Acute Sinusitis Treatment & Management

The guidelines of the American Academy of Pediatrics on the diagnosis and management of acute bacterial sinusitis in children and adolescents recommend the following:

• Previous diagnostic criteria for acute bacterial sinusitis in children were acute upper respiratory tract infection (URI) with either nasal discharge and/or daytime cough for longer than 10 days or severe onset of fever, purulent nasal discharge, and other respiratory symptoms for 3 or more consecutive days. A third criterion added to the updated guideline is URI with worsening symptoms such as nasal discharge, cough, and fever after initial improvement.

• Physicians may observe children with persistent infection lasting longer than 10 days for an additional 3 days before prescribing antibiotics, but antibiotics should still be given to children with severe onset or worsening symptoms.

• First-line therapy is amoxicillin with or without clavulanate.

• Imaging tests are not recommended for children with uncomplicated acute bacterial sinusitis, although children with suspected orbital or CNS complications should undergo CT scanning of the paranasal sinuses.

The Canadian clinical practice guidelines for acute bacterial rhinosinusitis based the diagnosis of acute bacterial sinusitis on the presence of specific symptoms and their duration; imagining or cultures are not needed in uncomplicated cases. ^[42] The guidelines for treatment depend on symptom severity and recommend intranasal corticosteroids (INCSs) as monotherapy for mild and moderate cases, although the benefit might be modest. The use of INCSs plus antibiotics is reserved for patients who fail to respond to INCSs after 72 hours and for initial treatment of patients with severe symptoms. The guidelines recommended that antibiotic selection must account for the suspected pathogen, the risk of resistance, comorbid conditions, and local antimicrobial resistance trends. Adjunctive therapies such as nasal saline irrigation are recommended. Failure to respond to treatment, recurrent episodes, and signs of complications should prompt referral to an otolaryngologist.

The guidelines by the American Academy of Otolaryngology--Head and Neck Surgery Foundation ^{[33, 34]}  recommend that clinicians (1) either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated acute bacterial rhinosinusitis or (2) prescribe amoxicillin with or without clavulanate as first-line therapy for 5-10 days (if the decision is made to treat acute bacterial rhinosinusitis with an antibiotic).

Clinicians may (1) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis; (2) recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of acute sinusitis; and (3) obtain testing for allergy and immune function in the evaluation of a patient with chronic or recurrent acute sinusitis.

The primary goals of management of acute sinusitis are to eradicate the infection, decrease the severity and duration of symptoms, and prevent complications. These goals are achieved through the provision of adequate drainage and appropriate systemic treatment of the likely bacterial pathogens.

Drainage of the involved sinus can be achieved both medically and surgically. Aggressively treat patients in intensive care who develop acute sinusitis in order to avoid septic complications. Consider removal of nasotracheal and nasogastric tubes and promote drainage either medically or surgically.

Sinus puncture and irrigation techniques allow for a surgical means of removal of thick purulent sinus secretions. The purpose of surgical drainage is to enhance mucociliary flow and provide material for culture and sensitivity. A surgical means of sinus drainage should be used when appropriate medical therapy has failed to control the infection and prolonged or slowly resolving symptoms result or when complications of sinusitis occur.

Another indication for sinus puncture is to obtain culture material to guide antibiotic selection if empiric therapy has failed or antibiotic choice is limited. This is particularly important in patients who are immunocompromised or in intensive care. Sinusitis can be a prominent source of sepsis in these patients. In adults, sinus puncture can usually be achieved using local anesthesia; however, in children, a general anesthetic is usually necessary.

Most patients with acute sinusitis are treated in the primary care setting. Further evaluation by an otolaryngologist is recommended when any of the following exist:

• When continued deterioration occurs with appropriate antibiotic therapy

• When episodes of sinusitis recur

• When symptoms persist after 2 courses of antibiotic therapy

• When comorbid immunodeficiency, nosocomial infection, or complications of sinusitis are present

While in the emergency department and upon discharge, patients may obtain significant immediate relief with the administration of first-generation antihistamines, decongestants, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Recommendations for nonantimicrobial therapy

Intranasal steroids have not been conclusively shown to be of benefit in cases of acute sinusitis. One meta-analysis of 4 double-blind, placebo-controlled trials of intranasal corticosteroid treatment in acute rhinosinusitis supports its use as monotherapy or as an adjuvant therapy to antibiotics. ^[43] However, a randomized, controlled trial of antibiotics and intranasal steroid showed no treatment benefit of intranasal steroids, either alone or with antibiotics. ^[44]

In a literature study, van Loon et al concluded that only limited evidence exists regarding the efficacy of intranasal corticosteroids in relieving the symptoms of recurrent acute rhinosinusitis. The best evidence, according to the investigators, came from a single study, which had a low bias risk but only moderate directness of evidence; according to that report, intranasal corticosteroids may shorten the time needed to achieve symptom relief. ^[45]

No available data suggest that antihistamines are beneficial in acute sinusitis. In fact, antihistamines may cause harm by drying mucous membranes and decreasing clearance of secretions. Antihistamines are beneficial for reducing ostiomeatal obstruction in patients with allergies and acute sinusitis; however, they are not recommended for routine use for patients with acute sinusitis. Antihistamines may complicate drainage by thickening and pooling sinonasal secretions.

