AUTHOR AND EDITOR INFORMATION

Section 1 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Background

Sinusitis refers to inflammation of the lining of the paranasal sinuses. Because the nasal mucosa is simultaneously involved and because sinusitis rarely occurs without concurrent rhinitis, rhinosinusitis is now the preferred term for this condition (Lanza, 1997). By definition, symptoms of acute rhinosinusitis last less than 3 weeks, symptoms of subacute rhinosinusitis last 21-60 days, and symptoms of chronic rhinosinusitis last more than 60 days. The Agency for Healthcare Research and Quality accepted this terminology in 1999.

Rhinosinusitis may be further classified according to the anatomic site (maxillary, ethmoidal, frontal, sphenoidal), pathogenic organism (viral, bacterial, fungal), presence of complication (orbital, intracranial), and associated factors (nasal polyposis, immunosuppression, anatomic variants).

Pathophysiology

The vast majority of rhinosinusitis episodes are caused by viruses. Most viral upper respiratory infections are caused by rhinovirus, but coronavirus, influenza A and B, parainfluenza, respiratory syncytial virus, adenovirus, and enterovirus are also causative agents.

Almost 90% of patients with upper respiratory infections have radiographic evidence of paranasal sinus involvement. However, only 0.5-2% of viral rhinosinusitis infections are complicated by bacterial infection (Gwaltney, 1996).

The pathophysiology of rhinosinusitis is related to 3 factors: obstruction of sinus drainage pathways (sinus ostia), ciliary impairment, and mucus quantity and quality.

• Obstruction of the natural sinus ostia prevents normal mucus drainage. Edema, inflammation, polyps, tumors, trauma, scarring, anatomic variants (eg, concha bullosa [pneumatized middle turbinate], septal deviation), and nasal instrumentation (nasogastric tubes or packing) can result in decreased patency of sinus ostia. Hypoxia within the obstructed sinus is thought to cause ciliary dysfunction and alterations in mucus production, further impairing the normal mechanism for mucus clearance.
• Contrary to earlier models of sinus physiology, the drainage patterns of the paranasal sinuses depend not on gravity but on the mucociliary transport mechanism. The metachronous coordination of the ciliated columnar epithelial cells propels the sinus contents toward the natural sinus ostia. Any disruption of the ciliary function results in fluid accumulation within the sinus. Poor ciliary function can result from the loss of ciliated epithelial cells; cold air; high airflow; viral, bacterial, or environmental ciliotoxins; inflammatory mediators; contact between 2 mucosal surfaces; scars; and primary ciliary dyskinesia (Kartagener Syndrome).
• Sinonasal secretions play an important role in the pathophysiology of rhinosinusitis. The mucus that lines the paranasal sinuses is composed of a thin periciliary layer, which enables ciliary mobility, and a thick gel layer, which anchors the tips of the cilia. This mucous blanket contains mucoglycoproteins, immunoglobulins, and inflammatory cells. Alterations in the water content of the mucous blanket can impair ciliary mobility. Overproduction of mucus can overwhelm the mucociliary clearance system, resulting in retained secretions within the sinuses.
• Acute bacterial rhinosinusitis is very frequently associated with viral upper respiratory infection, although allergy, trauma, neoplasms, midline destructive disease, environmental factors, dental infection, and anatomic variation, which may impair normal mucociliary clearance, are also thought to be factors that predispose to bacterial infection.

Frequency

United States

Rhinosinusitis affects 35 million people per year in the United States and accounts for close to 16 million office visits per year (Lucas, 2004). According to the National Ambulatory Medical Care Survey (NAMCS), approximately 14% of adults report having an episode of rhinosinusitis each year, and it is the fifth most common diagnosis for which antibiotics are prescribed. In 1996, Americans spent approximately $3.39 billion treating rhinosinusitis (Ray, 1999).

Approximately 0.5-2% of cases of viral rhinosinusitis are complicated by bacterial superinfection.

Sinusitis is more common from early fall to early spring.

Mortality/Morbidity

Forty percent of acute rhinosinusitis cases resolve spontaneously. Untreated or inadequately treated rhinosinusitis may lead to complications such as meningitis, cavernous sinus thrombophlebitis, orbital cellulitis or abscess, and brain abscess.

