital is di- when underlying atopic disease is 44. National Ambulatory Medical Care Survey. agnosed on the basis of orbital present, especially in persons with re- National Hospital swelling, redness of the conjunctiva, current episodes or persistent symp- Discharge Survey. National Center for and limitation of extraocular move- toms. Patients with other underlying Health Statistics. Se- ments. Periorbital and orbital celluli- ries 13. 1993-1995. disease may require referral to other 45. Cabrera CE, Deutsch tis are seen mainly in children. specialists. ES, Eppes S, et al. In- creased incidence of When sinusitis becomes chronic and head and neck ab- erodes the bony areas around the si- Specialty referral is also advised scesses in children. Otolaryngol Head nuses, it makes the infection more when serious complications, such Neck Surg. as , venous si- 2007;136:176-81. difficult to treat and increases the [PMID: 17275535] risk for intracranial and intraorbital nus thrombosis, an abscess or 46. Bayonne E, Kania R, Tran P, et al. Intracra- complications. Other potential com- meningeal spread of infection are nial complications of plications include an aneurysm or suspected. Consultation with an rhinosinusitis. A re- view, typical imag- blood clot that can be triggered otolaryngologist, ophthalmolo- ing data and algo- rithm of if the infection spreads from the gist, neurosurgeon, infectious management. Rhi- cavity to the carotid disease expert, or neurologist may nology. 2009;47:59- 65. [PMID: 19382497] artery or . This be appropriate, depending on

© 2010 American College of Physicians ITC3-12 In the Clinic Annals of Internal Medicine 7 September 2010 symptoms. Patients should be Failure to improve may indicate hospitalized if they have serious antibiotic resistance, significant al- complications of acute bacterial lergic inflammation, a fungal rather sinusitis, such as local extension than bacterial infection, or the of the infection or orbital in- presence of complications. volvement, infection or thrombo- sis of the intracranial venous si- In cases where sinusitis persists or recurs, a follow-up physical should nuses, or metastatic spread to the include a check for persistent fever, . These sinus tenderness, purulent discharge, complications require a long and changes in mental status or vi- course of parenteral antibiotics sion. Clinicians should assess factors and close observation. that could modify management, such Do special considerations exist for as allergic rhinitis, anatomic varia- clinical care of patients with tion, cystic fibrosis, ciliary dyskinesia, recurrent acute sinusitis? and immunocompromised state (7). In patients with persistent Imaging studies and bacterial symptoms, it can be difficult to cultures, such obtained from determine whether the recurrence nasal , may help deter- represents a relapse of previous in- mine the course of treatment and fection or a de novo episode. rule out complications. Patients Re-evaluation is warranted when with recurrent episodes of acute symptoms persist for several weeks sinusitis who have been evaluated or new or worsening symptoms and found not to have anatomic develop, especially symptoms anomalies may benefit from suggestive of serious complications. second-line antibiotic therapy.

Treatment... Steam inhalation, hydration, and sinus irrigation are frequently recom- mended nondrug measures for treating acute sinusitis. Nonantibiotic drugs, such as nasal steroids, antihistamines, and decongestants, can also help restore normal sinus environment and function. Expert opinions vary on the appropriate role of antibiotics in treating acute sinusitis. Many cases of suspected sinusitis will resolve without antibiotics. Antibiotic therapy is appropriate for patients with less severe symptoms with no improvement after 7 to 10 days, especially with adjunctive therapy. Anti- biotic therapy may be added in patients with a high likelihood of bacterial sinusitis. The choice of antibiotics depends on circumstances. Amoxicillin is generally recom- mended as a first-line agent for patients with no penicillin allergy. Serious complica- tions of acute bacterial sinusitis are rare when the infection is managed properly, but there is potential for the infection to be life-threatening if it spreads. Specialty con- sultation or hospitalization may be needed for complicated cases or for patients whose symptoms are severe or fail to respond to initial therapy.

