From the Guidelines
The approach to diagnosing and managing sinusitis should prioritize determining whether the cause is viral or bacterial, with treatment focusing on symptom relief for viral cases and antibiotics for bacterial cases, as evidenced by the 2015 clinical practice guideline update on adult sinusitis 1.
Diagnosis of Sinusitis
To diagnose sinusitis, it's essential to consider the symptoms and duration of the illness.
- Acute viral sinusitis is likely if symptoms have lasted less than 10 days and are not worsening, as stated in the patient information sheet on diagnosis of acute sinusitis 1.
- Acute bacterial sinusitis should be suspected if symptoms persist beyond 10 days, worsen after initial improvement, or are severe with high fever and purulent discharge.
Treatment of Sinusitis
For acute viral sinusitis, treatment focuses on symptom relief with:
- Saline nasal irrigation
- Intranasal corticosteroids like fluticasine (2 sprays per nostril daily)
- Analgesics such as acetaminophen or ibuprofen For bacterial cases, amoxicillin 500mg three times daily for 5-7 days is recommended as first-line therapy, with amoxicillin-clavulanate 875/125mg twice daily for 5-7 days used for complicated cases or treatment failures, as suggested by the clinical practice guideline update on adult sinusitis 1.
Imaging Studies
Radiographic imaging of the paranasal sinuses is unnecessary for diagnosis in patients who already meet clinical diagnostic criteria for ABRS, as stated in the evidence 1.
- CT imaging of the sinuses is appropriate when a complication of ABRS is suspected, such as severe headache, facial swelling, or cranial nerve palsies.
Chronic Sinusitis
Chronic sinusitis (symptoms lasting >12 weeks) may require longer courses of antibiotics, extended use of intranasal steroids, and possibly referral to an ENT specialist for evaluation of structural issues or consideration of endoscopic sinus surgery, as implied by the clinical practice guideline update on adult sinusitis 1. In summary, the management of sinusitis should prioritize symptom relief for viral cases and antibiotics for bacterial cases, with consideration of imaging studies and referral to an ENT specialist as needed, based on the most recent and highest quality evidence available 1.
From the Research
Diagnosis of Sinusitis
- The diagnosis of sinusitis is typically clinical, with the challenge lying in distinguishing between the symptoms of bacterial and viral sinusitis 2
- Cardinal features of acute bacterial rhinosinusitis include unilateral facial pain or pressure, fever greater than 102°F (39°C), and purulent nasal discharge with obstruction of the nasal passages 2
- Imaging tests, such as computed tomography, may be necessary to confirm the presence of acute sinusitis, especially in older children and adults 3
Treatment of Sinusitis
- Antibiotics should be considered for patients with 3 or more days of severe symptoms, significant worsening after 3 to 5 days of symptoms, or 7 or more days of symptoms 2
- Amoxicillin is as effective as amoxicillin-clavulanate as a first-line treatment for acute bacterial rhinosinusitis for those without a beta-lactam allergy 2
- For patients with a beta-lactam allergy, appropriate antibiotics include doxycycline or a respiratory fluoroquinolone; clindamycin plus a third-generation cephalosporin is an option for children with non-type I hypersensitivity to beta-lactam antibiotics 2
- Short-course antibiotic treatment (3-7 days) has similar effectiveness to longer-course treatment (6-10 days) for patients with acute uncomplicated bacterial sinusitis 4, 5
- High-dose amoxicillin/clavulanate may lead to more rapid improvement in symptoms, but also increases the risk of severe diarrhea 6
Management of Sinusitis
- Supportive care, including use of saline irrigation, nasal steroids or antihistamines, and decongestants, may help reduce the severity of symptoms 2
- Most episodes of rhinosinusitis are self-limited, lasting 7 to 10 days, but complications such as orbital cellulitis, meningitis, and abscess can occur 2
- Referral to an otolaryngologist should be considered for patients with recurrent rhinosinusitis or concern about complications 2