What is the classification and treatment of sinusitis?

Classification and Treatment of Sinusitis

Sinusitis is classified primarily based on symptom duration, with treatment approaches tailored to each classification type and severity. 1

Classification of Sinusitis

Primary Classification by Duration

1. Acute Sinusitis

   • Duration: Symptoms present for less than 4 weeks 1
   • Common symptoms: Persistent upper respiratory infection symptoms, purulent rhinorrhea, postnasal drainage, anosmia, nasal congestion, facial pain, headache, fever, and cough 1

2. Subacute Sinusitis

   • Duration: Symptoms from 4-8 weeks 1 or 4-12 weeks 1
   • Often represents unresolved acute sinusitis or inadequate/partial therapy 1

3. Chronic Sinusitis

   • Duration: Symptoms persisting more than 8 weeks 1, 2 or 12 weeks 1
   • Requires abnormal findings on CT or MRI for definitive diagnosis 1
   • May present with vague or insidious symptoms 1

4. Recurrent Acute Sinusitis

   • Definition: 3 or more episodes of acute sinusitis per year 1 or 4 or more episodes per year 1
   • Patients may be infected by different organisms during different episodes 1

Secondary Classification

1. By Pathology (for Chronic Sinusitis)

   • Infectious chronic sinusitis: Often due to anaerobic bacteria, gram-positive streptococcus, bacteroides, Fusobacterium species, or S. aureus 1
   • Chronic hyperplastic eosinophilic sinusitis: Marked by eosinophils and mixed mononuclear cells with few neutrophils; often associated with nasal polyps, asthma, and aspirin sensitivity 1

2. By Severity

   • Using visual analog scale (0-10): Mild (0-3), Moderate (>3-7), Severe (>7-10) 1

Treatment Approaches

1. Acute Sinusitis Treatment

• First-line antibiotics (if bacterial infection suspected):

  • Amoxicillin-clavulanate (875/125 mg twice daily for 7-14 days) 3, 4
  • Second-generation cephalosporins (cefuroxime-axetil) 3, 4
  • Third-generation cephalosporins (cefpodoxime-proxetil) 3
  • For penicillin-allergic patients: Pristinamycin 3

• Adjunctive therapy:

  • Intranasal corticosteroids 3, 2
  • Nasal saline irrigations 3
  • Pain assessment and management 1
  • Symptomatic relief with decongestants 5

• Treatment duration:

  • Standard: 7-10 days 3
  • Short-course regimens with certain antibiotics: 5 days 3
  • Assess response after 3-5 days; continue for additional 7 days if improvement seen 2

2. Chronic Sinusitis Treatment

• Medical management:

  • Intranasal corticosteroids 3
  • Saline irrigations 3
  • Antibiotics directed at likely pathogens (including anaerobes in chronic cases) 4
  • For chronic sinusitis with nasal polyps: Consider trial of oral corticosteroids 1

• Surgical considerations:

  • Indicated when medical management fails after appropriate trial 3
  • Functional endoscopic sinus surgery (FESS) for patients with symptoms >12 weeks despite medical treatment 3
  • CT imaging should be performed >4 weeks after acute bacterial sinusitis and after medical management 3
  • Coronal CT with extra cuts through the ostiomeatal complex is the gold standard for surgical planning 1, 3

3. Special Considerations

• Complications to monitor:

  • Orbital infections (pre- or postseptal cellulitis) 6
  • Intracranial infections (epidural and subdural abscesses) 6
  • Contribution to asthma, sleep-disordered breathing, and smell disorders 6

• Referral indications:

  • Recurrent sinusitis (2-3 episodes/year despite treatment) 3
  • Significant impact on quality of life 3
  • Suspected immunologic or allergic basis 3
  • Need for complex pharmacology for resistant pathogens 3
  • Anatomic abnormalities requiring surgical correction 1

Clinical Pearls and Pitfalls

• Important terminology note: The term "rhinosinusitis" is increasingly preferred over "sinusitis" since the nasal mucosa is almost always involved concurrently 1

• Common pitfall: Overuse of antibiotics in viral cases. Most acute sinus infections are viral, and patients typically improve within 2 weeks without antibiotics 2

• Treatment failure: If no clinical improvement within 3 days of starting antibiotics, consider an alternative antibiotic 3

• Diagnostic caution: More than 50% of patients with strong history of chronic sinusitis may have normal CT scans, suggesting a need for reevaluation of diagnostic criteria 1

• Surgical approach: Limited surgery targeting affected sinuses is recommended rather than routine complete ethmoidectomy 3

• Post-treatment follow-up: Should occur between 3-12 months to assess symptom relief, quality of life, and need for additional interventions 3