Sinusitis

Background

1. Acute (<4 weeks)
   1. Acute viral
   2. Acute bacterial (0.5-2% of cases)
2. Subacute (4-12 weeks)
3. Chronic (>12 weeks)
4. Other causes
   1. Fungal infections
   2. Allergies

Diagonsis

Classic History & Physical
	Viral	Bacterial
Duration (symptoms)	<10days	Usually >10 days OR worsening symptoms within 10 days after initial improvement
Color change (nasal discharge)	+/−	+++, quality usually yellow-green and thick
Maxillary dental pain		+++, often unilateral and associated with a particular sinus
Postnasal drip		More common
Fever, cough, fatigue		More common
Hyposmia/anosmia		More common

Treatment

• 1. <10 days of symptoms
  • Symptomatic treatment b/c most likely viral
    • Analgesia
    • Mechanical irrigation with buffered, hypertonic saline
    • Topical glucocorticoids
    • Topical decongestants (e.g., oxymetazoline for no more than three days)
    • Antihistamines
    • Mucolytics
• 2. >10 days or if pt gets better and then worse again (“double sickening”)
  • Mild bacterial sinusitis (pain is mild and temperature <38.3˚C)
    • Another seven days of observation
  • Severe bacterial sinusitis (pain is moderate-severe or temperature ≥38.3˚C)
    • Consider antibiotics
• If pt is immunocompromised, has underlying condition, or fails observation abx are indicated
• Obtain CT w/ contrast if concern for complications of sinusitis (e.g. postseptal cellulitis)

Antibiotics

1. Choice depends on recent antibiotic therapy (past 4-6 weeks)
   1. Amoxicillin 80mg/kg/d x 10-14d
   2. Azithromycin 10mg/kg PO on day 1; then 5mg/kg QD x 5-7d
   3. Cefpodoxime
   4. Cefdinir
   5. Cefuroxime

Antibiotic Failure

• If initial abx failure occurs consider further workup (e.g. CT) and/or further tx w/ amoxicillin-clavulanate or respiratory fluoroquinolone
• Nosocomial acute bacterial rhinosinusitis can occur (e.g., after prolonged nasotracheal intubation)
  • Associated with gram-negatives; remove foreign bodies and use culture-directed antibiotic therapy
• Immunocompromised patients at risk for acute fulminant fungal rhinosinusitis

Source

UpToDate

Tintinalli