Acute sinusitis in adults.
SOURCE(S):
Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 1999
Dec. 23 p. (ICSI health care guidelines; no. GRD02). [37 references]
Class of evidence (A-D, M, R, X) definitions are repeated at the end of the
Major Recommendations field.
The major recommendations contained within this algorithm have been
summarized below by NGC:
1. Conduct phone triage for diagnosis of acute sinusitis.
An individual reporting the following symptoms for acute sinusitis has a
reasonably high likelihood of having the disease, and such a patient’s
symptoms and chart should be presented to the physician or nurse
practitioner for further action:
* Upper respiratory symptoms have been present for at least 7 days,
and
* 2 or more of the following 4 factors are present at a point 7 days
or more after the onset of the illness:
* Colored nasal drainage
* Poor response to decongestant
* Facial pain or sinus pain, particularly if aggravated by postural
change or valsalva maneuver
* Headache
Conditions requiring actions before 7 days are as follows:
* Fever >102 degrees and a documented past history of sinusitis in
addition to the above symptoms are supportive of a sinusitis diagnosis.
* Tooth pain with any of the above findings is a more specific
indication of sinusitis. Patients with tooth pain should be considered for
treatment before 7 days.
* Severe symptoms should be considered for treatment before 7 days.
* Known anatomical blockage (e.g., chronic nasal polyps, severely
deviated septum, recurrent sinusitis) may need immediate treatment.
Patients not meeting the triage criteria for sinusitis should be triaged for
an alternative diagnosis.
2. Phone management of patients with presumed sinusitis should be
limited to a select group of patients. This group includes patients with the
following characteristics:
* Generally good health
* Mildly ill
* Established patient
* Patient is comfortable with phone management
* History of previous sinusitis treated successfully
* Earlier visit for treatment of viral upper respiratory tract
infection
3. Patients with the following characteristics should be scheduled for
a provider visit rather than be managed by phone:
* Patients who do not have an office record because background data
is insufficient for appropriate phone management of the patient
* Patients who have a pattern over time of telephone requests for
antibiotics
* Patients on antibiotics for 2 or more days whose sinus symptoms
are worsening
* Patients with any one of following complicating factors should be
seen urgently:
* Orbital pain
* Visual disturbances
* Periorbital swelling or erythema
* Facial swelling or erythema
* Signs of meningitis or "worst headache of my life"
* Patients who have multisystem disease, who are generally more
complicated/complex to treat by phone because their illnesses and
medications need to be taken into consideration as the treatment plan is
developed
* Patients who are determined by the phone triage person to be more
than mildly ill; the provider may determine if more intensive therapy is
required (i.e. whether the initial therapy may include a
beta-lactamase-resistant antibiotic if the patient is more severely ill)
4. The diagnosis of acute sinusitis is based primarily on the patient’
s presenting symptoms and history, and is supported by the physical exam.
The following recommendations are made for diagnosis of acute sinusitis
during the provider visit:
* Review of patient history to confirm information obtained during
phone triage
* Regional exam of the head and neck; the following findings may be
present:
* Purulent nasal discharge
* Sinus tenderness
* Decreased transillumination (Note: Transillumination is of limited
usefulness, and is dependent on the skill of the provider performing the
exam. As a single finding, transillumination cannot rule sinusitis in or
out.)
* Review of complicating factors; further evaluation will be needed
if the following findings are present:
Local
* External facial swelling/erythema over involved sinus
Orbital
* Visual changes
* Extraocular motion abnormal
* Proptosis
* Periorbital inflammation/soft tissue edema
* Periorbital erythema/cellulitis
* subperiosteal abscess
* orbital cellulitis
* orbital abscess
Intracranial, Central Nervous System Complications
* Cavernous sinus thrombosis
* Meningitis
* Subdural empyema
* Brain abscess
* Plain sinus x-rays and other imaging are usually not necessary in
making the diagnosis of acute sinusitis (Note: Plain films offer little
additional information in this setting; poor sensitivity and specificity
limit their usefulness.)
* Maxillary antrum aspiration for culture is indicated only when
precise microbial identification is required.
Evidence supporting this conclusion is of classes:
Sinus x-rays: C, R
5. Patients who meet the criteria for phone management should receive
the same treatment and instructions as those for visiting patients. The goal
of treatment is to promote adequate drainage of the sinuses. This in turn
will provide relief of symptoms; a combination of home care and medical
treatments may be required.