Race

No racial predilection exists.

Sex

No sex predilection exists.

Age

Sinusitis occurs in all age groups.

CLINICAL

Section 3 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

History

Ask about a preexisting history of allergic or occupational rhinitis, vasomotor rhinitis, nasal polyps, rhinitis medicamentosa, or an immunodeficiency. Rhinosinusitis is more common in patients with congenital defects that affect humoral immunity and ciliary motility, in those with cystic fibrosis, and in patients with AIDS. Obtain a history of diabetes or organ transplant if invasive fungal sinusitis is being considered.

Overdiagnosis of acute bacterial rhinosinusitis is common. Acute bacterial rhinosinusitis is the correct diagnosis in 40-50% of cases in which a primary care physician initially classifies a patient as likely having the condition (Hansen, 1995).

The natural history of rhinovirus infection, as described by Gwaltney et al, lasts from 1-33 days. One fourth of patients have symptoms that last longer than 14 days (Gwaltney, 1967).

• Patients with uncomplicated upper respiratory infections usually report some of the following symptoms: sneezing, rhinorrhea, nasal congestion, hyposmia/anosmia, facial pressure, postnasal drip, sore throat, cough, ear fullness, fever, and myalgia.
• Although diagnostic criteria for acute rhinosinusitis have been proposed (Lanza, 1997), no single sign or symptom has strong diagnostic value for bacterial rhinosinusitis (Hickner, 2001). However, acute bacterial rhinosinusitis should be suspected in patients who exhibit symptoms of a viral upper respiratory infection that do not improve after 10 days or worsen after 5-7 days.
• Symptoms of acute bacterial rhinosinusitis include the following:
• • Facial pain or pressure (especially unilateral)
  • Hyposmia/anosmia
  • Nasal congestion
  • Nasal drainage
  • Postnasal drip
  • Fever
  • Cough
  • Fatigue
  • Maxillary dental pain
  • Ear fullness/pressure
• A change in the color or characteristic of the nasal discharge is not a specific sign of bacterial rhinosinusitis.
• A previous diagnosis of rhinosinusitis is not a predictor of acute bacterial rhinosinusitis (Hickner, 2001).

Physical

• Purulent nasal secretions
• Purulent posterior pharyngeal secretions
• Mucosal erythema
• Periorbital edema
• Tenderness overlying sinuses
• Air-fluid levels on transillumination of the sinuses (60% reproducibility rate for assessing maxillary sinus disease)
• Facial erythema

Causes

The most common pathogens isolated from maxillary sinus cultures in patients with acute bacterial rhinosinusitis include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Streptococcus pyogenes, Staphylococcus aureus, and anaerobes are less commonly associated with acute bacterial rhinosinusitis.

• S pneumoniae are gram positive, catalase-negative, facultatively anaerobic cocci that account for 20-43% of acute bacterial rhinosinusitis in adults. The rise of antimicrobial resistance in S pneumoniae is a major concern. A 1998 surveillance study of respiratory tract isolates estimated that 12.3% of S pneumoniae isolates obtained from the paranasal sinuses had intermediate resistance to penicillin; 37.4% were penicillin-resistant. The paranasal sinuses represented the anatomic location with the highest resistance rate (Jacobs, 2004). Resistance to macrolide, clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), and doxycycline was more common in isolates with intermediate penicillin resistance and those that were penicillin-resistant.
• H influenzae are gram-negative, facultatively anaerobic bacilli. H influenza type B was a leading cause of meningitis until the widespread use of the vaccine. Nontypeable strains of H influenza are responsible for 22-35% of acute bacterial rhinosinusitis cases in adults. M catarrhalis are gram-negative, oxidase-positive, aerobic diplococci. M catarrhalis is the responsible pathogen in 2-10% of acute bacterial rhinosinusitis cases in adults. Beta-lactamase production is the mechanism of antimicrobial resistance for both M catarrhalis and H influenza. Of isolates from the paranasal sinus, 32.7% and 98% were found to be beta-lactamase–positive for H influenza and M catarrhalis, respectively.
• Rarely, sinusitis may be caused by fungi, including Mucorales genera and Aspergillus or Candida species. Fungal infections are more common in people with diabetes and those who are immunocompromised. Clinicians should maintain a high index of suspicion for acute invasive fungal sinusitis in immunocompromised patients with orbital or CNS complications of rhinosinusitis.

