Background |
- Respiratory viruses typically cause inflammation of the nasalmucosa and maxillary sinuses.
- Most cases of acute rhinosinusitis are due to uncomplicated viral infections.
|
Diagnosis |
- Most rhinovirus colds last 7 to 11 days (J Clin Microbiol 1997; 35:2864; JAMA 1967; 202:158).
- Bacterial rhinosinusitis may be present if symptoms have been present >7 days and there is localization to the maxillary sinus.
|
Signs/Symptoms of
Acute Maxillary Sinusitis (BMJ 1995;311:233) |
|
Present
(N=92) |
Absent
(N=82) |
Odds
Ratio |
Fever |
89% |
79% |
2.1 |
Unilateral maxillary
pain |
51% |
38% |
1.9 |
Maxillary toothache |
66% |
51% |
1.9 |
Unilateral
maxillary
sinus
tenderness |
49% |
32% |
2.5 |
- Generalized facial pain or tenderness, postnasal drainage, headache, and cough do not increase the predictive value of maxillary sinus symptoms.
- Patients may rarely present with severe symptoms of bacterial rhinosinusitis less than 7 days duration (acute focal sinusitis). Consider immediate referral to an otolaryngologist for evaluation and drainage.
- Sinus radiography is not recommended for routine evaluation of acute, uncomplicated bacterial rhinosinusitis.
- Opacification and air-fluid level have sensitivity of ~ 73% and specificity of 80% (J Clin Epidemiol 2000;53:852).
- Mucosal abnormalities are common in patients with viral infections (J Allergy Clin Immunol 1998;102:403).
|
Treatment |
- Most patients with acute bacterial rhinosinusitis improve without antibiotic treatment.
- About 81% of antibiotic treated patients and 66% of controls are improved at 10-14 days (absolute benefit of 15%).
- Patients with mild symptoms should not receive antibiotics, but symptomatic treatment may be helpful.
- Topical and oral decongestants may reduce nasal symptoms.
- Most randomized trials of symptomatic therapies have been inconclusive. Patients with moderate or severe symptoms may benefit from antibiotics.
Use a narrow spectrum agent that covers S. pneumoniae and H. influenzae.
- Amoxicillin remains an appropriate choice for uncomplicated infections.
- Consider second line agent if no improvement or worsening after 72 hours.
|
Tips to Reduce Antibiotic Use |
- Tell patients that antibiotic use increases the risk of an antibiotic resistant infection.
- Identify and validate patient concerns.
- Recommend specific
symptomatic therapy.
- Spend time answering questions and offer a contingency plan if symptoms worsen.
- Provide patient education materials on antibiotic resistance.
- REMEMBER: Effective communication is more important than an antibiotic for patient satisfaction.
|
Key Reference
Cooper RJ et al. Principles of appropriate antibiotic use for acute pharyngitis in adults: Background. Annals of Internal Medicine 2001;134(6):509-17. |
