in the clinic

in the clinic

Acute Sinusitis
Risk Factors page ITC3-3

Diagnosis page ITC3-4

Treatment page ITC3-8

Practice Improvement page ITC3-13

CME Questions page ITC3-16

Section Editors The content of In the Clinic is drawn from the clinical information and
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Sankey Williams, MD PIER (Physicians’ Information and Education Resource) and MKSAP (Medical
Darren Taichman, MD, PhD Knowledge and Self-Assessment Program). Annals of Internal Medicine
editors develop In the Clinic from these primary sources in collaboration with
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mksap/15/?pr31, and other resources referenced in each issue of In the Clinic.

CME Objective: To review current evidence for the risk factors, diagnosis, and
treatment of acute sinusitis.

The information contained herein should never be used as a substitute for clini-
cal judgment.

© 2010 American College of Physicians

This article has been corrected. The specific correction appears on the last page of this document.
For original version, click "Original Full Text (PDF)" in column 2 of the article at www.annals.org.
 cute sinusitis affects millions of persons in the United States every

A year and is among the most common reasons for physician visits,
prompting over 3 million visits annually (1). The more accurate term
for this condition is acute rhinosinusitis, because symptoms involve both the
nasal cavity and the sinuses. For simplicity, this review uses the term “sinusi-
tis” for rhinosinusitis. There are 4 pairs of air-filled paranasal sinuses: 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 infection or allergic rhinitis but oc-
casionally to other stimuli. The paranasal sinuses become inflamed, and mu-
cus cannot drain properly, providing an environment where bacteria, or rarely
fungus, can thrive. Persons with chronic nasal congestion, and particularly
those with allergies and asthma, may be more prone to developing acute si-
nusitis, but it can affect anyone. Suggestive symptoms include headache, con-
gestion, facial pain, fatigue, and cough, all of which can be disruptive to usual
activities but are rarely severe.

