Low DE, Desrosiers M, McSherry J, Garber G, Williams JW Jr, Remy H, Fenton RS, Forte V, Balter M, Rotstein C, Craft C, Dubois J, Harding G, Schloss M, Miller M, McIvor RA, Davidson RJ.
University of Toronto, Ont.
OBJECTIVE: To develop guidelines for the diagnosis and management of acute sinusitis.
OPTIONS: Diagnostic clinical criteria and imaging techniques, the role of antimicrobial therapy and duration of treatment, and the role of adjunct therapy, including decongestants, glucocorticosteroids and nasal irrigation.
OUTCOMES: Improved accuracy of clinical diagnosis, better utilization of imaging techniques and rational use of antimicrobial therapy.
EVIDENCE: A MEDLINE search for relevant articles published from 1980 to 1996 using the MeSH terms "sinusitis," "acute sinusitis," "respiratory infections," "upper respiratory infections," "sinusitis" and "diagnosis," "sinusitis" and "therapy," "sinusitis" and "etiology," and "antimicrobial resistance" and search for additional articles from the reference lists of retrieved articles. Papers referring to chronic sinusitis, sinusitis in compromised patients and documented nonbacterial sinusitis were excluded. The evidence was evaluated by participants at the Canadian Sinusitis Symposium, field in Toronto on April 26-27, 1996.
VALUES: A hierarchical evaluation of the strength of evidence modified from the methods of the Canadian Task Force on the Periodic Health Examination was used. Strategies were identified to deal with problems for which no adequate clinical data were available. Recommendations arrived at by consensus of the symposium participants were included.
BENEFITS, HARMS AND COSTS: Increased awareness of acute sinusitis, accurate diagnosis and prompt treatment should reduce costs related to unnecessary investigations, time lost from work and complications due to inappropriate treatment. As well, physicians will be better able to decide which patients will not require antimicrobial therapy, thus saving the patient the cost and potential side effects of treatment.
RECOMMENDATIONS: Clinical diagnosis can usually be made from the patient's history and findings on physical examination only. Five clinical findings comprising 3 symptoms (maxillary toothache, poor response to decongestants and a history of coloured nasal discharge) and 2 signs (purulent nasal secretion and abnormal transillumination result) are the best predictors of acute bacterial sinusitis (level I evidence). Transillumination is a useful technique in the hands of experienced personnel, but only negative findings are useful (level III evidence). Radiography is not warranted when the likelihood of acute sinusitis is high or low but is useful when the diagnosis is in doubt (level III evidence). First-line therapy should be a 10-day course of amoxicillin (trimethoprim-sulfamethoxazole should be given to patients allergic to penicillin) (level I evidence) and a decongestant (level III evidence). Patients allergic to amoxicillin and those not responding to first-line therapy should be switched to a second-line agent. As well, patients with recurrent episodes of acute sinusitis who have been assessed and found not to have anatomic anomalies may also benefit from second-line therapy (level III evidence).
VALIDATION: The recommendations are based on consensus of Canadian and American experts in infectious diseases, microbiology, otolaryngology and family medicine. The guidelines were reviewed independently for the advisory committee by 2 external experts. Previous guidelines did not exist in Canada.
- Consensus Development Conference
PMID: 9347786 [PubMed - indexed for MEDLINE]
Marks SC, Kissner DG.
Department of Otolaryngology, Wayne State University School of Medicine, Detroit, Michigan, USA.
Until recently, cystic fibrosis was frequently fatal during childhood.
However, with current medical management, many patients are living into adulthood.
This has created a new population of patients with chronic sinusitis and severe medical problems.
In this report, experience with 22 patients, eight of whom have undergone sinus surgery, is presented, and recommendations for management are proposed.
Presenting symptoms are typical of sinusitis, but in a few patients, severe debilitating headaches predominate.
Oral antibiotics are often of little use due to the numerous courses of high dose intravenous antibiotics used for resistant pulmonary infections.
Topical nasal steroids and mucolytics have been of some benefit.
Fourteen operative procedures were performed on eight patients.
These procedures included 12 endoscopic sphenoethmoidectomies, four Caldwell-Luc procedures, two frontal sinus obliterations, and one transseptal sphenoidotomy (many of these were in combination.) Results from this experience indicate 1) Failure of endoscopic surgery to control frontal and maxillary sinus disease; 2) Delayed healing of the ethmoid cavity with persistent crusting; and 3) Significant, albeit short term, symptomatic relief following surgical intervention.
Based on this limited series, we conclude that surgery should be delayed until absolutely necessary and that an aggressive approach should be adopted when surgery is performed.
In our hands this included initial endoscopic sphenoethmoidectomy with open surgical techniques used for removal of trapped inspissated secretions.
We recommend long term intravenous antibiotics postoperatively and frequent cleaning of the ethmoid cavity after surgery, continuing indefinitely, to optimize the benefit of surgery.
PMID: 9065342 [PubMed - indexed for MEDLINE]
Brigham Young University, College of Nursing, Provo, Utah.
