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.