Rhinosinusitis: A Guide for Diagnosis and Management

Pediatric acute and chronic rhinosinusitis: References Publications referenced by this paper. Showing of references. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. Williams , David L. Clinical evaluation for sinusitis. Making the diagnosis by history and physical examination. The clinician's view of sinusitis. Cynthia Stafford Otolaryngology--head and neck surgery: Current diagnosis and management of sinusitis Dr. Journal of General Internal Medicine Etiology and antimicrobial treatment of acute sinusitis.

Gwaltney , A Sydnor , M. Its adjunctive effect to standard treatment with antibiotics and oral steroids was examined in a double-blind, placebo-controlled RCT in adults with acute rhinosinusitis associated with a strong history of allergy [ ]. All patients received amoxicillin-clavulanate 2 g daily for 14 days and oral prednisone. Loratadine 10 mg daily or placebo was administered for 28 days.

Nasal symptom scores based on self-reporting as well as a rhinologic examination at baseline and 4 weeks were significantly improved in the loratadine compared with the placebo group at the end of 2 and 4 weeks. In particular, the degree of improvement was significantly greater for certain symptoms including sneezing and nasal obstruction. However, this patient population is unique in that all had acute exacerbation of allergic rhinosinusitis, and these findings do not apply to the typical patient with ABRS.

Furthermore, it is unclear whether INCSs rather than oral steroids would have been more efficacious and thus minimizes the adjunctive effect of loratadine. The recommendation against the use of decongestants or antihistamines as adjunctive therapy in ABRS places a relatively high value on avoiding adverse effects from these agents and a relatively low value on the incremental improvement of symptoms. These agents may still provide symptom relief in some patients with acute viral rhinosinusitis when antimicrobial therapy is not indicated.

Topical and oral decongestants may provide a subjective impression of improving nasal airway patency. Topical decongestants may induce rebound congestion and inflammation, and oral antihistamines may induce drowsiness, xerostomia, and other adverse effects.

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Topical and oral decongestants and antihistamines should be avoided in patients with ABRS. Instead, symptomatic management should focus on hydration, analgesics, antipyretics, saline irrigation, and INCSs. An alternative management strategy is recommended if symptoms worsen after 48—72 hours of initial empiric antimicrobial therapy, or fail to improve despite 3—5 days of initial empiric antimicrobial therapy strong, moderate. In general, patients with ABRS should begin to respond clinically by 3—5 days following initiation of effective antimicrobial therapy [ 61 ].

Bacteriological eradication studies also indicate that most causative organisms are eliminated from the maxillary sinuses by 3 days following appropriate antimicrobial therapy. Ambrose and his colleagues [ , , ] devised an innovative technique to determine the time course for bacteriological eradication and pharmacodynamic endpoints in the antimicrobial treatment of ABRS, by inserting an indwelling catheter into the maxillary sinus.

This allowed serial sinus aspirate sampling for Gram stain, culture, and drug level measurements. Patients were treated with either gatifloxacin or levofloxacin. Among 8 patients with positive cultures 5 with S. Similarly, Ariza et al [ ] obtained cultures of the middle meatus by endoscopy from 42 patients who were receiving treatment with moxifloxacin for microbiologically documented ABRS. Figure 4 shows a Kaplan-Meier plot of the proportion of patients with positive cultures for S. Interestingly, the time to bacterial eradication was longest for S.

In the studies by Ambrose et al [ ], excellent correlation between time to bacterial eradication and time to clinical resolution was observed. Thus, a bacteriologic as well as clinical response may be expected within 3—5 days in most patients receiving appropriate antimicrobial therapy. If symptoms and signs worsen despite 72 hours of initial empiric antimicrobial therapy, the possible reasons for treatment failure must be considered, including resistant pathogens, structural abnormalities, or a nonbacterial cause.

Similarly, if there is no clinical improvement within 3—5 days despite empiric antimicrobial therapy, an alternate management strategy should be considered even though there is no clinical worsening. It should be noted that elderly patients and those with comorbid diseases may require longer time for clinical improvement. Lindbaek [ ] conducted a prospective evaluation of factors present at the onset of acute sinusitis that might predict the total duration of illness among adults receiving antimicrobial therapy. As might be expected, age of the patient and the clinical severity of sinusitis at the onset of treatment were independent predictors of illness duration.