DIFFERENTIALS

Section 4 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Other Problems to be Considered

Gastroesophageal reflux
Cystic fibrosis
Immotile cilia syndrome
Migraine headache
Sinonasal polyposis
Chemical rhinitis
Nasal foreign body
Chronic invasive fungal sinusitis
Sinonasal neoplasm

WORKUP

Section 5 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Lab Studies

• The erythrocyte sedimentation rate and C-reactive protein level may be elevated, but these findings are nonspecific.
• The findings of CBC count with differential may be within reference ranges.
• Nasal cytology examinations may be useful to elucidate the following entities:
• • Allergic rhinitis
  • Eosinophilia
  • Nasal polyposis
  • Aspirin sensitivity
• Sweat chloride test screening should be performed if cystic fibrosis is suggested.
• Ciliary function studies help screen for Kartagener syndrome.
• Tests for immunodeficiency are indicated if history findings indicate recurrent infection, to include the following:
• • Immunoglobulin levels
  • HIV serology
• Cultures of nasal secretions are of limited value because they are usually contaminated by normal flora.

Imaging Studies

• Findings on standard radiographs are insensitive, especially for ethmoidal disease. Waters view is best.
• CT scanning is the preferred imaging method.
• • A screening sinus CT scan is adequate for diagnosis and less expensive than other methods but is necessary only in cases of treatment failure or chronic disease.
  • A complete sinus CT scan with frontal and coronal planes is used if an alternate diagnosis (eg, tumors) must be excluded.
  • CT scan findings are used to differentiate orbital cellulitis from periorbital cellulitis as a complication or to evaluate extension into intracranial space.
• MRI is useful only if fungal infection or a tumor is suggested.
• Ultrasound is of limited use.

Procedures

• A paranasal biopsy is used to help exclude neoplasia, fungal disease, and granulomatous disease.
• Fiberoptic sinus endoscopy is used to visualize posterior sinonasal structures. This test is useful in chronic or recurrent disease and to help exclude structural lesions, fungal disease, and granulomatous diseases.

TREATMENT

Section 6 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical Care

Improved mucociliary function and control of infection are the goals of therapy.

Surgical Care

Antral puncture and irrigation are used for diagnostic culture and sensitivity testing in immunosuppressed or critically ill patients if the organism must be identified. However, more recent data support the role of endoscopically guided middle meatus cultures instead.

Consultations

• Ear, nose, and throat specialist for complications or when routine management techniques fail
• Infectious disease specialist in complicated cases

MEDICATION

Section 7 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Viral rhinosinusitis does not require antimicrobial treatment.

Standard nonantimicrobial treatment options include topical steroids, topical and/or oral decongestants, mucolytics, and intranasal saline spray. However, intranasal steroid spray is the only medication whose use is supported by placebo-controlled trials. Topical steroids have been shown to reduce time to symptom resolution in cases of acute rhinosinusitis treated both with and without antibiotics (Meltzer, 2005).

No data are available to suggest that antihistamines are beneficial in acute sinusitis. In fact, antihistamines may cause harm by drying mucous membranes and decreasing clearance of secretions.

Drug Category: Antibiotics

Bacterial efficacy rates are as follows:

• Levofloxacin, moxifloxacin, and amoxicillin/clavulanate - Greater than 90%
• High-dose amoxicillin, cefpodoxime proxetil, cefixime, cefuroxime axetil and trimethoprim-sulfamethoxazole - 80-90%
• Clindamycin, doxycycline, cefprozil, azithromycin, clarithromycin, and erythromycin - 70-80%
• Cefaclor and loracarbef - 50-60%

Based on the 2000 Sinus and Allergy Health Partnership treatment guidelines for acute bacterial rhinosinusitis, patients are divided into 3 groups, as follows:

• Adults with mild disease who have not received antibiotics: Amoxicillin/clavulanate, amoxicillin (1.5-3.5 g/d), cefpodoxime proxetil, or cefuroxime is recommended as initial therapy.
• Adults with mild disease who have had antibiotics in the previous 4-6 weeks and adults with moderate disease: Amoxicillin/clavulanate, amoxicillin (3-3.5 g), cefpodoxime proxetil, or cefixime is recommended.
• Adults with moderate disease who have received antibiotics in the previous 4-6 weeks: Amoxicillin/clavulanate, levofloxacin, moxifloxacin, or amoxicillin or clindamycin plus cefpodoxime proxetil or cefixime is recommended.