CLINICAL BOTTOM LINE Practice Are there practice guidelines that fungi are increasingly being rec- relevant to acute sinusitis? ognized as a factor in chronic sinusi- Improvement In 2005, the Joint Council of Allergy, tis, particularly in the southeast and Asthma, and Immunology updated southwest parts of the country. their 1998 guidelines on diagnosis and management of sinusitis (47). In 2006, the American College of The guidelines incorporated new Chest Physicians (ACCP) Expert concepts in diagnosis and manage- Panel on the Diagnosis and Man- ment and new insights into patho- agement of Cough (URTI) recom- genesis. In particular, the authors note mended that, in patients with cough

7 September 2010 Annals of Internal Medicine In the Clinic ITC3-13 © 2010 American College of Physicians and acute upper respiratory tract in- Guidelines from the British National 47. Slavin RG, Spector fection, the diagnosis of bacterial si- Institute for Health and Clinical Ex- SL, Bernstein IL, et al; nusitis should not be made during cellence recommend a “no antibiotic American Academy of Allergy, Asthma the first week of symptoms (48). The or delayed antibiotic strategy” for and Immunology. The diagnosis and authors noted that the symptoms, most cases of sinusitis (49). Recom- management of si- signs, and sinus imaging abnormali- mendations do, however, advise an nusitis: a practice parameter update. J ties of an upper respiratory tract in- immediate antibiotic prescription and Allergy Clin Im- munol. fection may be indistinguishable further appropriate investigation and 2005;116:S13-47. from acute bacterial sinusitis. management for patients who are sys- [PMID: 16416688] 48. Pratter MR. Cough temically sick or who have symptoms and the common Guidelines released in 2007 from and signs suggestive of serious illness cold: ACCP evi- dence-based clinical the American Academy of Oto- or complications; for patients who practice guidelines. laryngology and Head and Neck Chest. 2006;129:72S- have a preexisting comorbid condi- 74S. Surgery Foundation recommended tion that increases risk for serious [PMID: 16428695] 49. Centre for Clinical that clinicians should reevaluate the complications; and for elderly patients Practice. Respiratory diagnosis and consider other causes tract infections—an- who have additional criteria that in- tibiotic prescribing. of illness and possible complica- crease risk, such as diabetes or oral Prescribing of antibi- tions when symptoms worsen or do otics for self-limiting use. respiratory tract in- not improve by 7 days after diagno- fections in adults and children in pri- sis and management (7). If the di- An evidence report sponsored by the mary care. London: agnosis of acute bacterial sinusitis is Agency for Healthcare Research and National Institute for Health and Clinical confirmed, the clinician should be- Quality on the treatment of acute Excellence; 2008. 50. Ip S, Fu L, Balk E, et gin antibiotic therapy in patients bacterial sinusitis noted that studies al. Update on acute initially managed with observation comparing newer antibiotics with bacterial rhinosinusi- tis. Evid Rep Technol and should change the prescribed older, less expensive ones like amoxi- Assess (Summ). antibiotic in patients initially man- cillin and trimethoprim–sulfamethox- 2005;124:1-3. [PMID: 15989375] aged with an antibiotic. azole are lacking (50).

PIER Modules http://pier.acponline.org/physicians/diseases/d096/d096.html in the clinic Access the PIER module on acute sinusitis from the American College of Physicians.

PIER modules provide evidence-based, updated information on current diagnosis and c treatment in an electronic format designed for rapid access at the point of care. Patient Information Tool Kit http://pier.acponline.org/physicians/diseases/d096/d096-pi.html Access the Patient Information material that appears on the following pages for dupli- cation and distribution to patients. www.aaaai.org/patients/publicedmat/tips/sinusitis.stm Acute Sinusitis Access a Tips to Remember: Sinusitis, a patient handout from the American Academy of

