• University of Michigan Health System. Acute rhinosinusitis in adults. Ann Arbor (MI): University of Michigan Health System; 2007 Mar. 8 p. [6 references]

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. Acute rhinosinusitis in adults. Ann Arbor (MI): University of Michigan Health System; 2005 Feb. 8 p.

Acute rhinosinusitis

Diagnosis
Management
Treatment

Family Practice
Internal Medicine
Otolaryngology

Advanced Practice Nurses
Nurses
Physician Assistants
Physicians

To improve quality of care and decrease costs by:

• Accurate diagnosis
• Appropriate medical therapy
• Effective radiological imaging
• Appropriate subspecialist referral

Non-immune compromised adults with suspected or diagnosed acute rhinosinusitis

Diagnosis

1. Probability estimate via history, physical examination, physician's overall clinical impression, transillumination, and temporality of symptoms
2. Identification of predisposing conditions and complications
3. Diagnostic imaging, including limited sinus computed tomography (CT)

Treatment

1. First line antibiotics: amoxicillin or trimethoprim/sulfamethoxazole
2. Alternative antibiotics for those allergic or intolerant of first line antibiotics, including doxycycline hyclate, azithromycin, and others
3. Second line antibiotics: amoxicillin high dose, amoxicillin/clavulanate potassium, usual dose, amoxicillin/clavulanate potassium, high dose levofloxacin

   Note: Guideline developers considered but do not recommend ciprofloxacin or telithromycin as second line antibiotics.

4. Adjuvant therapies including:
   • Likely to be effective
     • Oral decongestants: pseudoephedrine
     • Topical decongestants
     • Topical anticholinergics
     • Oral antihistamines (first generation with significant anticholinergic effect): chlorpheniramine, clemastine, diphenhydramine
   • Likely to be effective for acute sinusitis in presence of chronic or recurrent sinusitis
     • Corticosteroid nasal spray in high doses
   • Possibly effective
     • Zinc gluconate lozenges
     • Vitamin C
     • Echinacea extract
     • Saline irrigation

   Note: Adjuvant therapy with no proven benefit or not studied in controlling symptoms include steam, saline spray, less-sedating (2^nd generation) antihistamines (loratadine, fexofenadine, cetirizine), guaifenesin (except possibly at high doses)

5. Surgery

Management

Referral for otolaryngology evaluation with possible nasal endoscopy and computed tomography

• Symptom improvement
• Bacteriologic cure rates
• Efficacy and safety of medications

Searches of Electronic Databases

The literature search for this update began with the results of the literature searches performed in 1996 to develop the initial guideline and in 1998 for an update. The literature search conducted in 2004 for this update was conducted prospectively on Medline using the major keywords of acute rhinitis, rhinosinusitis, sinusitis; consensus development conferences, practice guidelines, guidelines, outcomes and process assessment (health care); clinical trials, controlled clinical trials, multicenter studies, randomized controlled trials, cohort studies; adults; English language; and published between 7/1/99 and 4/30/04. Terms used for specific topic searches within major key words included history; physical exam, signs, symptoms, predictors; computed tomography, magnetic resonance imaging, x-ray, ultrasound; sinus aspiration; nasal culture; diagnosis not included above; observation, saline, steam, postural drainage, salt water gargle; decongestants; cough suppressants; antihistamines, antibiotics; guaifenesin; corticosteroids; zinc, vitamin C; ipratropium; capsaicin, Echinacea, treatment failure, recurrence, persistent; immunocompromised, immunosuppressed, transplant; treatment or management not included above. Specific search strategy available upon request.

The search was conducted in components each keyed to a specific causal link in a formal problem structure. The search was supplemented with very recent clinical trials known to expert members of the panel. Negative trials were specifically sought.

Not stated

Weighting According to a Rating Scheme (Scheme Given)

Levels of evidence for the most significant recommendations:

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational trials
4. Opinion of expert panel

Review of Published Meta-Analyses
Systematic Review

Not stated

Expert Consensus

Not stated

Not applicable

A limited sinus computed tomography (CT) ($644) provides adequate information compared to a full sinus CT scan/maxillofacial CT ($1,193) and provides much better definition than a plain sinus x-ray series ($279).

June 2008 Update

At University of Michigan Health System the charge is $1,416 for any sinus computed tomography (CT) scan (low dose, limited, or full).