Patients who remain symptomatic despite appropriate antibiotic therapy may be evaluated with sinus endoscopy, CT scan, or sinus aspiration/culture.

Drug Name	Penicillin V potassium (Beepen-VK, Pen-Vee K)
Description	First-line antibiotic choice. Inhibits biosynthesis of cell wall mucopeptide. Bactericidal against sensitive organisms when adequate concentrations are reached and most effective during stage of active multiplication. Inadequate concentrations may produce only bacteriostatic effects.
Adult Dose	250 mg PO q6h for 10-12 d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Probenecid may increase effectiveness by decreasing clearance; tetracyclines are bacteriostatic, causing a decrease in effectiveness when administered concurrently
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in renal impairment; superinfections may occur with prolonged use; reduces efficacy of oral contraceptives

Drug Name	Erythromycin (E.E.S., E-Mycin, Eryc)
Description	First-line treatment in patients allergic to penicillin. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult Dose	250 mg PO q6h for 10-12 d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; hepatic impairment
Interactions	Coadministration may increase toxicity of theophylline, digoxin, carbamazepine, benzodiazepines, and cyclosporine; may potentiate anticoagulant effects of warfarin; coadministration with lovastatin and simvastatin increases risk of rhabdomyolysis; may prolong QT interval, resulting in cardiac arrest if combined with nonsedating antihistamines
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Caution in liver disease; estolate formulation may cause cholestatic jaundice; adverse GI effects are common (give doses pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Drug Name	Trimethoprim and sulfamethoxazole (Bactrim DS, Septra)
Description	First-line agent with more convenient dosing. Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid.
Adult Dose	160 mg TMP/800 mg SMZ PO q12h for 10-12 d
Pediatric Dose	<2 months: Do not administer >2 months: Not established
Contraindications	Documented hypersensitivity; megaloblastic anemia due to folate deficiency
Interactions	May increase PT when used with warfarin (perform coagulation tests, and adjust dose accordingly); coadministration with dapsone may increase blood levels of both drugs; coadministration of diuretics increases incidence of thrombocytopenia purpura in elderly persons; phenytoin levels may increase with coadministration; may potentiate effects of methotrexate in bone marrow depression; hypoglycemic response to sulfonylureas may increase with coadministration; may increase levels of zidovudine
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Discontinue at first appearance of skin rash or sign of adverse reaction; obtain CBC counts frequently; discontinue therapy if significant hematologic changes occur; goiter, diuresis, and hypoglycemia may occur with sulfonamides; prolonged IV infusions or high doses may cause bone marrow depression (if signs occur, give 5-15 mg/d leucovorin); caution in folate deficiency (eg, people with long-term alcoholism, elderly people, those receiving anticonvulsant therapy, those with malabsorption syndrome); hemolysis may occur in G-6-PD deficiency; patients with AIDS may not tolerate or respond to TMP-SMZ; caution in renal or hepatic impairment (perform urinalyses and renal function tests during therapy); give fluids to prevent crystalluria and stone formation

Drug Name	Cefprozil (Cefzil)
Description	Second-line agent. Binds to one or more of the penicillin-binding proteins, which, in turn, inhibits cell wall synthesis and results in bactericidal activity.
Adult Dose	250-500 mg PO q12h for 10 d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Probenecid increases effect; coadministration with furosemide and aminoglycosides increases nephrotoxic effects
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy

Drug Name	Cefuroxime (Ceftin)
Description	Second-line agent. Second-generation cephalosporin maintains gram-positive activity of first-generation cephalosporins. Adds activity against Proteus mirabilis, H influenzae, Escherichia coli, Klebsiella pneumoniae, and M catarrhalis.
Adult Dose	250 mg PO bid for 10 d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increases nephrotoxic potential; concomitant use with agents that lower gastric pH decreases absorption
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Reduce dosage by half if CrCl is 10-30 mL/min and by three fourths if <10 mL/min (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy

