Acute Sinusitis

1. Acute Sinusitis Author: Marie Carson, MD Editor: Amy Shaheen, MD, Assistant Professor of Clinical Medicine Duke University Medical Center

2. Acute Sinusitis: Overview and Epidemiology • The diagnosis is common, as it is one of the top 10 most common diagnoses in ambulatory practice, and 5th most common diagnosis for which an antibiotic is prescribed • Usually due to secondary infection from preceding URI, though only 0.2% to 2% of viral URIs are complicated by bacterial rhinosinusitis; bacterial sinusitis rarely presents before 7 days of illness • Viral pathogens include rhinovirus, parainfluenza, influenza, RSV, adenovirus • Common bacterial pathogens include Strep pneumo, H flu, Moraxella

3. Acute Sinusitis: Diagnosis • The gold standard is sinus puncture and drainage, though this is seldom performed in primary care; this limits the quality of the evidence related to diagnostic testing • How good are symptoms and signs? Williams et al. Ann Int Med 1992 (117): 705-710 (note that this study compared clinical signs/symptoms to plain films)

4. Acute Sinusitis: How good are symptoms & signs (cont.) • If there are 4 or more signs, the positive LR is 6.4, 3 signs yield LR 2.6, 2 signs yield LR 1.1, 1 sign yields LR 0.5, no signs yield LR 0.1. • Physician assessment is just as good: an impression that sinusitis was “definitely or most likely present” generated a LR of 4.7

5. Acute Sinusitis: What about radiographic studies? • A single Waters view (maxillary) is the best studied, with sensitivity of about 80% (compared to puncture); it correlates well to standard 4 view sinus series • There is minimal data on CT; probably highly sensitive, but lacks specificity (about 80% of pts with viral URI may have evidence of sinusitis on CT). Its true value may be in diagnosing recurrent or chronic sinusitis with impacted secretions, anatomical abnormalities, etc.

6. Acute Sinusitis: Radiographic studies http://www.ahcpr.gov/clinic/sinussum.htm

7. Acute Sinusitis: Diagnosis – Bottom Line The bottom line for diagnosis: A combination of clinical signs and symptoms is adequate; radiology doesn’t add anything to diagnosing uncomplicated rhinosinusitis

8. Acute Sinusitis: Treatment • There are no RCTs of antibiotic treatment using pre and post cultures of sinus aspirates • Most utilize “clinical failure” as negative outcome, “clinical improvement” as positive outcome at 10-14 days • Patients who receive antibiotics tend to get better and get better somewhat faster; HOWEVER: • Most pts who receive placebo ALSO get better—by 2 weeks, symptoms improved or resolved in 70%; antibiotic therapy (any) pushed the resolution rate to 74-90% • In none of the treatment trials reviewed in 2 recent meta-analyses did a patient have a complication of untreated sinusitis (abscess, etc)

9. Acute Sinusitis: Treatment A Cochrane systematic review in 1999 found no difference between penicillin, amoxicillin, amox-clav, macrolides, cephalosporins in cure rates or relapse of sinusitis From AHCPR meta-analysis March 1999:

10. Acute Sinusitis: Adjunctive Therapies • Are there any adjunctive therapies that have been proven to work? • The CAFFS trial in 2001 looked at recurrent and chronic sinusitis and suggests that adding Flonase to Ceftin shortened duration of illness and improved response at 8 weeks (74% response for antibiotic plus decongestant v. 94% with the addition of nasal fluticasone) • Anti-histamines have not been proven to work • Decongestants may provide symptomatic relief • There is no data for nasal saline lavage or systemic steroids

11. Acute Sinusitis: Antibiotic Resistance and “Treatment Failure”, Treatment Length • What about antibiotics resistance and “treatment failure”? • Not well studied. The recommendations are to choose narrow spectrum antibiotics initially. For treatment failures, recurrence, etc., referral to ENT for sinus aspirate and culture should be considered. • How long to treat? • Controversial. Most studies done with therapy for 10 – 14 days.

12. Acute Sinusitis: Treatment – The Bottom Line Most patients, regardless of whether the pathogen is viral or bacterial get better spontaneously. It is reasonable to treat symptomatically at first. Consider antibiotic therapy if severe or moderate symptoms present for more than 7 days, and consider adjunct therapies such as decongestants and intranasal steroids (particularly if recurrent or if there is history of atopy).

13. Acute Sinusitis: Recommendations • Sinus radiography is not recommended for diagnosis of uncomplicated sinusitis • Acute bacterial sinusitis does not require antibiotic treatment, especially if mild or moderate • Patients with severe or persistent moderate symptoms and specific findings of bacterial sinusitis that persist after 7 days should be treated with antibiotics. Amoxicillin, doxycycline, or TMP-SMX are favored antibiotic choices.

