August 2000
WASHINGTON, D.C. - Sinusitis accounts for an estimated 16 million office visits annually. Despite its prevalence, accurate diagnosis and treatment remain difficult.
As many as 80% of sinusitis cases may be misdiagnosed, according to Itzhak Brook, MD, MSc, professor of pediatrics and medicine at Georgetown University Medical School.
New guidelines, developed by the Clinical Advisory Committee on Pediatric and Adult Sinusitis, were devised to help clinicians take the challenge out of diagnosing and treating sinusitis.
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Diagnosis of acute sinusitis is clinical. In children, symptoms may be difficult to differentiate from the common cold. They are nonspecific and include rhinorrhea, nasal congestion or obstruction, fever, purulent anterior or posterior nasal discharge, snoring, mouth breathing, feeding problems, bad breath, cough and hyponasal speech. Cough and nasal discharge are most common, and facial pain and headache are rare. It is important to differentiate acute sinusitis from allergic rhinitis. Adenoidal hypertrophy or a severely deviated nasal septum may also be contributing factors to sinusitis-like symptoms. It is important to rule out the presence of a foreign body, asthma or neoplasm as well.
Symptom duration is important. If symptoms worsen after five days, persist for 10 days or longer or are especially severe, bacterial sinusitis should be considered. Only about 0.5% of upper respiratory tract infections (RTIs) progress to sinusitis. However, if these symptoms last longer than seven days, it may indicate the development of a secondary infection of the sinuses with bacteria.
The guidelines state that presence of at least two major diagnostic factors or one major factor and two minor factors is necessary for accurate diagnosis of acute sinusitis. Major factors include facial pain or pressure, facial congestion or fullness, nasal obstruction, nasal purulence or discolored postnasal discharge, hyposmia or anosmia and fever. Minor factors include headache, halitosis, fatigue, dental pain, cough, ear pain and pressure or fullness.
Other complaints, such as a recent prolonged upper RTI, a lack of response to decongestants, nasal airway obstruction, sore throat and edema of the eyelids or chemosis, may also increase the probability of sinusitis.
Use of a nasal speculum or otoscope may be especially helpful for diagnosing sinusitis. Viewing the turbinates and septum, evaluating quality of the mucus and determining the presence of polyps and bleeding are all important.
The guidelines do not recommend imaging studies for the routine diagnosis of uncomplicated sinusitis. Poor sensitivity and specificity limit sinus radiographs. For example, patients with viral rhinitis frequently have radiologic evidence of sinusitis. Additionally, transillumination is not reliable as a single finding to confirm or rule out the diagnosis of acute sinusitis.
Computed tomography (CT) scans are only recommended when patients do not respond adequately to medical therapy, have numerous bacterial infections throughout the year or have a history of polyposis. CT scans are not considered particularly reliable, as they often show evidence of sinusitis in patients with a viral infection of the upper respiratory tract. However, they may be useful in identifying the underlying cause of a chronic infection, sinuses involved and complications. The guidelines do not recommend contrast enhancement, unless there is a central nervous system complication.
Forty percent of bacterial sinusitis patients will recover without the use of antibiotics. However, the guidelines recommend antibiotics for children with symptoms persisting longer than 10 days without improvement. They help symptoms resolve more quickly and may arrest acute infection before it progresses to more serious sequelae such as facial osteomyelitis, cavernous sinus thrombosis, meningitis, orbital cellulitis or brain abscess. Additionally, antibiotics may decrease the rate of complications like tissue edema and thus prevent progression to chronic sinusitis by reducing bacterial contamination more rapidly. Drainage and ventilation of the sinus cavity are also reestablished and permanent mucosal damage is thought to be prevented.
Treatment should continue for 10 to 14 days. However, longer treatment may be needed if symptoms persist.
"I like to treat for seven days beyond when the patient has improved," said Brook, lead author of the guidelines. "About 5% of patients need to be treated longer."
Shorter courses are under evaluation, but are not yet recommended.
Amoxicillin or trimethroprim-sulfamethozazole is recommended for first-line therapy. Dosing for amoxicillin should be high, up to 80 mg/kg/day to 90 mg/kg/day, with a maximum of 3 g/day, especially in areas where Streptococcus pneumoniae resistance is prevalent.
Reevaluation is important. "Patients should be evaluated 48 to 72 hours after therapy is started," Brook said. "If they are not better, second-line agents should be given, sometimes in conjunction with surgical drainage and obtaining a bacterial culture."
Second-line agents include amoxicillin-clavulanate (Augmentin, Smith-Kline Beecham) or a second-generation cephalosporin such as cefprozil (Cefzil, Bristol-Myers Squibb), cefpodoxime-proxetil (Vantin, Pharmacia) or cefuroxime-axetil (Ceftin, Glaxo Wellcome). They should all be dosed twice daily. They have excellent activity against all major pathogens and provide adequate coverage of ß-lactamase producing organisms. They also maintain good activity against intermediate-level resistant pneumococci.
Newer macrolides may be another option for patients with penicillin allergy. However, resistance is a growing problem with these agents as well.
"Third-line are the newer quinolones (in adults) or a combination of clindamycin and a third-generation cephalosporin," Brook said.
According to the guidelines, cephalosporins should be considered on an individual basis. Cefadroxil (Duricef, Bristol-Myers Squibb) has limited activity against some gram-negative bacteria and S. pneumoniae. Cefixime (Suprax, Lederle Laboratories), loracarbef (Lorabid, Lilly) and ceftibuten (Cedax, Schering Corp.) also have reduced activity against S. pneumoniae. Still the guidelines state that they may be combined with another agent, such as clindamycin, to provide this coverage.
Children younger than 6 months, or who attend child care, live with a smoker or have a history of multiple upper RTIs, are at increased risk of recurrence. In children who do not respond to treatment, immunologic defects should be considered. According to the guidelines, children with severe sinusitis may have inadequate humoral defenses and require prolonged courses of antibiotics.
Supportive measures, while unproved, may be of benefit to some patients as well. "Adjuvant therapy helps open the obstructed sinuses and is generally enough for viral sinusitis," Brook said.
Saline nasal sprays, humidifiers, aromatic vapors, hot soups and teas moisturize the nasal cavity and remove thick mucous crusts. Topical decongestants may relieve nasal congestion, although they should not be used for longer than three days. Systemic decongestants are not recommended for use in children, especially when cardiac stimulation, hypertension or neurologic complications are possible.
Studies in adults have shown that both symptoms and total costs decrease when decongestants are prescribed with antibiotics.
The guidelines were recently published in the Annals of Otology, Rhinology and Laryngology.
For more information:
- Clinical Advisory Committee on Pediatric and Adult Sinusitis. Medical management of acute bacterial sinusitis. Ann Otol Rhinol Laryngol 2000;109: Supp 182.
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