* The patient should be instructed to implement the following
comfort and prevention measures:
* Maintain adequate hydration (drink 6-10 glasses of liquid a day to
thin mucus)
* Steamy shower or increase humidity in home
* Apply warm facial packs (warm wash cloth, hot water bottle, or gel
pack for 5-10 minutes 3 or more times per day)
* Analgesics (acetaminophen, ibuprofen, aspirin as needed)
* Saline irrigation (homemade or commercial nasal drops or spray)
* Decongestants (topically or orally)
* Adequate rest
* Sleep with head of bed elevated
* Avoidance of cigarette smoke and extremely cool or dry air,
pollution, swimming in contaminated water, barotrauma
* Treatment of allergies and viral upper respiratory infections to
prevent the development of sinusitis
* Intranasal corticosteroid spray (a rational but unproved
adjunctive therapy)
* Antihistamines are not recommended for treatment of sinusitis
because they cause further inspissation of secretions.
* Antibiotics should be reserved for those patients who failed
decongestant therapy, those who present with symptoms and signs of a more
severe illness, and those who have complications of acute sinusitis.
* Amoxicillin 500 mg tab three times a day or 875 mg tab twice daily
for 10 days is the initial drug of choice
* In patients who are penicillin-allergic,
trimethoprim-sulfamethoxazole one double strength tab twice daily for 10
days is recommended initially
* Cephalosporins could be considered but there is an approximately
10% cross-reaction between cephalosporin and amoxicillin
* Generally quinolone antibiotics should not be used since they are
relatively inactive against pneumococci
* Patients should be instructed to complete the course of
antibiotics and to call back if symptoms worsen or if symptoms have not
resolved within one week.
Evidence supporting this conclusion is of classes:
Antibiotics: A, C, R
* Patients who have little or no symptomatic improvement after
finishing a 10 day course of amoxicillin or trimethoprim-sulfamethoxazole,
should receive further treatment:
* In case of partial response, an additional 10-14 days of
amoxicillin or trimethoprim-sulfamethoxazole should be given
* In case of failure of initial therapy, amoxicillin/clavulanate
(Augmentin) 875 mg twice daily for 14 days or trimethoprim-sulfamethoxazole
one double–strength tab twice daily for 10-14 days should be given
* Patients allergic to both amoxicillin and
trimethoprim-sulfamethoxazole can be prescribed macrolides
* A cephalosporin could be considered but there is approximately a
10% cross-reaction between cephalosporins and amoxicillin.
* Comfort and prevention measures should be reinforced
* In patients who have not responded to three weeks of continuous
antibiotic therapy, sinus x-ray series or limited coronal computed
tomography scan and/or referral to ear, nose and throat provider should be
considered.
Definitions:
Rating Scheme for the Strength of the Evidence
Evidence Grading System: Classes of Research Reports:
A. Primary Reports of New Data Collection:
Class A:
* Randomized, controlled trial
Class B:
* Prospective cohort study
* Case-control study nested within a prospective cohort study
Class C:
* Non-randomized trial with concurrent or historical controls
* Case-control study (except as above)
* Retrospective cohort study
* Study of sensitivity and specificity of a diagnostic test
* Population-based descriptive study
Class D:
* Cross-sectional study
* Case series
* Case reports
B. Reports that Synthesize or Reflect upon Collections of Primary
Reports
Class M:
* Meta-analysis
* Decision analysis
* Cost-benefit analysis
* Cost-effectiveness study
Class R:
* Review article
* Consensus statement
* Consensus report
Class X:
* Medical opinion
CLINICAL ALGORITHM(S):
A detailed and annotated clinical algorithm is provided for the management
of acute sinusitis.
DEVELOPER(S):
Institute for Clinical Systems Improvement (ICSI) - Private Nonprofit
Organization
COMMITTEE:
Respiratory Steering Committee (RSC)
GROUP COMPOSITION:
Steering Committee Members: Richard Pfohl, MD (Work Group Leader)
(HealthSystem Minnesota) (Internal Medicine); Pamela Harris, MD
(HealthSystem Minnesota) (Allergy); David Sherris, MD (Mayo Clinic) (ENT);
Dale Duthoy, MD (Family HealthServices Minnesota) (Family Practice); Tom
Bisig, MD (Mayo Clinic) (Internal Medicine); Allan Boyum, MD
(HealthPartners) (Internal Medicine); Peter Marshall, PharmD
(HealthPartners) (Pharmacy); Susan Virant, RN (HealthPartners) (Adult
Nursing); Heather Hagen (Ceridian Corporation) (Buyers Health Care Action
Group Representative); Margaret Healey, PhD (Institute for Research &
Education, HealthSystem Minnesota) (Measurement Advisor); Mary Stadick, MA
(ICSI) (Facilitator).
Edward E. Rylander, M.D.
Diplomat American Board of Family Practice.
Diplomat American Board of Palliative Medicine.
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