Acute Sinusitis

Excerpt

Rhinosinusitis is the inflammation of the nasal cavity and paranasal sinuses, typically resulting from infection, allergy, or other causes. Rhinosinusitis is classified into the following categories, based more on consensus rather than empirical research:

1. Acute: Symptoms lasting less than 4 weeks

2. Subacute: Symptoms lasting between 4 and 12 weeks

3. Chronic: Symptoms lasting more than 12 weeks

4. Recurrent: Four episodes lasting less than 4 weeks with complete symptom resolution between episodes

Acute sinusitis involves inflammation of the lining of the paranasal sinuses. Because the sinus passages are connected to the nasal passages, the term rhinosinusitis is often more accurate. Acute rhinosinusitis is a frequently diagnosed condition, accounting for approximately 30 million primary care visits annually and contributing to an estimated $11 billion in healthcare costs. This condition is also a primary reason for antibiotic prescriptions in both the United States and worldwide. Given recent guidelines and concerns about antibiotic resistance and responsible antibiotic use, having clear treatment protocols for this common condition is essential for diagnosis.

Acute rhinosinusitis caused by viral upper respiratory infections and noninfectious conditions should be distinguished from acute bacterial rhinosinusitis based on illness pattern and duration of illness. Acute sinusitis diagnosis depends on the presence of purulent nasal drainage for up to 4 weeks. The clinical challenge lies in the fact that neither purulent nasal drainage nor symptom duration is diagnostic for both bacterial and viral agents. Most clinicians rely on the three main symptoms, including purulent nasal drainage, facial or dental pain, and nasal obstruction complaints; however, these do not lead to definitive diagnoses. Evaluation should always include vital signs and a thorough examination of the head and neck. To complicate the clinical picture, up to 2% of patients with viral rhinosinusitis also develop a bacterial infection concurrently. Finally, fever may be present with viral rhinosinusitis initially, but it also does not predict a bacterial infection.

Generally, radiographic imaging has limited utility in acute rhinosinusitis unless there is evidence of a complication or an alternative diagnosis. Plain film radiographs are less reliable than coronal computed tomographic (CT) scans when surgical intervention is needed. Magnetic resonance imaging (MRI) is generally not helpful unless a fungal infection or tumor is suspected. Ultrasound offers limited usefulness. Most otolaryngologists prefer fiberoptic sinus endoscopy combined with targeted culture in challenging cases.

Management typically involves symptomatic treatment and close monitoring in most cases. These measures include humidification, warm compresses, hydration, nonsteroidal anti-inflammatory drugs, and, in some cases, mucolytic agents to enhance patient comfort. Antihistamines are not advised, and decongestants should be used cautiously and only temporarily.

Although antibiotics are often presumed to be the preferred treatment, their use in acute bacterial rhinosinusitis remains a topic of discussion, as randomized controlled trials have not conclusively demonstrated significant advantages in employing antibiotics for the management of acute sinusitis. Furthermore, systematic reviews of patients with radiologic or bacteriologic confirmation showed no significant difference in clinical resolution rates between those treated with amoxicillin or amoxicillin-clavulanate and those treated with cephalosporins or macrolides.

In most cases of acute rhinosinusitis, surgical intervention is not required, and medical treatment remains the standard approach. Exceptions include patients who do not respond to medical management, show rapidly worsening symptoms, or have a suspicion of an abscess or complications involving the eyes or nervous system that could threaten the patient's safety or life.

Treatment may fail in many patients without close follow-up. Fortunately, complications are infrequent. Preventing complications such as mucoceles, osteomyelitis, and orbital and intracranial issues should be the top priority in patients showing unusual signs and symptoms.