From the Guidelines
Bacterial sinusitis typically presents with nasal congestion, purulent nasal discharge, facial pain or pressure, and decreased sense of smell lasting for 10 or more days without improvement, as indicated by clinical guidelines 1.
Presentation of Bacterial Sinusitis
The clinical symptoms of bacterial sinusitis include:
- Nasal congestion and obstruction
- Purulent nasal discharge
- Maxillary tooth pain
- Facial pain or pressure
- Fever
- Fatigue
- Cough
- Hyposmia or anosmia
- Ear pressure or fullness
- Headache
- Halitosis These symptoms can last from 1 to 33 days, with most episodes resolving within a week 1.
Determining the Likelihood of a Bacterial Infection
Acute bacterial rhinosinusitis (ABRS) is considered a secondary infection resulting from obstruction of the sinus ostia that leads to impaired mucosal clearance as a result of a viral upper respiratory tract infection (URI) 1. A bacterial cause is more likely when symptoms persist for more than 10 days without clinical improvement, symptoms are severe, or symptoms worsen after an initial period of improvement (double sickening) for more than 3 days 1.
Diagnosis and Management
Diagnosis is primarily clinical, as imaging is not routinely recommended for uncomplicated cases 1. The 2012 IDSA clinical practice guidelines recommend empirical antibiotics as soon as a clinical diagnosis of ABRS is established on the basis of clinical criteria 1. Amoxicillin–clavulanate is the preferred agent, and doxycycline or a respiratory fluoroquinolone may be used as an alternative in certain cases 1.
From the Research
Presentation of Bacterial Sinusitis
- Bacterial sinusitis is a clinical diagnosis, and the challenge lies 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)
- Purulent nasal discharge with obstruction of the nasal passages
- The symptoms of bacterial sinusitis can be similar to those of viral sinusitis, making diagnosis difficult 2
Diagnostic Testing
- Diagnostic testing for acute rhinosinusitis with antral puncture is impractical due to its invasiveness 2
- Point-of-care testing for elevated C-reactive protein may be helpful, but it is not widely available 2
- Computed tomography and referral to an otolaryngologist should be considered for patients with recurrent rhinosinusitis or concern about complications 2
Treatment Options
- 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, 3
- 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
- Other treatment options include levofloxacin 4 and azithromycin 5, which have been shown to be effective in treating acute sinusitis
- Amoxicillin/clavulanate has been shown to distribute well in sinus tissue and serum, making it a potentially effective treatment option for chronic rhinosinusitis 6
Supportive Care
- Supportive care for rhinosinusitis, 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 2
- Complications of rhinosinusitis are rare but may include orbital cellulitis, meningitis, and abscess 2