Comparison with Guidelines from Other Groups
Peer Review

University of Michigan Health System (UMHS) guidelines are reviewed by leadership and in clinical conferences of departments to which the content is most relevant. Guidelines are then endorsed by the Executive Committee for Clinical Affairs. The major update performed in 2005 went through this process. The interim updates regarding specific drugs (2006, 2007) were reviewed by the Director of UMHS Pharmacy, the guideline team lead, and the Guideline Oversight Committee. The interim update regarding imaging (2008) was reviewed by the guideline team lead with a radiology consultant and by the Guideline Oversight Committee.

The University of Michigan Hospitals and Health Centers (UMHHC) Clinical Guideline on Rhinosinusitis is consistent with "Antimicrobial treatment guidelines for acute bacterial rhinosinusitis" (2004), developed by the Sinus and Allergy Health Partnership.

Note from National Guideline Clearinghouse (NGC): The following key points summarize the content of the guideline. Refer to the full text for additional information, including detailed information on best predictors of rhinosinusitis, preferred treatment regimens, and dosing and cost considerations for first and second trial antibiotic treatments.

The levels of evidence [A-D] are defined at the end of the "Major Recommendations" field.

Definitions

Acute rhinosinusitis is an inflammation of the paranasal sinuses and the nasal cavity lasting no longer than 4 weeks. It can range from acute viral rhinitis (the common cold) to acute bacterial rhinosinusitis. Fewer than 5 in 1,000 colds are followed by bacterial rhinosinusitis.

Diagnosis

Estimate the probability of acute bacterial rhinosinusitis based on history and physical examination. The best predictors include maxillary toothache, poor response to decongestants, patient report of colored nasal discharge, purulent secretions by exam, and abnormal transillumination.

Treatment

Prescribe antibiotic therapy based on benefits and risks. Benefits depend on the probability of bacterial infection and the severity of symptoms. Risks of antibiotics include allergic reaction, potential side effects, and promotion of bacterial resistance. Antibiotics have not been shown to decrease the risk of complication or progression to chronic rhinosinusitis. Symptoms resolve within two weeks without antibiotics in 70% of cases and with antibiotics in 85% of cases.

First line antibiotics for acute bacterial rhinosinusitis are amoxicillin and trimethoprim/sulfamethoxazole. They are superior to placebo and as effective as other agents that are more expensive, have greater risk of side effects, and/or should be reserved for more serious infections [A]. Use first-line alternatives (e.g., doxycycline, azithromycin) only for patients allergic to both first line drugs. The usual initial course of antibiotics should be 10 to 14 days. An exception is azithromycin (500 mg daily), which should be prescribed for 3 days.

For partial but incomplete resolution after an initial course of antibiotics, extend the duration of antibiotic therapy by an additional 7 to 10 days for a total of 3 weeks of antibiotics.

For minimal or no improvement with initial treatment, consider changing to an antibiotic with broader coverage, including resistant strains. Options include amoxicillin at high dose, amoxicillin/clavulanate, and levofloxacin. Avoid ciprofloxacin due to limited activity against Streptococcus pneumoniae. Do not use telithromycin because risks for hepatotoxicity, loss of consciousness, and visual disturbances appear to outweigh potential benefits for this indication.

Ancillary therapies for acute rhinosinusitis have little supporting data. Some studies examining treatments for viral upper respiratory infections have shown:

• Efficacy in symptom control: decongestants and anticholinergics, including "first-generation" antihistamines (diphenhydramine, chlorpheniramine, clemastine) [A].
• Possible efficacy: zinc gluconate lozenges, vitamin C, Echinacea extract, saline irrigation [conflicting or insufficient data].
• No significant benefit: guaifenesin (except possibly at high dose), saline spray, steam, "non-sedating" antihistamines (loratadine, fexofenadine, cetirizine).

For recurrent acute rhinosinusitis or acute rhinosinusitis superimposed on chronic rhinosinusitis, the addition of high dose nasal corticosteroids may decrease duration of symptoms and improve rate of clinical success [A]. However, this approach is inconvenient, has potential side effects, and significant cost.

Imaging

If symptoms of rhinosinusitis persist for more than three weeks despite antibiotics or recur more than three times per year, a sinus computed tomography (CT) scan should be performed while the patient is symptomatic to reassess diagnosis and determine need for referral [C, D]. CT scans provide much better definition than a plain sinus x-ray series. Plain sinus x-rays, therefore, are not recommended.