Medical drainage is achieved with topical and systemic vasoconstrictors. Oral alpha-adrenergic vasoconstrictors, including pseudoephedrine and phenylephrine, can be used for 10-14 days to allow for restoration of normal mucociliary function and drainage.

Because oral alpha-adrenergic vasoconstrictors may cause hypertension and tachycardia, they may be contraindicated in patients with cardiovascular disease. Oral alpha-adrenergic vasoconstrictors may also be contraindicated in competitive athletes because of rules of competition.

Topical vasoconstrictors (eg, oxymetazoline hydrochloride) provide good drainage, but they should be used only for a maximum of 3-5 days, given the increased risk of rebound congestion, vasodilatation, and rhinitis medicamentosa when used for longer periods.

Mucolytic agents (eg, guaifenesin, saline lavage) have the theoretical benefit of thinning mucous secretions and improving drainage. They are not, however, commonly used in clinical practice in the treatment of acute sinusitis.

Recommendations for antimicrobial therapy

Ahovuo-Saloranta et al, in a 2008 Cochrane Review meta-analysis of 57 studies, concluded that antibiotics yield a small treatment effect in a primary care setting in patients with uncomplicated sinusitis whose symptoms have lasted more than 7 days. ^[46] However, another meta-analysis found no treatment effect of antibiotics, even in patients whose symptoms had persisted for more than 10 days. ^[47]

In cases of suspected or documented bacterial sinusitis, the second principle of treatment is to provide adequate systemic treatment of the likely bacterial pathogens (ie, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis). The physician should be aware of the probability of bacterial resistance within their community. Reports range from approximately 33-44% of H influenzae and almost all of M catarrhalis strains have beta-lactamase–mediated resistance to penicillin-based antimicrobials in children. 

Risk factors for pneumococcal and H. influenzae resistance are:

• Residing in a region with rates of penicillin-nonsusceptible  Streptococcus pneumoniae >10 %.
• Antibiotic use by the patient or member of their household in the last 6 weeks.
• Attendance in a day care center.
• Age ≥65 years
• Residing in nursing home or hospitalization in the last 6 weeks.
• Comorbidities (eg, Immunocompromised, diabetic or chronic cardiac, liver, or renal disease).

A study by Garbutt et al evaluated the effect of amoxicillin treatment over symptomatic treatments for adults with clinically diagnosed acute sinusitis. In a randomized, placebo-controlled trial of 166 adults with uncomplicated, acute sinusitis patients received a 10-day course of either amoxicillin (85 patients) or placebo (81 patients). On day 3 of treatment, there was no difference in improvement between placebo-takers and those prescribed antibiotics. On day 7, the antibiotic group reported a slight improvement, but that edge disappeared by day 10, when 80% of patients in both groups reported they felt better or cured. ^[48]

The reduced efficacy of amoxicillin led the Infectious Diseases Society of America to generate new guidelines for the treatment of acute rhinosinusitis. These guidelines recommend amoxicillin-clavulanate over amoxicillin as empiric antimicrobial therapy in adults and children with acute bacterial rhinosinusitis. ^[49]

Several systematic reviews have also been published on antimicrobial therapy versus placebo, with at least 5 since 2005. Pediatric studies have also examined antimicrobial treatment. Evaluating the results of meta-analyses is essential to determine the quality of the studies included in the meta-analyses. A review of many of these studies indicates 2 common methodologic flaws: (1) many patients were declared eligible for study with only 7 days of symptoms (without a qualifier regarding whether these symptoms have begun to improve) and (2) images (plain radiographs, CT scans, ultrasounds, MRIs) were often used as diagnostic entry criteria. Accordingly, good logic exists to believe that many patients enrolled in these studies had uncomplicated viral upper respiratory tract infections rather than acute bacterial rhinosinusitis, thereby diluting the results. Nonetheless, most studies do show a modest benefit with the use of antimicrobials. This benefit may possibly be substantially magnified if more of the study patients actually had acute bacterial rhinosinusitis.

