What is the assessment and plan for sinusitis?

Assessment and Plan for Sinusitis

The first-line treatment for acute sinusitis is amoxicillin for 10-14 days, with amoxicillin-clavulanate as an alternative if no improvement occurs after 3-5 days of initial therapy. 1

Assessment

Diagnostic Criteria

• Acute sinusitis: Symptoms lasting less than 4 weeks
  • Diagnosis based primarily on clinical history and physical examination 2
  • Bacterial sinusitis is likely when:
    • Symptoms persist ≥10 days beyond onset of upper respiratory symptoms
    • Symptoms worsen within 10 days after initial improvement (double worsening) 3

Key Physical Examination Findings

• Nasal examination:
  • Mucosal erythema and purulent secretions
  • Nasal endoscopy offers better visualization than nasal speculum 2
• Sinus examination:
  • Tenderness overlying sinuses
  • Dark circles beneath eyes
  • Periorbital edema 2, 1
• Pharyngeal findings:
  • Erythema
  • Lymphoid hyperplasia
  • Purulent material in posterior pharynx 2

Warning Signs Requiring Urgent Evaluation

• Orbital swelling or pain
• Swelling of forehead
• Diplopia
• Visual changes
• Abnormal extraocular movements
• Proptosis
• Any signs of intracranial involvement 2

Treatment Plan

First-line Treatment

1. Antibiotics:

   • Amoxicillin: First-line therapy for most adults with acute bacterial sinusitis
     • Duration: 10-14 days (continue for 7 days after patient is well) 2, 1
   • If no improvement after 3-5 days: Switch to alternative antibiotics:
     • Amoxicillin-clavulanate (high-dose)
     • Cefuroxime axetil 2, 1
   • For penicillin-allergic patients:
     • Cephalosporins (cefpodoxime proxetil, cefuroxime axetil, cefdinir)
     • Respiratory fluoroquinolones for moderate disease 1
     • Levofloxacin (750 mg daily for 5 days or 500 mg daily for 10-14 days) 4

2. Adjunctive Therapy:

   • Nasal corticosteroids: Particularly helpful for patients with marked mucosal edema 2, 1
   • Decongestants: To reduce congestion and facilitate drainage
     • Limit use to 5 days to avoid rebound congestion 1
   • Saline irrigation: To prevent crust formation and improve mucociliary clearance 1

Monitoring and Follow-up

• Evaluate response to treatment after 3-5 days 2, 1
• If symptoms are improving, continue treatment until patient is well for 7 days 2
• If no improvement after 3-5 days:
  • Reassess diagnosis
  • Change antibiotic therapy
  • Consider referral to specialist 1, 3

Special Considerations

Chronic Sinusitis

• Defined as symptoms persisting for ≥12 consecutive weeks 5
• Management approach:
  • Nasal saline irrigation and intranasal corticosteroids as first-line therapy 5
  • Consider longer courses of antibiotics for acute exacerbations
  • Referral to otolaryngologist if medical management fails 5

Complications and Comorbidities

• Asthma: Sinusitis may initiate or worsen asthma symptoms 2, 6
  • Consider chest auscultation and spirometry in patients with cough
• Nasal polyps: May contribute to recurrent sinusitis 2
  • More common when sinusitis complicates allergic rhinitis 6
  • In children, consider evaluation for cystic fibrosis 2

Surgical Intervention

• Consider when appropriate medical therapy fails and there is objective evidence of disease 1
• Endoscopic sinus surgery can provide:
  • Relief of nasal obstruction
  • Improved sinus ventilation and drainage
  • Enhanced delivery of topical medications 1

Common Pitfalls to Avoid

1. Unnecessary imaging: Plain radiographs generally not necessary for diagnosis of acute sinusitis and have significant false-positive and false-negative results 2, 3
2. Overuse of antibiotics: Distinguish between viral rhinitis and bacterial sinusitis 1
3. Inadequate duration of therapy: Ensure complete course of antibiotics to prevent relapse 2
4. Failure to recognize complications: Carefully evaluate for orbital or intracranial involvement 2