Practice Essentials

Sinusitis is characterized by inflammation of the lining of the paranasal sinuses. Because the
nasal mucosa is simultaneously involved and because sinusitis rarely occurs without
concurrent rhinitis, rhinosinusitis is now the preferred term for this condition. Rhinosinusitis
affects an estimated 35 million people per year in the United States and accounts for close to
16 million office visits per year. [1] See the image below.

Signs and symptoms

Clinical findings in acute sinusitis may include the following:

Pain over cheek and radiating to frontal region or teeth, increasing with straining or bending
down

Redness of nose, cheeks, or eyelids

Tenderness to pressure over the floor of the frontal sinus immediately above the inner canthus

Referred pain to the vertex, temple, or occiput

Postnasal discharge

A blocked nose

Persistent coughing or pharyngeal irritation

Facial pain

Hyposmia

Symptoms of acute bacterial rhinosinusitis include the following:

Facial pain or pressure (especially unilateral)

Hyposmia/anosmia

Nasal congestion

Nasal drainage

Postnasal drip

Fever

Cough

Fatigue
 Maxillary dental pain

Ear fullness/pressure

The diagnosis of acute bacterial sinusitis should be entertained under either of the following
circumstances:

Presence of symptoms or signs of acute rhinosinusitis 10 days or more beyond the onset of
upper respiratory symptoms

Worsening of symptoms or signs of acute rhinosinusitis within 10 days after an initial

improvement

The following signs may be noted on physical examination:

Purulent nasal secretions

Purulent posterior pharyngeal secretions

Mucosal erythema

Periorbital edema

Tenderness overlying sinuses

Air-fluid levels on transillumination of the sinuses (60% reproducibility rate

for assessing maxillary sinus disease)

Facial erythema

See Clinical Presentation for more detail.

Diagnosis
Acute sinusitis is a clinical diagnosis. However, the evaluation might include the following
laboratory tests [2] :

Nasal cytology

Nasal-sinus biopsy

Tests for immunodeficiency, cystic fibrosis, or ciliary dysfunction

Nasal cytology examinations may be useful to elucidate the following entities:

[3]
Allergic rhinitis

Eosinophilia
 Nasal polyposis

Aspirin sensitivity

Tests for immunodeficiency are indicated if history findings indicate recurrent infection; they
include the following:

Immunoglobulin studies

HIV serology

Cultures are not routinely obtained in the evaluation of acute sinusitis but should be obtained
in the following cases:

Patients in intensive care or with immunocompromise

Children not responding to appropriate medical management

Patients with complications of sinusitis

In adults, cultures are directed at the middle meatus. Aspiration of the sinus by direct antral
puncture is the only accurate way to obtain a culture but is reserved for patients with any of
the following:

Life-threatening illness

Immunocompromise

Disease unresponsive to therapy

Computed tomography scanning is the preferred imaging method for rhinosinusitis. A

complete sinus CT scan with frontal and coronal planes is used if an alternative diagnosis (eg,
tumors) must be excluded. CT scanning is characteristic in allergic fungal sinusitis and is one
of the major criteria for diagnosis.

See Workup for more detail.

Management
Treatment of acute sinusitis consists of providing adequate drainage of the involved sinus and
appropriate systemic treatment of the likely bacterial pathogens. Drainage can be achieved
surgically with sinus puncture and irrigation techniques. Options for medical drainage are as
follows:
 Oral alpha-adrenergic vasoconstrictors (eg, pseudoephedrine, and
phenylephrine) for 10-14 days

Topical vasoconstrictors (eg, oxymetazoline hydrochloride) for a maximum

of 3-5 days

Antibiotic treatment is usually given for 14 days. Usual first-line therapy is with one of the
following:

Amoxicillin, at double the usual dose (80-90 mg/kg/d), especially in areas

with known Streptococcus pneumoniae resistance

Clarithromycin

Azithromycin

Second-line antibiotic should be considered for patients with any of the following:

Residence in communities with a high incidence of resistant organisms

Failure to respond within 48-72 hours of commencement of therapy

Persistence of symptoms beyond 10-14 days

The most commonly used second-line therapies include the following:

Amoxicillin-clavulanate

Second- or third-generation cephalosporins (eg, cefuroxime, cefpodoxime,

cefdinir)

Macrolides (ie, clarithromycin)

Fluoroquinolones (eg, ciprofloxacin, levofloxacin, moxifloxacin)

Clindamycin

Antibiotic selection with respect to previous antibiotic use and disease severity is as follows:

Adults with mild disease who have not received antibiotics:

Amoxicillin/clavulanate, amoxicillin (1.5-3.5 g/day), cefpodoxime proxetil,
or cefuroxime is recommended as initial therapy.