The diagnosis is usually based on clinical signs and symptoms. 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
antibiotics 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 antibiotic 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, sinus 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 mucociliary
clearance in smokers,
sinusitis and allergic
rhinitis patients. Asian
Pac J Allergy 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 aspirin intolerance.
are generally characterized by more In addition, persons with a deviated
recurrent or chronic symptoms. Im- nasal septum may also have an in-
munocompromised persons are at creased risk for both acute and
increased risk for fungal infection. chronic sinusitis.
Age Dental disease
Older persons have more compro- Infections from dental disease,
mised immune systems and a such as dental abscesses and peri-
greater prevalence of serious upper odontal infection, or procedures,
respiratory tract infections, both of such as sinus perforations during
which increase their risk for the tooth extraction, can precipitate
complication 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-
derlying dental condition may be
Smoke and other air pollutants
asymptomatic or only mildly
Cigarette and cigar smoke and other
symptomatic. Intervention is
forms of air pollution, 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
Medical conditions that cause in-
Air travel and changes in atmospheric
pressure
flammation in the airways or create
Air travel as well as other situations persistent thickened stagnant mucus
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 diabetes 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
the nose and sinuses and can lead sive sinusitis (6). Pregnancy can also Med. 2007;120:289-
94. [PMID: 17398218]
to sinusitis. cause temporary congestion and 5. Brook I. Sinusitis of
odontogenic origin.
symptoms of sinusitis. Otolaryngol Head
Asthma and allergies Neck Surg.
Asthma and respiratory allergies An autoimmune disease, Wegener 2006;135:349-55.
[PMID: 16949963]
increase sinus inflammation, which granulomatosis, causes long-term 6. Deshazo RD. Syn-
dromes of invasive
can increase the risk for infection. swelling and tumor-like masses in fungal sinusitis. 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 pathogens from the si-
In most cases, acute iary function or mucous produc- nuses (Box). Using saline irrigation
tion, such as cystic fibrosis or the and steam inhalation can help keep
sinusitis is diagnosed Kartagener syndrome (triad of the nose moist and the sinuses
based on the history and bronchiectasis, 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 corticosteroids, which
How to Perform Nasal Irrigation 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.
icantly increase the risk for sinusitis strong odors. Limit time swimming
Pour or gently squeeze water into
the upper nostril. 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 influenza. Nasal irriga- decongestant 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 hand washing and should avoid persons
with the common cold 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
nosed on the basis of the history and duration of symptoms, because per-
Head Neck Surg.
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. acute bacterial sinusitis. The gold- to have a bacterial infection. The
Clinical evaluation for
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 diseases, 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?
According to a multidisciplinary Establishing the duration of symp- is the main distinguishing
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-
rately, these symptoms and physi- nusitis occurring from 1 week to less
less than 4 weeks after
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
the diagnosis. Purulent rhinorrhea
sinusitis lasts longer
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 • Hyposmia or anosmia
theless, the absence of these spe- many months or even years and are • Ear pressure
• Cough
cific symptoms does not exclude often associated with a persistent
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 Differential Diagnosis of Acute
toms and seasonal patterns. conventional antibiotic therapy 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, cocaine)
turbinates, purulent rhinorrhea, obstruction whose sinusitis is refrac-
• 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- • Migraine 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 evaluating a patient for acute ily Physicians. Princi-
ples of appropriate
lasting 4 or more weeks, patients were sinusitis? antibiotic use for
given a structured history and physical A key distinguishing feature of treatment of acute
bronchitis 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
than 12 weeks represent chronic si- OP, Ertama L, et al;
oropharyngeal red streak had a sensitivi-
ty of 70% and a specificity of 67% (11). nusitis, which has a different differ- Finnish Society of
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 maxillary sinus-
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 radiography is sinus flu-
diagnosis of acute sinusitis? id or opacity. Some studies also con-
The history and physical examina- sider mucous membrane 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.
Curr Allergy Asthma
A lower threshold for imaging may of clinician expertise. On the basis of this
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
Headaches due to tion or the individual’s likelihood of diagnostic information, whereas ultrasono-
nasal and paranasal
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. duces radiation exposure compared
Boston: New Eng-
Acute viral sinusitis resembles acute
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 scans also have high false-positive
17. Varonen H, Mäkelä
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
studies are also useful in patients ported sinus mucosal abnormalities in up
diagnosis of acute
maxillary sinusitis: a with predisposing factors for atypi- to 49% of apparently healthy persons with
systematic review. J
cal microbial causes, such as no symptoms of sinusitis (20, 21). The clini-
Clin Epidemiol.
2000;53:940-8. cal importance of these chance findings is
Pseudomonas aeruginosa, or fungal in-
[PMID: 11004420] uncertain. Asymptomatic patients with
18. Engels EA, Terrin N, fection in immunocompromised pa- abnormalities on imaging studies do not
Barza M, et al. Meta-
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 been Streptococcus pneumonia and Timmons JH. Com-
parison of sinus x-
needed to diagnose acute sinusitis. Haemophilus influenzae. One early rays with computed
tomography scans in
In cases that do not respond to study estimated that these organ- acute sinusitis. Acad
treatment or that get worse, tissue isms accounted for more than 50% Emerg Med.
1994;1:235-9.
cultures may help pinpoint the spe- of acute bacterial sinusitis (24). [PMID: 7621202]
cific cause. The sinus puncture is With recent pneumococcal vaccina- 20. Havas TE, Motbey
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 more recent years have also shown graphic scans of the
paranasal sinuses.
the organism responsible for sinusi- more Moraxella 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 more Streptococcus pyogenes. [PMID: 3390327]
21. Patel K, Chavda SV,
uses a large-bore needle to with- Violaris N, et al. Inci-
draw small amounts of fluid from About one third of H. influenzae iso- dental paranasal si-
nus inflammatory
the maxillary sinus to culture. Be- lates and most isolates of M. ca- changes in a British
population. J Laryn-
cause this test is invasive and car- tarrhalis produce β-lactamases and gol Otol.
ries the risk for complications, such are resistant to penicillin and amoxi- 1996;110:649-51.
[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 penicillins 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-
antral puncture. It is also per- (Streptococcus pneumoniae) (25). In pa- cally directed middle
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 rected against all pathogens in mixed nusitis: a meta-
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.
dictive value of 82.6%, and negative fungal infections usually occur in im- Clin Infect Dis.
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-
mens obtained from a direct swab are immunocompetent. Acute fungal gy and antimicrobial
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 Aspergillus or Mucor [PMID: 15949076]
a sinus puncture, because of con- species (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, fever, halitosis, maxillary toothache, 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 abscess 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 therapies. 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 placebo
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
symptoms by a nonsignificant 0.3 adults reported a statistically signif-
nasal irrigation for
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. tion was associated with less time (pooled relative risk [RR], 0.66
2010;3:CD006821.
[PMID: 20238351] off work, but minor discomfort was [95% CI, 0.44 to 0.98]) (2). The
28. Anzai Y, Jarvik JG,
not uncommon (27). review considered trials with clini-
Sullivan SD, et al. The
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- acute bacterial sinusitis and of pro-
purulent discharge (nasal,
tis found that persons receiving an- pharyngeal, or both).
longed viral upper respiratory tract Low probability (<25%) when only
tibiotics did no better than those re- 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 to use antibiotic therapy should be days, facial pain, or purulent
persistence of symptoms (in terms of discharge.
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 amoxicillin (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 macrolides 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
31. Arroll B, Kenealy T.
line” strategy. 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- in the community and in the host. [PMID: 16861253]
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 pharynx 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)
Doxycycline (200 mg on first day then 100 mg Potential adverse effects: gastrointestinal upset, photosensitivity, neutropenia.
twice daily for 2 to 10 days) Not recommended in children aged ≤8 y.
Macrolides (e.g., clarithromycin, 500 mg twice daily, Consider in patients allergic to both penicillin and trimethoprim–sulfamethoxazole.
or azithromycin, 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., ciprofloxacin, Side effects: gastrointestinal upset, diarrhea, headache, confusion. Concern about
500 twice a day, levofloxacin, 500 mg once daily) antibiotic resistance.†
Oral antihistamines (e.g., loratadine, 10 mg daily) Inhibits inflammatory pathways, helpful especially with history of allergic rhinitis.
Nasal decongestant (e.g., xylometazoline 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 decongestants (e.g., pseudoephedrine Use caution with underlying cardiovascular disease, 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,
macrolide 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 cial, particularly for people with less
Montgomery A, et
al. The relationship
antimicrobial resistance when pro- severe symptoms. In particular, in- between primary
care antibiotic pre-
viding treatment for acute sinusitis. tranasal steroids have received some scribing and bacteri-
al resistance in
recent attention. adults in the com-
Trimethoprim–sulfamethoxazole 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]
pneumococcal resistance rates pants (73% versus 66.4%; risk ratio, 1.11 [CI, 37. University of Michi-
gan Health System.
to trimethoprim–sulfamethoxa- 1.04 to 1.18]). Mometasone furoate Acute rhinosinusitis