Allergy, Asthma & Immunology (AAAAI). lini www.nlm.nih.gov/medlineplus/sinusitis.html Access MEDLINE Plus information about acute sinusitis for patients, including an interactive tutorial available in both English and Spanish. Clinical Guidelines www.entnet.org/Practice/adultSinusitis.cfm Clinical practice guidelines, released in 2007, from the American Academy of Oto- laryngology and Head and Neck Surgery Foundation on adult sinusitis. www.aaaai.org/professionals/resources/pdf/sinusitis2005.pdf Practice recommendations, issued in 2005, from the Joint Council of Allergy, Asthma, ec and Immunology on the diagnosis and management of sinusitis. http://chestjournal.chestpubs.org/content/129/1_suppl/1S.full Practice recommendations, released in 2006, from the American College of Chest Physicians (ACCP) Expert Panel on the diagnosis and management of cough (URTI). Diagnostic Tests and Criteria www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=erta9&part=A13283 Sensitivity and Specificity of a 4-Item Clinical Score for Diagnosing Acute Bacterial Sinusitis. Quality of Care Guidelines www.guideline.gov/content.aspx?id=12682&search=acute+sinusitis A 2007 update of an earlier guideline from the University of Michigan Health System in th

© 2010 American College of Physicians ITC3-14 In the Clinic Annals of Internal Medicine 7 September 2010 THINGS YOU SHOULD In the Clinic Annals of Internal Medicine KNOW ABOUT ACUTE SINUSITIS

What is acute sinusitis? What is the difference between a cold • Acute sinusitis, also known as a sinus infection or and acute sinusitis? rhinosinusitis, refers to inflammation and infection • A cold is caused by a and usually lasts about 1 in one or more of the paranasal sinuses. week. Persons with symptoms of acute sinusitis for less than 1 week are still usually only infected with a • It often occurs after a cold, when mucus gets virus. trapped in inflamed sinuses and does not drain properly. This condition encourages bacterial growth, • Acute bacterial sinusitis generally occurs after or rarely fungal growth, that can lead to infection. symptoms have persisted for 7 to 10 days. • Sinusitis affects is one of the most common reasons people visit the doctor. How do you know if you have acute sinusitis? • It is acute when in the early stages, from 1 to 4 weeks after symptoms start. Subacute or chronic sinusitis has • Your doctor will make the diagnosis based on your symptoms that last longer than 1 month. symptoms and a physical examination.

• In complicated, severe, or persistent cases, x-rays or Who gets it? computed tomography may be needed. A sample of • Anyone can get sinusitis, but it is more common in sinus fluid may need to be obtained by a specialist very young people and elderly people. to identify the exact of bacteria causing the sinusitis. • People with nasal allergies or asthma have an increased risk for sinusitis. How is it treated? • Smoking, swimming, air travel, and dental problems • Resting, drinking plenty of fluids, and using a saline are factors that increase risk for sinusitis. spray or neti pot can reduce symptoms. • Decongestants, antihistamines, and other over-the- What are the signs and symptoms? counter medications may also reduce symptoms. • Symptoms include a headache, congestion with in the nose, facial pressure and pain, postnasal drip, • Antibiotics may be prescribed if your doctor believes cough, , and fatigue. your symptoms and the duration of the disease warrant this treatment. • A fever lasting more than 3 to 4 days is suggestive of a bacterial infection.

For More Information

https://aaaai.org/patients/topicofthemonth/1206/ Sinusitis FAQs from the American Academy of Allergy, Asthma, and Immunology.

www.entnet.org/HealthInformation/doIHaveSinusitis.cfm Fact Sheet: Do I Have Sinusitis? From the American Academy of Otolaryngology-Head and Neck Surgery.

http://www3.niaid.nih.gov/topics/sinusitis/ Information on sinusitis from the National Institute of Allergy and Infectious Disease. Patient Information Patient CME Questions