Sng and Wang evaluated 31 random control trials studying the clinical efficacy and side effects of cefuroxime axetil, telithromycin, amoxicillin/potassium clavulanate, levofloxacin, moxifloxacin and clarithromycin in the treatment of acute bacterial sinusitis. Among them, 9 studies were performed double-blinded with placebo controls. The results showed that, while antibiotics are more efficacious than placebo in the treatment of acute bacterial sinusitis, the risks of potential side effects need to be weighed against the potential benefits. ^[50]

As many as 64% of S pneumoniae strains are penicillin resistant because of altered penicillin-binding proteins. Multidrug-resistant S pneumoniae strains are also found in substantial numbers of children in daycare settings. ^[35]

Initial selection of the appropriate antibiotic therapy (see Table 1, below) should be based on the likely causative organisms given the clinical scenario and the probability of resistant strains within a community. The course of treatment is usually 5-10 days.

First-line therapy at most centers is usually amoxicillin or a macrolide antibiotic in patients allergic to penicillin because of the low cost, ease of administration, and low toxicity of these agents. Amoxicillin should be given at double the usual dose (80-90 mg/kg/d), especially in areas with known S pneumoniae resistance.

Table 1. Dosage, Route, and Spectrum of Activity of Commonly Used First-Line Antibiotics* (Open Table in a new window)

Patients who live in communities with a high incidence of resistant organisms, those who fail to respond within 48-72 hours of commencement of therapy, and those with persistence of symptoms beyond 10-14 days should be considered for second-line antibiotic therapy (see Table 2, below).

The most commonly used second-line therapies include amoxicillin-clavulanate, second- or third-generation cephalosporins (eg, cefuroxime, cefpodoxime, cefdinir), macrolides (ie, clarithromycin), fluoroquinolones (eg, ciprofloxacin, levofloxacin, moxifloxacin), and clindamycin.

In patients with dental causes of sinusitis or those with foul-smelling discharge, anaerobic coverage using clindamycin or amoxicillin with metronidazole is necessary.

Table 2. Dosage, Route, and Spectrum of Activity of Commonly Used Second-Line Antibiotics* (Open Table in a new window)

Patients with nosocomial acute sinusitis require adequate intravenous coverage of gram-negative organisms (see Table 3, below). Aminoglycoside antibiotics are usually the drugs of choice for the treatment of such patients because of their excellent gram-negative coverage and sinus penetration. Selection of an antibiotic is usually based on the culture results of attained maxillary secretion.

In addition to surgical management, complications of acute sinusitis should be managed with a course of intravenous antibiotics. Third-generation cephalosporins (eg, cefotaxime, ceftriaxone) in combination with vancomycin provide adequate intracranial penetration, making them a good first-line choice.

Table 3. Dosage, Route, and Spectrum of Activity of Commonly Used Intravenous Antibiotics (Second-Line)* (Open Table in a new window)

Symptomatic or adjunctive therapies may include the following:

• Humidification/vaporizer

• Warm compresses

• Adequate hydration

• Smoking cessation

• Balanced nutrition

• Nonnarcotic analgesia

Antihistamines are not recommended and have not been proven beneficial. Topical decongestants such as oxymetazoline can be used to decrease mucosal edema. To prevent rebound congestion, they should not be used for more than 3 days.

A 15- to 21-day course of intranasal corticosteroids may reduce symptom duration when compared to placebo. ^{[18, 51]} Mometasone 200, 400, and 800 μg twice daily for 15 days is the usual regimen given, with minimal adverse effects. Systemic steroids have no proven benefit in sinusitis.

Topical ipratropium bromide 0.06% can be used to decrease rhinorrhea. Antihistamines have not been shown to be of benefit in decreasing nasal congestion; in fact, they may cause overdrying of the nasal mucosa. Mucolytics such as guaifenesin can be used to thin secretions, though they have not been definitively shown to be of benefit.

Antimicrobial therapy is the mainstay of medical treatment in sinusitis. Choice of antibiotic depends on whether the sinusitis is acute, chronic, or recurrent. The AAAAI 2005 practice parameter states that choice of antibiotic should be based on predicted effectiveness, cost, and side effects. ^[4]

In clinically diagnosed acute sinusitis, little evidence from randomized, controlled trials supports the use of antibiotics for the treatment of acute sinusitis. ^[18] Antibiotics have, however, been shown to have a role in the treatment of acute maxillary sinusitis that is diagnosed radiologically or bacteriologically.