zole have increased to at least (MFNS), 400 µg versus 200 µg, was associ- in adults. Ann Arbor,
MI: Univ Michigan
24% (39). For patients who are ated with greater improvement (risk ratio, 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.
1997;50:881-90.
concerns, failure to respond lergies and acute rhinosinusitis confirmed [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
have minimal efficacy against tion (P = 0.002) after 28 days compared 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 medications nidis JP, Lau J, et al.
cephalosporins, such as cefpo- may also be used to reduce sinusitis-
Are amoxycillin and
folate inhibitors as
doxime, are considered second- related congestion and discomfort. effective as other an-
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 of RCTs testing the effect of any 41. Zalmanovici A,
Yaphe J. Intranasal
20% of patients in most reports herbal medicine as sole or adjunc- steroids for acute si-
and as many as half in some tri- tive treatment for sinusitis found
nusitis. Cochrane
Database Syst Rev.
als. In most cases, side effects re- limited evidence that any are bene- 2009:CD005149.
[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
even severe episodes. However, clini- cause permanent loss of sense of
acute bacterial sinusitis 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-
brain, the infection can become life cialist. Appropriate diagnostic imag-
properly. 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-
fluid that lines the brain. In severe bate asthma; therefore, treating the
Orbital swelling, erythema of
conjunctiva, 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 laryngopharyngeal reflux; 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 meningitis 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 orbit 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 cellulitis 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- disease may require referral to other
ries 13. 1993-1995.
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. difficult to treat and increases the as periorbital cellulitis, venous si-
2007;136:176-81.
[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- sphenoid sinus cavity to the carotid disease expert, or neurologist may
nology. 2009;47:59-
65. [PMID: 19382497] artery or cavernous sinus. 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,
central nervous system. 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 endoscopy, 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;
American Academy
nusitis should not be made during cellence recommend a “no antibiotic
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 have a preexisting comorbid condi-
Chest. 2006;129:72S-
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 who have additional criteria that in-
tract infections—an-
tibiotic prescribing. of illness and possible complica- crease risk, such as diabetes or oral
Prescribing of antibi- tions when symptoms worsen or do glucocorticoid use.
otics for self-limiting
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).

in the clinic
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

Tool Kit
treatment in an electronic format designed for rapid access at the point of care.

Patient Information
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).
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,
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

© 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 virus 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 strain 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.

Patient Information
• Symptoms include a headache, congestion with pus
in the nose, facial pressure and pain, postnasal drip, • Antibiotics may be prescribed if your doctor believes
cough, sore throat, 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.
 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. Nonallergic rhinitis
diphenhydramine; however, her symptoms had similar episodes in the past that
D. Rhinitis medicamentosa
returned, and she began having low-grade were helped by antibiotics. Medical
E. Viral upper respiratory infection
fevers 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 sense of smell. Over the
thickened postnasal drip and erythema pharyngeal erythema or exudate. 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 antihistamine C. Plain films of sinuses amoxicillin–clavulanate in combination
C. Sinus radiography D. Symptomatic treatment with a nasal steroid inhaler, 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
management? are not in season.
C. Sinus MRI
A. Oral prednisone taper Nasal examination shows congested D. Sinus CT
nasal mucosa with a profuse watery E. Sinus radiography
B. Amoxicillin
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]