1. A 37-year-old woman is evaluated for a 3. A 32-year-old man has a 5-day history Which is the most likely reason for this 2-week history of sinus congestion. She of persistent nasal congestion and pain patient’s symptoms? initially believed she had a cold and felt in the right forehead area associated A. Allergic rhinitis better after taking an over-the-counter with a clear nasal discharge and mild B. Bacterial sinusitis combination of oral pseudoephedrine and cough. The patient reports that he has C. diphenhydramine; however, her symptoms had similar episodes in the past that D. returned, and she began having low-grade were helped by antibiotics. Medical E. Viral upper respiratory infection and increased nasal secretions. She history is otherwise unremarkable, and has no drug allergies. he currently takes no medications. 5. A 37-year-old man is evaluated for On physical examination, the On physical examination, vital signs, frontal headaches, nasal congestion, and temperature is 37.4°C (99.4°F). There is including temperature, are normal. Mild mucopurulent nasal drainage that have right maxillary pressure when her head is right suborbital ridge tenderness is persisted intermittently for several years. down, erythematous turbinates, present. The nares are patent with a He also has fatigue, a nighttime cough, yellowish-green nasal secretions and a clear mucoid discharge. There is no and decreased . Over the thickened postnasal drip and erythema pharyngeal erythema or . The past 4 months, he has received 3 of the posterior pharynx. lungs are clear to auscultation. successive courses of antibiotics for Which is the most appropriate Which is the best initial management? worsening symptoms—initially with management for this patient’s disorder? week-long courses of trimethoprim– A. Amoxicillin sulfamethoxazole and doxycycline. Most A. Oral amoxicillin B. CT of the sinuses recently, he completed a 3-week course of B. Oral nonsedating C. Plain films of sinuses amoxicillin–clavulanate in combination C. Sinus radiography D. with a nasal steroid , nasal saline D. Sinus computed tomography (CT) E. Trimethoprim–sulfamethoxazole irrigation, and an oral decongestant. This E. Oral amoxicillin–clavulanate treatment regimen provided only partial 4. A 24-year-old man requests antibiotics relief. He has no history of allergic rhinitis, 2. A 28-year-old man presents with 4 days during an evaluation for symptoms he eczema, or drug allergy. of upper respiratory congestion and sinus has attributed to a sinus infection. He pain. The patient has had no significant reports sinus congestion and clear nasal On physical examination, he is afebrile. medical history. He notes that he may drainage that has persisted for 1 month The turbinates are edematous, with have initially had a mild fever but he has after he developed a cold; he has no yellowish mucus between the right not been febrile in the past 48 hours. He fever, sinus pain, purulent nasal drainage, middle turbinate and lateral nasal wall. describes some yellowish nasal sneezing, or nasal itching. Since the The septum is deviated to the right but discharge. On examination, he has fluid onset of his symptoms, he has been with no nasal polyps. Percussion of his behind his tympanic membranes and using a nasal decongestant spray with right maxillary sinus elicits mild moderate tenderness over his maxillary only short-term symptomatic relief, but tenderness. sinuses. He has taken acetaminophen for he states that antibiotics have been Which is the most appropriate his discomfort and an “herbal” drug for effective in the past for treating his management for this patient’s condition? colds. sinus infections. His history includes A. Allergy testing What is the most appropriate initial allergic rhinitis, but his primary allergens B. Nasal swab cultures are not in season. management? C. Sinus MRI A. Oral prednisone taper Nasal examination shows congested D. Sinus CT B. Amoxicillin with a profuse watery E. Sinus radiography discharge. The nasal septum seems C. Oral decongestants normal, the turbinates are pale, and D. Trimethoprim–sulfamethoxazole there are no polyps. The remainder of the E. Azithromycin physical examination is normal.

Questions are largely from the ACP’s Medical Knowledge Self-Assessment Program (MKSAP, accessed at http://www.acponline.org/products_services/mksap/15/?pr31). Go to www.annals.org/intheclinic/ to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.

© 2010 American College of Physicians ITC3-16 In the Clinic Annals of Internal Medicine 7 September 2010 Correction: Acute Sinusitis contained an error. The last line In the recent In the Clinic on acute should be: “Repeat on the other side.” sinusitis (1), the figure title on page ITC3-2 was incorrect. The correct These errors been corrected in the title is: “Diffuse pansinusitis with online version. mucosal thickening and polyposis in the anterior sinuses.” Reference 1. Wilson JF. In the clinic. Acute si- Also, the sidebar “How to Perform nusitis. Ann Intern Med. 2010;153: Nasal Irrigation” on page IT3-4 ITC3-1-15. [PMID: 20820036]