• New low dose CT scanners are becoming available with the advantage of radiation exposure of about 10% to 15% of a full sinus CT scan.
• A limited (coronal plan only) sinus CT scan provides excellent imaging detail with only 50% of the radiation exposure of a full (axial and coronal planes) sinus CT scan.
• At University of Michigan Health System the charge is $1,416 for any sinus CT scan (low dose, limited, or full).

Definitions:

Levels of evidence for the most significant recommendations:

1. Randomized controlled trials
2. Controlled trials, no randomization
3. Observational trials
4. Opinion of expert panel

An algorithm is provided in the original guideline document for the diagnosis of acute bacterial rhinosinusitis.

When possible, conclusions were based on prospective randomized clinical trials. In the absence of randomized controlled trials, observational studies were considered. If none were available, expert opinion was used.

The type of evidence is identified and graded for the most significant recommendations (see "Major Recommendations").

Accurate diagnosis and appropriate treatment of acute rhinosinusitis

• Risks of treating with antibiotics include severe allergic reaction, potential antibiotic side effects, and bacterial resistance.
• Topical decongestant agents use should be limited to 3 days due to the risk of rebound vasodilation (rhinitis medicamentosa) or atrophic rhinitis.
• Although they have not been found to affect blood pressure significantly in patients with stable hypertension, oral decongestants should be used with caution in patients with hypertension, ischemic heart disease, glaucoma, prostatic hypertrophy, or diabetes mellitus.
• Geriatric patients may be more sensitive to the effects of oral decongestants.
• Note that antihistamines may impair psychomotor performance often without sedation or other noticeable symptoms. Patients should not drive or operate heavy machinery while using them. Also, avoid use in elderly patients (>65 to 70 years of age) due to risk of delirium and cognitive decline.

Oral decongestants are contraindicated in patients using monoamine oxidase inhibitors (MAOIs) or having uncontrolled hypertension or severe coronary artery disease.

These guidelines should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgement regarding any specific clinical procedure or treatment must be made by the physician in light of the circumstances presented by the patient.

An implementation strategy was not provided.

Getting Better

Effectiveness

• University of Michigan Health System. Acute rhinosinusitis in adults. Ann Arbor (MI): University of Michigan Health System; 2007 Mar. 8 p. [6 references]

Not applicable: The guideline was not adapted from another source.

1996 May (revised 2007 Mar)

University of Michigan Health System - Academic Institution

University of Michigan Health System

Rhinosinusitis Guideline Team

Team Leader: Jane T. McCort, MD, General Internal Medicine

Team Members: R. Van Harrison, PhD, Medical Education; James F. Peggs, MD, Family Medicine; Jeffrey E. Terrell, MD, Otolaryngology

Guidelines Oversight Team: Connie J. Standiford, MD; Lee A. Green, MD, MPH; R. Van Harrison, PhD

The University of Michigan Health System endorses the Guidelines of the Association of American Medical Colleges and the Standards of the Accreditation Council for Continuing Medical Education that the individuals who present educational activities disclose significant relationships with commercial companies whose products or services are discussed.  Disclosure of a relationship is not intended to suggest bias in the information presented, but is made to provide readers with information that might be of potential importance to their evaluation of the information.

Team Member; Company; Relationship:

Jane T. McCort, MD (none)

R. Van Harrison, PhD (none)

James F. Peggs, MD (none)

Jeffrey E. Terrell, MD, Pfizer, Speaker

This is the current release of the guideline.

This guideline updates a previous version: University of Michigan Health System. Acute rhinosinusitis in adults. Ann Arbor (MI): University of Michigan Health System; 2005 Feb. 8 p.

None available

This summary was completed by ECRI on August 21, 2000. The information was verified by the guideline developer on November 22, 2000. This NGC summary was updated on May 16, 2005. The updated information was verified by the guideline developer on May 20, 2005. This summary was updated by ECRI on January 27, 2006 following the U.S. Food and Drug Administration (FDA) advisory on Ketek (telithromycin). This summary was updated by ECRI on July 3, 2006 following the updated U.S. Food and Drug Administration (FDA) advisory on Ketek (telithromycin). This summary was updated by ECRI on March 6, 2007 following the updated FDA advisory on Ketek (telithromycin). This summary was updated by ECRI Institute on July 31, 2008. The updated information was verified by the guideline developer on August 15, 2008.

This NGC summary is based on the original guideline, which is copyrighted by the University of Michigan Health System (UMHS).