Drug Name	Cefpodoxime (Vantin)
Description	Second-line agent. Binds to one or more penicillin-binding proteins, which, in turn, inhibits cell wall synthesis and results in bactericidal activity.
Adult Dose	100 mg PO q12h for 10 d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Probenecid increases effect; coadministration with furosemide and aminoglycosides increases nephrotoxic effects; antacids and H2 blockers decrease absorption
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Reduce dosage by half if CrCl is 10-30 mL/min and by three fourths if <10 mL/min (high doses may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy

Drug Name	Cefixime (Suprax)
Description	Second-line agent. By binding to one or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.
Adult Dose	400 mg PO qd for 10 d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Increases carbamazepine levels; coadministration of aminoglycosides increases nephrotoxicity; probenecid may increase effects
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy

Drug Name	Amoxicillin and clavulanate (Augmentin)
Description	Second-line agent. Drug combination treats bacteria resistant to beta-lactam antibiotics.
Adult Dose	875 mg PO q12h or 500 mg PO q8h for 10 d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity
Interactions	Coadministration with warfarin or heparin increases risk of bleeding
Pregnancy	B - Usually safe but benefits must outweigh the risks.
Precautions	Presence of mononucleosis produces skin rash; interstitial nephritis and renal failure may occur in high doses

Drug Name	Clarithromycin (Biaxin)
Description	Second-line agent. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult Dose	500 mg PO bid for 10 d
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; coadministration of pimozide or cisapride
Interactions	Toxicity increases with coadministration of fluconazole, astemizole, and pimozide; effects decrease and adverse GI effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; serious cardiac arrhythmia may occur with coadministration of cisapride; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmia and increase in QT intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies

Drug Name	Levofloxacin (Levaquin)
Description	Used to treat acute maxillary sinusitis caused by S pneumoniae, H influenzae, or M catarrhalis. Fluoroquinolones should be used empirically in patients likely to develop exacerbation due to resistant organisms to other antibiotics. This is the L stereoisomer of the D/L parent compound ofloxacin, the D form being inactive. Good monotherapy with extended coverage against Pseudomonas species, as well as excellent activity against pneumococcus. Agent acts by inhibition of DNA gyrase activity. PO form has bioavailability that is reportedly 99%.
Adult Dose	500 mg PO qd for 7-14 d
Pediatric Dose	<18 years: Not recommended >18 years: Administer asin adults
Contraindications	Documented hypersensitivity
Interactions	Antacids, iron salts, and zinc salts may reduce serum levels;administer antacids 2-4 h before or after taking fluoroquinolones; cimetidinemay interfere with metabolism of fluoroquinolones; reducestherapeutic effects of phenytoin; probenecid may increase serumconcentrations; may increase toxicity of theophylline, caffeine, cyclosporine,and digoxin (monitor digoxin levels); may increase effects of anticoagulants(monitor PT)
Pregnancy	C - Safety for use during pregnancy has not been established
Precautions	In prolonged therapy, perform periodic evaluations of organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy

Drug Name	Doxycycline (Periostat, Doryx, Bio-Tab, Vibramycin Vibra-tabs)
Description	Inhibits protein synthesis, and thus bacterial growth, by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria.
Adult Dose	100-200 mg PO bid for 14 d
Pediatric Dose	<8 years: Not recommended >8 years: 2-5 mg/kg/d PO in 1-2 divided doses; not to exceed 200 mg/d
Contraindications	Documented hypersensitivity; severe hepatic dysfunction
Interactions	Bioavailability decreases with antacids that contain aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Pregnancy	D - Safety for use during pregnancy has not been established
Precautions	Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines

Drug Category: Topical decongestants

-- These agents cause vasoconstriction, which reduces nasal congestion.