Sinusitis, a very common health care complaint, is one of the most frequently overlooked and misunderstood diseases in clinical practice.
An understanding of the pathophysiology is essential for health care providers to treat sinusitis effectively and to teach clients and families regarding management and possible complications.
This article addresses clinical signs and symptoms and the differences between adults and children, as well as the subtle distinctions between acute and chronic sinusitis, and appropriate diagnostic techniques.
Emphasis is placed on the diagnostic profiles of acute sinusitis relative to the different sinuses with progression to chronic sinusitis.
Bacterial etiology of sinusitis is reviewed as well as management goals of sinusitis.
Traditional management of sinusitis focuses on appropriate use of antibiotics, decongestants, steroids, antihistamines, and saline washes.
A section on implications for practice discusses the important role of the health care provider relevant to populations at risk and possible complications, with an emphasis on primary and secondary prevention.
PMID: 7532290 [PubMed - indexed for MEDLINE]
Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Sinusitis is a very common and increasingly recognized disorder affecting patients of all ages and genders.
It is most commonly due to infection of the paranasal sinuses with symptoms varying from cough and anterior nasal drainage in children to headache and post nasal drip in adults.
Diagnosis relies heavily on medical history with corroboration by careful physical examination including nasal endoscopy.
The most accurate imaging technique to evaluate sinusitis and to delineate the extent of involvement of individual sinuses and identify possible anatomic abnormalities is computerized tomography scanning in the coronal plane.
The mainstay of medical treatment of sinusitis is antibiotics with adjuvant treatments such as saline irrigation, decongestants, mucolytics and antiinflammatory agents playing a more secondary role.
The use of these agents will be discussed in detail after an introduction about the risk factors, diagnosis and bacteriology of the disease.
Surgical treatment of sinusitis will be the subject of another article.
PMID: 8558575 [PubMed - indexed for MEDLINE]
[Article in Japanese]
Nonoyama T, Majima Y, Nishii S, Okada E, Takahashi Y, Yuta A, Sakakura Y.
Department of Otorhinolaryngology, Mie University School of Medicine, Tsu.
The managements and the results of therapy for children with chronic sinusitis were reported.
During the period of 1980 to 1988, 190 patients, aged 3 to 15, were examined at our outpatient clinic.
The pathologic conditions of the maxillary sinus were examined by the contrast x-ray study (X-MFT).
The mild, moderate and severe lesions in the maxillary sinus evaluated by X-MFT were 22%, 44; and 34%, respectively.
Sixty-two per cent of ethmoid sinus was opacified in occipito-frontal view.
The degree of patency of the maxillary ostium was evaluated by an application of the constant pressure to the maxillary sinus.
Almost all maxillary ostia of these patients were patent.
Nasal mucociliary clearance was reduced in 37% of the patients examined after the saccharin method.
Antral lavages were performed once in a week for the therapy of 72% of children with chronic sinusitis.
The efficacy of this modality was evaluated by the above mentioned items.
The maxillary and ethmoid lesions, and nasal mucociliary transit time were significantly improved by the modality after 25 months in average.
These results indicate that the antral lavage is an useful therapy for chronic sinusitis in children.
PMID: 2352042 [PubMed - indexed for MEDLINE]
Incaudo G, Gershwin ME, Nagy SM.
When faced with the diagnosis of sinusitis, the physician should carefully review the clinical setting from which the condition arose, its potential origins, as well as initiate management.
In most instances, medical management will suffice for acute and subacute disease although some surgical intervention is occasionally helpful.
If nasal polyps are present with radiographic evidence of sinus obstruction, standard medical treatment is initiated with the addition of systemic corticosteroids once the suppurative component is controlled.
A lack of response in each of these circumstances is evaluated on an ongoing basis.
If successful treatment is seen clinically, repeat radiographs with those views which best reveal the sinus involved are obtained in approximately 6 weeks to hopefully demonstrate normality.
Persistent radiographic abnormalities can then be either treated surgically or, if clinical judgement dictates, further medical management can be pursued.
However, in the chronic phase of sinusitis or after the patient has been followed with persistent abnormalities for over three months, irreversibly diseased mucosa is generally present and surgical intervention is commonly indicated.
We would like to emphasize that during the course of treatment, frequently consider the origin of the sinusitis.
Commonly it is infectious (e.g. viral) and no further investigation is necessary.
However, anatomic abnormalities or systemic disease may be present whose correction can prevent the recurrence of acute sinusitis or, more importantly, the evolution into chronic irreversible sinus disease.
PMID: 3541552 [PubMed - indexed for MEDLINE]
The treatment of acute bacterial sinusitis is medical, the regimen including oral and nasal decongestants and antibiotics. Progression to chronic sinusitis can sometimes be prevented by periodic sinus washings until the acute process subsides. Sinus x-ray examinations are important in follow-up when symptoms or signs persist.
PMID: 59365 [PubMed - indexed for MEDLINE]
PMID: 14146701 [PubMed - OLDMEDLINE for Pre1966]