14. Acute Sinusitis: Review Question 1 43 yo woman presents with fatigue, rhinorrhea, left facial pressure, mild pharyngitis, left maxillary toothache and postnasal drip for the past 3 weeks. She has felt feverish, but has not taken her temperature. She uses an oral anti-histamine for allergic rhinitis. She has no allergies to antibiotics. On PE, she has an oral temp of 37.4C. There is mucopurulent discharge from the left hostril, tenderness over the left maxillary sinus, mildly erythematous tympanic membranes, poor transillumination of the left maxillary sinus, no cervical adenopathy and clear lungs.

15. Revew Question 1

16. Acute Sinusitis: Review Question 1 - Rationale Answer: E Amoxicillin This pt has acute sinusitis, given symptoms > 1 week, unilateral or bilateral purulent rhinorrhea, local pain and maxillary toothache. Acute sinusitis is defined as having symptoms lasting up to 4 weeks, chronic sinusitis greater than 12 weeks duration. Other therapy for rhinitis includes administration of intranasal glucocorticoids and intranasal decongestants. (cont. next slide)

17. Acute Sinusitis: Review Question 1 – Rationale (cont.) Patients can have multiple episodes of acute sinusitis. Allergic rhinitis may predispose and should be addressed. Antihistamines should be continued for the pt’s underlying allergic rhinitis, and the first choice of treatment is antibiotics. Treatment with amoxicillin or TMP-SMX is successful in 90% of patients and should be first line therapy. If antibiotics are used, choosing the agent with narrower coverage is consistent with the need to avoid antibiotic resistance. In pts with acute sinusitis, 69% had resolution or improvement without antibiotics by 14 days. Recommendations on the duration of therapy vary, with data showing that 3 days of therapy is as effective as 10 days for acute maxillary sinusitis. This patient does not have chronic sinusitis. Therefore, therapy with amoxicillin-clavulanate is not appropriate. Regarding possible imaging studies, plain films of the sinuses are not indicated; CT scan of the sinuses would be the imaging test of choice, but it is reserved for patients who have sinusitis or who have failed to respond to treatment.

18. Acute Sinusitis: Review Question 2 A 27 yo man presents with 4 days of malaise, fatigue, and yellow discharge from his right nostril, along with sneezing, mild sore throat, congestion, dry cough, and myalgias. He wants relief from his symptoms because he must travel by plane in 3 days. He smokes one pack of cigarettes per day. On physical examination, his temperature is 37.4C. There is no facial tenderness, and normal transillumination of his sinuses, yellow rhinorrhea from right nostril, mild pharyngeal erythema, no cervical adenopathy and clear lungs.

19. Review Question 2

20. Acute Sinusitis: Review Question 1 - Rationale Answer: B Pseudoephedrine therapy  This patient does not meet the criteria for sinusitis. His symptoms have lasted less than 7 days, and he likely has a viral URI. Other than unilateral purulent discharge, he does not have specific criteria for sinusitis. Systemic adrenergic agonists may play a role, as may nasal glucocorticoids, guaifenesin, oral hydration or nasal saline spray. Patients with controlled hypertension may use short-term adrenergic agonists or decongestants. Smoking cessation should also be stressed in this patient. Antibiotics are over-prescribed for colds, URI and bronchitis. In one study, more than 50% of patients who presented with any of these three conditions was prescribed an antibiotic, even though antibiotics have little to no benefit in these conditions. Ipratropium bromide has been shown to decrease nasal discharge and sneezing, but routine use of this medication is questioned because of cost and because it does not releive many other symptoms related to the common cold. Sinus radiography is not indicated win the evaluation of uncomplicated viral URI.

21. Course Evaluation • Please complete the Course Evaluation here

22. Acute Sinusitis: References • Snow, V., et al. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Int Med 2001 Mar 20; 134(6): 495-7. • Lau, J., et al. Diagnosis and treatment of acute bacterial sinusitis. www.ahcpr.gov/clinic/epcsums/sinussum.htm 1999 • Williams, J., et al. Antimicrobial therapy for acute maxillary sinusitis. Cochrane Review, latest version 26 May 1999. • Dolor, R., et al. Comparison of cefuroxime with or without intranasal fluticasone for the treatment of rhinosinusitis. The CAFFS Trial: a randomized controlled trial. JAMA. 2001 Dec 26; 286:3097-105. • Williams, J., et al. Does this patient have sinusitis? The rational clinical examination series. JAMA 1993. 270(10); 1242-1246.