Based on a literature review, Kaper et al concluded that no studies have adequately addressed whether the effects of antibiotic therapy in recurrent acute rhinosinusitis differ from those in primary or sporadic episodes of acute rhinosinusitis. The authors concluded, therefore, that the question of whether or not to use initial antibiotic therapy in patients with recurrent episodes of the condition should be decided by employing the same criteria used to weigh the need for antibiotic treatment in patients with primary or sporadic episodes of uncomplicated acute rhinosinusitis. ^[52]

Antibiotics are indicated for sinusitis that is thought to be bacterial, including sinusitis that is severe or involves the frontal, ethmoid, or sphenoid sinuses, since this type of sinusitis is more prone to complications. ^[53] Penicillins, cephalosporins, and macrolides seem to be equally efficacious. ^[18] A 5- to 10-day regimen of amoxicillin 500 mg 3 times a day is recommended as first-line therapy. ^{[34, 49, 54]}

One study suggests that a single dose of 2 g of extended-release azithromycin may be more effective than a 10-day course of amoxicillin/clavulanate. ^[55] However, azithromycin is not likely a good choice in sinusitis because symptoms may improve only because of the anti-inflammatory efficacy of the agent and because it has poor efficacy against S pneumoniae and H influenzae. The risk of adverse effects should be weighed against the severity of disease and patient comorbidities prior to initiating antibiotic treatment.

Patterns of bacterial resistance should also be taken into account in the choice of antibiotic. 

Recurrent or persistent sinusitis and presence of complications may require surgical therapy. Failure to respond to appropriate antibiotic therapy, especially in chronic and persistent sinusitis (eg, cystic fibrosis), is an indication for surgical intervention.

Functional endoscopic sinus surgery (FESS) has revolutionized the treatment of sinusitis in recent years. The therapeutic benefits of FESS have helped a large number of patients with chronic sinus disease. ^{[56, 57]}

 

Surgical treatment for acute frontal sinusitis is undertaken when the infection fails to respond to conservative therapy (defined as the use of intravenous antibiotics and mucolytic agents along with topical and systemic decongestants for 3-5 days) or when dangerous complications arise. An additional indication is recurrent acute sinusitis, defined as 3-4 infections per year.

Several techniques have been described for drainage of the maxillary sinus. The inferior meatus and canine fossae are optimal drainage sites because of their ease of accessibility and relatively thin well-vascularized bone.

Preoperative imaging is necessary to document the presence of acute sinusitis and to guide surgical planning. Place conscious patients in the sitting position to allow for drainage of the sinus contents into a provided basin. Protect the airway and suction the oropharynx during sinus puncture performed on unconscious patients. In patients in the intensive care unit, catheterization of the sinus may be undertaken with puncture to ensure continued adequate drainage.

 

In general, start medical treatment of acute sphenoid sinusitis once the diagnosis is made. Institute antibiotics and decongestants for 24 hours, and if the patient does not improve over this time course, schedule surgical therapy. If the patient has evidence of complications, undertake urgent surgical decompression.

Some individuals advocate early and aggressive surgical and medical treatment for acute sphenoid sinusitis. Hnatuk comments on the aggressive nature of the disease and concludes that nonoperative medical management is not indicated. ^[58] These conclusions are based on a small number of patients, all in their teenage years.

 

The typical case of acute ethmoidal sinusitis is treated with medical therapy. Medical treatment can reduce the inflammation and edema of the mucosa, alleviate the pain, combat the infection, open the ostia of the sinuses, and restore normal mucociliary secretions. However, surgery is indicated in the following instances:

• Sinusitis not responsive to medical management

• Rapidly progressing sinusitis

• Sinusitis that creates an abscess either in the sinus or adjacent areas such as the orbit or brain

• Sinusitis that compromises the survival of the patient

See the article on Acute Ethmoid Sinusitis for more information.

Treatment fails in 10-25% of patients. If this occurs, consider taking a repeat history and perform an additional physical examination; consider an imaging study. Start second-line antibiotics. Approximately 75% of orbital or periorbital infections are the result of extending sinusitis. Untreated, inadequately treated, or partially treated rhinosinusitis may lead to chronic rhinosinusitis, meningitis, brain abscess, or other extra-sinus complications.

Local complications

Mucoceles are chronic epithelial cysts that develop in sinuses in the presence of either an obstructed sinus ostium or minor salivary gland duct. They have the potential for progressive concentric expansion that can lead to bony erosion and extension beyond the sinus.

Maxillary sinus mucoceles are usually found incidentally on sinus radiographs and are of little significance in the absence of symptomatology or infection. Surgical treatment is not usually necessary, and these lesions often regress spontaneously over time.