Adults with mild disease who have had antibiotics in the previous 4-6
weeks and adults with moderate disease: Amoxicillin/clavulanate,
amoxicillin (3-3.5 g), cefpodoxime proxetil, or cefixime is recommended.
 Adults with moderate disease who have received antibiotics in the
previous 4-6 weeks: Amoxicillin/clavulanate, levofloxacin, moxifloxacin, or
doxycycline is recommended.

Symptomatic or adjunctive therapies may include the following:

Humidification/vaporizer

Warm compresses

Adequate hydration

Smoking cessation

Balanced nutrition

Nonnarcotic analgesia

See Treatment and Medication for more detail.

Treatment

Approach Considerations
In June 2013, the American Academy of Pediatrics published updated guidelines on the
diagnosis and management of acute bacterial sinusitis in children and adolescents. Changes
include 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 now 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. [36] 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 2007 guidelines by the American Academy of Otolaryngology--Head and Neck Surgery
Foundation [29] were updated in 2015 [30] and recommended 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 rst-line therapy for 5-10 days (if the decision is made to treat acute bacterial
rhinosinusitis with an antibiotic).

The guidelines state that 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. [37] However, a randomized, controlled trial of antibiotics and
intranasal steroid showed no treatment benefit of intranasal steroids, either alone or with
antibiotics. [38]

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. [39]

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. [40] However, another
meta-analysis found no treatment effect of antibiotics, even in patients whose symptoms had
persisted for more than 10 days. [41]

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-
lactamasemediated resistance to penicillin-based antimicrobials in children.

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. [42]
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. [43]

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. [44]

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. [31]

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)

Antibiotic Dosage Streptoc Haemop Morax Anaerobic bacteria

occus hilus ella
pneumo influenz catarr
niae ae halis
Sensitive Interme Resistan
diate t
Amoxicillin 500 mg +++ ++ + ++ + +++
PO tid

(except
beta-
lactam
ase
produc
ers)

Clarithrom 250-500 ++ ++ + ++ + +
ycin mg PO +
bid +
Azithromy 500 mg ++ ++ + ++ + +
cin PO first +
day, then +

250
mg/d PO
for 4
days
*+, low
activity
against
microorga
nism; ++,
moderate
activity
against
microorga
nism; ++
+, good
activity
against
microorga
nism
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)
 Streptoco Haemophi Moraxel
ccus lus la Anaerobic
Antibiotic Dosage
pneumoni influenza catarrh bacteria
ae e alis

Intermedi
Sensitive Resistant
ate

Amoxicillin/

+
500 mg PO ++
+++ ++ + +++ +
tid +
clavulanate +

250-500 +
Cefuroxime +++ ++ + +++ ++
mg PO bid +

Cefpodoxime +
200 mg PO +
++
bid - +++ ++ + +

400 mg/d ++ - - +++ +

-
PO +
cefixime +

+
500-750
Ciprofloxacin ++ + + ++ + +
mg PO bid
+

+
500 mg/d
Levofloxacin +++ +++ +++ +++ + ++
PO
+

Trovafloxacin 200 mg/d +++ +++ +++ +++ + ++

PO +
 + +

300 mg PO ++
Clindamycin +++ +++ ++ - -
tid +

500 mg PO ++
Metronidazole - - - - -
tid +

*+, low activity

against
microorganism; +
+, moderate
activity against
microorganism; +
++, good activity
against
microorganism; -,
no activity
against
microorganism

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)
 Streptoco Haemoph Moraxel Anaero
Gram-
Dosa ccus ilus la bic
Antibiotic negati
ge pneumoni influenza catarrh bacteri
ve
ae e alis a

3-4 g
Piperacillin IV q4- +++ + - +++ +++
6h

3.375
Piperacillin/tazobactam g IV +++ +++ +++ +++ ++
q6h

3 g IV
Ticarcillin +++ - - +++ ++
q4h

3.1 g
Ticarcillin/clavulanate +++ +++ - +++ ++
IV q4h

500
Imipenem mg IV +++ +++ +++ +++ +++
q6h

1 g IV
Meropenem +++ +++ +++ +++ +++
q8h

1 g IV
Cefuroxime +++ +++ +++ ++ ++
q8h

2 g IV
Ceftriaxone +++ +++ +++ +++ ++
bid

2 g IV
Cefotaxime +++ +++ +++ +++ ++
q4-6h

2 g IV
Ceftazidime +++ +++ +++ +++ ++
q8h

1.7
Gentamicin mg/kg - +++ +++ ++ -
IV q8h

Tobramycin 1.7 - +++ +++ ++ -

mg/kg
 IV q8h

1 g IV
Vancomycin q6- +++ - - - ++
12h

*+, low activity against

microorganism; ++,
moderate activity
against
microorganism; +++,
good activity against
microorganism; -, no
activity against
microorganism Does
not take into account
penicillin-resistant
types.