Sinusitis

Background

Rhinosinusitis - Inflammation of the lining of the paranasal sinuses

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
Feature	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 symptomatic treatment b/c most likely viral
   1. Analgesia
   2. Mechanical irrigation with buffered, hypertonic saline
   3. Topical glucocorticoids
   4. Topical decongestants (e.g., oxymetazoline for no more than three days)
   5. Antihistamines
   6. Mucolytics
2. 10 days or if pt gets better and then worse again (“double sickening”)
   1. Mild bacterial sinusitis when pain is mild and temperature < 38.3˚C
   2. Another seven days of observation
   3. Severe bacterial sinusitis when pain is moderate-severe or temperature ≥38.3˚C
   4. Consider antibiotics
   5. If the patient is immunocompromised, has an underlying or complicating condition, or patient fails observation, antibiotics are indicated

Antibiotics

1. Choice of antibiotic depends on recent antibiotic therapy (past 4-6 weeks).
   1. Amoxicillin (500mg PO TID for 10 days)
   2. TMP-SMX
   3. Erythromycin
   4. Azithromycin
   5. Cefpodoxime
   6. Cefdinir
   7. Cefuroxime

Antibiotic Failure

#If initial antibiotic failure occurs consider further workup (e.g. CT) and/or further tx with either amoxicillin-clavulanate or respiratory fluoroquinolone

1. Nosocomial acute bacterial rhinosinusitis can occur (e.g., after prolonged nasotracheal intubation) and often is associated with gram-negatives; remove foreign bodies and use culture-directed antibiotic therapy
2. Immunocompromised patients at risk for acute fulminant fungal rhinosinusitis

Source

DeBonis, Kaji, UpToDate "Rhinosinusitis"