Frontoethmoidal and sphenoethmoidal mucoceles, on the other hand, tend to be symptomatic and have a high potential for bony erosion. Frontoethmoidal mucoceles should be completely removed and the sinus obliterated. Sphenoethmoid mucoceles should be widely opened into the nasal cavity.

Osteomyelitis is a potential local complication most commonly occurring with frontal sinusitis. Osteomyelitis of the frontal bone is called a Pott puffy tumor and represents a subperiosteal abscess with local edema anterior to the frontal sinus. This can advance to form a fistula to the upper lid with sequestration of necrotic bone. This rare complication should be managed with a combination of systemic antibiotics, surgical drainage of affected sinuses, and debridement of necrotic bone.

Orbital complications

Orbital complications are the most common complications encountered with acute bacterial sinusitis. Infection can spread directly through the thin bone separating the ethmoid or frontal sinuses from the orbit or by thrombophlebitis of the ethmoid veins.

Diagnosis should be based on an accurate physical examination, including ophthalmological evaluation and appropriate radiological studies. CT scanning is the most sensitive means of diagnosing an orbital abscess, although ultrasound has been found to be 90% effective for diagnosing anterior abscesses. ^[32] The classification by Chandler, which is based on physical examination findings, provides a reasonable framework to guide management. This classification consists of 5 groups of orbital inflammation ^[37] :

• Group 1 - Inflammatory edema (preseptal cellulitis) with normal visual acuity and extraocular movement

• Group 2 - Orbital cellulitis with diffuse orbital edema but no discrete abscess

• Group 3 - Subperiosteal abscess beneath the periosteum of the lamina papyracea resulting in downward and lateral globe displacement

• Group 4 - Orbital abscess with chemosis, ophthalmoplegia, and decreased visual acuity

• Group 5 - Cavernous sinus thrombosis with rapidly progressive bilateral chemosis, ophthalmoplegia, retinal engorgement, and loss of visual acuity; possible meningeal signs and high fever

Medical management, including sinus drainage and intravenous antibiotics, is advocated for any degree of orbital complication. Among the classifications by Chandler, surgical drainage of both the infected sinuses and the orbit are advocated for groups 3-5 if inadequate improvement or progression of orbital cellulitis occurs despite medical therapy or if the patient has loss of visual acuity.

Intracranial complications

Intracranial complications may occur as a result of direct extension through the posterior frontal sinus wall or through retrograde thrombophlebitis of the ophthalmic veins. Subdural abscess is the most common intracranial complication, although cerebral abscesses and infarction that result in seizures, focal neurological deficits, and coma may occur. Intracranial complications of sinusitis should be managed surgically with drainage of both the affected sinus and the cranial abscess.

In a retrospective review of 23 cases (8 epidural, 10 subdural, 2 intracerebral abscess, and 3 meningitis) of intracranial complications of sinusitis (ICS) to identify the role and effectiveness of endoscopic sinus surgery (ESS) in the acute setting of ICS, DelGuadio et al concluded that ESS did not alter the need for neurosurgical intervention, which was ultimately necessary in most patients, even those with lesions less than 1 cm. ^[59]

In the study by DelGuadio et al, of the 23 patients, 22 (96%) had radiologic evidence of frontal sinusitis with prefrontal or frontal lobe ICS at presentation. Medical therapy alone was successful in avoiding craniotomy in only 3 of 8 cases, and treatment with endoscopic sinus surgery and intravenous antibiotics was successful in avoiding craniotomy in only 1 of 6 patients. Of 23 patients, 18 required neurosurgical procedures (9 emergent procedures for abscesses more than 1 cm and 9 delayed procedures for persistent disease despite ICS less than 1 cm).

Systemic complications

Sinusitis can result in sepsis and multisystem organ failure caused by seeding of the blood and various organ systems. Reports of bacteremia, thoracic empyema, and nosocomial pneumonia have been documented in the intensive-care population with acute sinusitis, and the mortality rate in this group can be as high as 11%.

Emergent otolaryngology consultation for admission and definitive care should be obtained in all patients with suspected CNS or orbital invasion or fungal infections. These patients may present with the following symptoms:

• Abnormal vision

• Mental status changes

• Periorbital edema

Consider outpatient referral to an otolaryngologist for patients with subacute or chronic sinusitis. The following consultations are indicated:

• Ear, nose, and throat specialist for complications or when routine management techniques fail

• Infectious disease specialist in complicated cases

• Ophthalmological or neurosurgical consultation when either orbital or intracranial complications develop

• Surgical consultation when chronic sinusitis is refractory to maximal medical therapy or a complication such as formation of mucopyocele with orbital or intracranial extension is suspected