What are the guidelines for managing acute and chronic sinusitis?

Guidelines for Managing Acute and Chronic Sinusitis

For acute bacterial sinusitis, clinicians should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy, with amoxicillin with or without clavulanate as first-line therapy for 5-10 days when antibiotics are deemed necessary. 1

Diagnosis and Classification

Acute Rhinosinusitis

• Definition: Symptomatic inflammation of paranasal sinuses and nasal cavity lasting less than 4 weeks
• Types:
  • Viral rhinosinusitis (VRS): Most common, typically resolves within 10 days
  • Acute bacterial rhinosinusitis (ABRS): Diagnosed when one of these patterns is present:
    • Persistent symptoms: Nasal discharge or cough for >10 days without improvement
    • Severe symptoms: Fever ≥102.2°F (39°C) with purulent nasal discharge for ≥3 consecutive days
    • Worsening symptoms: Initial improvement followed by worsening nasal discharge, cough, or fever 1, 2

Chronic Rhinosinusitis

• Definition: Symptomatic inflammation lasting more than 12 weeks
• Diagnosis: Must be confirmed with objective documentation of sinonasal inflammation via anterior rhinoscopy, nasal endoscopy, or CT scan 1
• Assessment: Determine presence/absence of nasal polyps and evaluate for underlying conditions (asthma, cystic fibrosis, immunocompromised state, ciliary dyskinesia) 1

Management of Acute Bacterial Rhinosinusitis

Initial Approach

1. Watchful Waiting vs. Antibiotics:

   • For uncomplicated ABRS, either watchful waiting or initial antibiotic therapy is appropriate 1
   • Watchful waiting is suitable even for patients with more severe symptoms, as evidence supports this approach 1

2. Antibiotic Selection (if prescribed):

   • First-line: Amoxicillin with or without clavulanate for 5-10 days 1, 2
     • Standard dose: Amoxicillin-clavulanate 875/125 mg twice daily for 5-7 days
     • High-dose: Amoxicillin-clavulanate 2000/125 mg twice daily for 5-7 days (for areas with high S. pneumoniae resistance) 2
   • For penicillin allergy:
     • Cephalosporins (cefdinir 300-600 mg twice daily, cefuroxime 250-500 mg twice daily, or cefpodoxime 200-400 mg twice daily) 2
     • Doxycycline is an acceptable alternative 2
     • Clarithromycin extended-release 1 gram daily for 14 days for acute maxillary sinusitis 3

3. Reassessment:

   • If patient worsens or fails to improve within 7 days of initial management, reassess to:
     • Confirm ABRS diagnosis
     • Exclude other causes
     • Detect complications 1
   • Consider switching to broader-spectrum antibiotic if no improvement within 72 hours 2

Adjunctive Therapies

• Intranasal corticosteroids: Reduce inflammation and promote drainage 2
• Saline nasal irrigation: Helps clear mucus and reduce inflammation 2
• Nasal decongestants: May be used short-term (≤5 days) to reduce congestion 2

Management of Chronic Rhinosinusitis

1. Diagnostic Confirmation:

   • Objective documentation of sinonasal inflammation via anterior rhinoscopy, nasal endoscopy, or CT scan 1
   • Determine presence/absence of nasal polyps 1

2. Assessment for Modifying Conditions:

   • Evaluate for asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia 1
   • For unilateral maxillary sinusitis, evaluate for dental infection 2

3. Treatment:

   • First-line: Saline nasal irrigation, topical intranasal corticosteroids, or both 1
   • Antibiotics: May be considered for acute exacerbations, though evidence shows limited benefit 4
   • Avoid: Topical or systemic antifungal agents (not recommended) 1

4. Referral Considerations:

   • Persistent symptoms despite appropriate therapy
   • Suspected complications
   • Need for imaging studies (CT scan indicated for recurrent or chronic sinusitis) 2

Warning Signs of Complications

• Meningeal syndrome
• Exophthalmos
• Palpebral edema
• Ocular mobility disorders
• Severe pain preventing sleep
• Persistent fever despite appropriate therapy 2, 5

These signs necessitate immediate specialist referral, hospitalization, bacteriological testing, and parenteral antibiotic therapy 2.

Common Pitfalls to Avoid

1. Overuse of antibiotics for viral rhinosinusitis or mild ABRS where watchful waiting would be appropriate
2. Failure to distinguish between viral and bacterial causes of acute rhinosinusitis
3. Inappropriate antibiotic selection (e.g., using trimethoprim/sulfamethoxazole or azithromycin despite high resistance patterns) 2
4. Inadequate follow-up for patients who fail to improve with initial management
5. Missing underlying conditions that modify management of chronic rhinosinusitis
6. Delayed recognition of complications that require immediate intervention

By following these evidence-based guidelines, clinicians can effectively manage both acute and chronic sinusitis while promoting judicious use of antibiotics and appropriate use of adjunctive therapies.