Drug Name	Oxymetazoline (Afrin)
Description	Applied directly to mucous membranes. Stimulates alpha-adrenergic receptors and causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure, vascular redistribution, or cardiac stimulation.
Adult Dose	2 puffs in each nostril bid; not to exceed 3 d of use
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; MAOI therapy; angle-closure glaucoma
Interactions	Hypotensive action of guanethidine may be reversed; concurrent administration with methyldopa may result in increased vasopressor response; concurrent use of MAOIs and ephedrine may result in hypertensive crisis; pressor sensitivity to mixed-acting agents, such as ephedrine, may be increased; guanethidine potentiates effects of epinephrine and inhibits effects of ephedrine; phenothiazines may reverse action of nasal decongestants; TCAs potentiate vasopressor response and may result in dysrhythmia
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Caution in hyperthyroidism, coronary artery and ischemic heart disease, diabetes mellitus, increased intraocular pressure, or prostatic hypertrophy; because of increase in vasoconstriction, patients who are hypertensive may experience change in blood pressure; may produce rhinitis medicamentosa

Drug Name	Guaifenesin (Anti-Tuss, Humibid LA, Robitussin)
Description	Increases respiratory tract fluid secretions and helps to loosen phlegm and bronchial secretions. Indicated for patients with bronchiectasis complicated by tenacious mucous and/or mucous plugs.
Adult Dose	600-mg SR tab 1-2 tab PO q12h
Pediatric Dose	<2 years: Not recommended 2-6 years: One-half tab PO q12h 6-12 years: 1 tab q12h >12 years: Administer as in adults
Contraindications	Documented hypersensitivity
Interactions	May increase renal clearance of urate and lower serum uric acid levels May interfere with urine laboratory tests for 5-hydroxyindoleacetic acid and urine testing for catecholamines
Pregnancy	B - Unsafe in pregnancy
Precautions	When prescribing medication that may suppress cough, important to identify cause of the cough and that suppression will not increase risk of clinical or physiologic complications

Drug Category: Corticosteroids: Topical decongestants

-- These agents are beneficial, especially if underlying rhinitis is present.

Drug Name	Triamcinolone (Nasacort, Nasacort AQ)
Description	Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.
Adult Dose	2 puffs in each nostril qd
Pediatric Dose	Not established
Contraindications	Documented hypersensitivity; fungal, viral, and bacterial skin infections
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Prolonged use can result in systemic absorption, which may cause Cushing syndrome, reversible HPA axis suppression, hyperglycemia, and glycosuria; nasal septum perforation, angioedema, or bronchospasm may occur

Drug Name	Flunisolide (AeroBid, Nasalide)
Description	Inhibits bronchoconstriction mechanisms. Produces direct smooth muscle relaxation. May decrease number and activity of inflammatory cells, in turn decreasing airway hyperresponsiveness. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability. Does not depress the hypothalamus.
Adult Dose	2 sprays/nostril bid/tid (25 mcg/spray)
Pediatric Dose	<6 years: Not established >6 years: 1 spray/nostril tid or 2 sprays/nostril bid (25 mcg/spray)
Contraindications	Documented hypersensitivity
Interactions	None reported
Pregnancy	C - Safety for use during pregnancy has not been established.
Precautions	Educate patient that this agent is not to be used as a rescue treatment for acute bronchospasm

FOLLOW-UP

Section 8 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Further Outpatient Care

• Symptomatic or adjunctive therapies may include the following:
• • Humidification/vaporizer
  • Warm compresses
  • Adequate hydration
  • Smoking cessation
  • Balanced nutrition
  • Nonnarcotic analgesia
• Antihistamines are not recommended and have not proven beneficial:

Complications

• Treatment fails in 10-25% of patients. If this occurs, consider the following:
• • Take a repeat history and perform an additional physical examination; consider an imaging study.
  • Start second-line antibiotics.
• Approximately 75% of orbital or periorbital infections are the result of extending sinusitis.
• Untreated, inadequately treated, or partially treated rhinosinusitis may lead to chronic rhinosinusitis, meningitis, brain abscess, or other extra-sinus complications.

Prognosis

• Approximately 40% of acute sinusitis cases resolve spontaneously without antibiotics.
• The relapse rate after successful treatment is less than 5%.

MISCELLANEOUS

Section 9 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

Medical/Legal Pitfalls

• Failure to recognize and aggressively evaluate and treat in light of the following concurrent diagnoses:
• • HIV/AIDS
  • Diabetes
  • Hematologic malignancy
  • Immunocompromise
• Failure to recognize complications

ACKNOWLEDGMENTS

Section 10 of 11  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous coauthor Michael Cunningham, DO, to the development and writing of this article.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• References

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Article Last Updated: Feb 14, 2007