Acute Rhinosinusitis in Adults

Background

• Acute sinusitis is an inflammation of the mucosa of the paranasal sinuses, typically from an infectious process.
• Sinusitis is reported to be the fifth most common diagnosis made during family physician visits.
• 50%-67% of sinusitis cases are reportedly attributable to viruses.
• The most common bacterial pathogens that cause sinusitis include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.

Evaluation

• Consider the diagnosis of acute bacterial sinusitis if any of the following are present:
  • signs or symptoms of sinusitis (cough, congestion, and/or post-nasal drip) that last ≥ 10 days without clinical improvement
  • worsening signs or symptoms following initial improvement (double sickening)
  • severe symptoms including fever ≥ 39 degrees C (102 degrees F) and purulent nasal discharge lasting ≥ 3-4 consecutive days
  • unilateral cheek or maxillary tooth pain and purulent nasal discharge
• Testing is not necessary for most cases of acute sinusitis.

Management

• For mild-to-moderate acute sinusitis:
  • Consider analgesics, antipyretics, and/or intranasal corticosteroids (consider intranasal corticosteroids particularly in patients with history of allergic rhinitis) (Weak recommendation).
  • Consider intranasal saline irrigation with either physiologic or hypertonic saline (Weak recommendation).
  • Decongestants are generally not recommended, but may be an option for symptom relief.
  • Antihistamines are not indicated unless an allergic component is present.
• Only consider treatment with antibiotics if the patient meets the criteria for acute bacterial sinusitis.
  • Antibiotics can result in improved symptoms at 7-15 days in adults with acute maxillary sinusitis, but there is a high rate of clinical improvement without antibiotics.
  • There is no clear consensus on when to initiate antibiotics in adults.
    • Infectious Diseases Society of America (IDSA) recommends starting antibiotics as soon as a clinical diagnosis of acute bacterial sinusitis is made.
    • American Academy of Otolaryngology-Head and Neck Surgery Foundation suggests:
      • Consider watchful waiting without antibiotics in patients with uncomplicated mild illness (mild pain and temperature < 101 degrees F [38.3 degrees C]) and presumed acute bacterial rhinosinusitis with assurance of follow-up.
      • If the patient worsens or fails to improve with the initial management option by 7 days after diagnosis, reconfirm diagnosis of bacterial rhinosinusitis and, if reconfirmed, start antibiotic therapy.
    • Canadian consensus guidelines recommend intranasal corticosteroids as the sole therapy for mild-to-moderate acute viral or bacterial sinusitis.
      • Antibiotics may be prescribed to improve the rate of symptom resolution within 14 days or when the patient has quality of life or productivity issues, or severe sinusitis with comorbidities.
      • Begin antibiotics if using intranasal corticosteroid therapy as initial therapy and it fails after 72 hours.
      • Change the antibiotic class if the antibiotic treatment fails after 72 hours.
  • Amoxicillin or amoxicillin clavulanate is the preferred first-line treatment.
  • Recommended duration of therapy ranges from 5 to 10 days for most adults (Weak recommendation).
• Surgery may be considered for recurrent acute or chronic infective sinusitis refractory to medical treatment.