However, even among elderly and severely ill patients, some improvement should be clinically evident after 3—5 days of appropriate antimicrobial therapy. Careful clinical evaluation of the patient at 3—5 days is critical to assess the response to empiric antimicrobial therapy and to consider alternative management options if treatment failure is suspected. Premature discontinuation of first-line antimicrobial therapy in favor of second-line agents with broader antimicrobial coverage may promote overuse of antibiotics and increase costs as well as adverse effects.

Little information is currently available on bacterial eradication rates in ABRS by antimicrobial classes other than the respiratory fluoroquinolones. Treatment failure should be considered in all patients who fail to improve at 3—5 days after initiation of antimicrobial therapy. In the final analysis, clinical judgment and close monitoring of the patient are critical in determining whether there is treatment failure or simply a slow clinical response. More studies are needed to examine the bacterial eradication rates associated with different antimicrobial classes by sequential cultures of the middle meatus and correlate them with the clinical response.

Patients with presumed ABRS who fail to respond to initial empiric antimicrobial treatment should be investigated for possible causes of failure, including infection with resistant pathogens, inadequate dosing, and noninfectious causes including allergy and structural abnormalities. There are few RCTs in which the microbiological diagnosis of ABRS is confirmed by sinus puncture at the time of clinical failure or follow-up. A review of available placebo-controlled trials almost all involving patients with a clinical diagnosis found only 1 study that provided data on the effect of a specific antimicrobial agent to treat clinical failures [ 61 ].

In this study, 4 children randomized to high-dose amoxicillin-clavulanate and 19 randomized to placebo who experienced treatment failure were provided cefpodoxime. All experienced successful outcomes following treatment with cefpodoxime for 10 days, although the reason for treatment failure with the study antibiotics was unclear, as sinus puncture was not performed in these patients. Brook et al [ 96 ] performed consecutive cultures from maxillary sinus aspirates of 20 children with ABRS who failed initial empiric antimicrobial therapy. Thus, both inadequate dosing and bacterial resistance should be considered in all patients who fail to respond to initial empiric antimicrobial therapy.

In choosing a second-line regimen in a patient who has failed initial antimicrobial therapy, an agent with broader spectrum of activity and in a different antimicrobial class should be considered [ 82 , ]. Antimicrobials selected should be active against PNS S. The recommended list of second-line antimicrobial agents suitable for children and for adults who experience treatment failure to first-line agents is shown in Tables 9 and 10 , respectively.

If symptoms persist or worsen despite 72 hours of treatment with a second-line regimen, referral to an otolaryngologist, allergist, or infectious disease specialist should be considered. Additional investigations such as sinus puncture or acquisition of cultures of the middle meatus, and CT or MRI studies should be initiated. Provide a systematic and algorithm-based approach to antimicrobial therapy of patients failing initial therapy.

RCTs are needed to evaluate and optimize clinical approaches to the management of patients who fail to respond to initial empiric antimicrobial therapy, and to systematically assess all causes of clinical treatment failure. It is recommended that cultures be obtained by direct sinus aspiration rather than by nasopharyngeal swabs in patients with suspected sinus infection who have failed to respond to empiric antimicrobial therapy strong, moderate.

RHINOSINUSITIS NOMENCLATURE

Endoscopically guided cultures of the middle meatus may be considered as an alternative in adults but their reliability in children has not been established weak, moderate. Benninger et al [ 31 ] reviewed the data from 5 studies correlating the microbiology obtained from nasopharyngeal swabs with cultures of sinus aspirates both in healthy adults and patients with acute maxillary sinusitis.

When the maxillary sinus aspirate culture yielded a presumed sinus pathogen ie, S. Overall, nasopharyngeal cultures were considered unreliable for establishing the microbiologic diagnosis of ABRS. In contrast to nasopharyngeal swabs, endoscopically directed cultures of the middle meatus correlated better with cultures from direct sinus puncture. Benninger et al [ ] performed a meta-analysis involving adult patients from 3 published studies and additional unpublished data. The correlation between endoscopically directed cultures of the middle meatus and sinus puncture in pediatric patients with ABRS has not been established.

However, even in children without respiratory symptoms, cultures of the middle meatus often show S. Sinus culture provides the most accurate information compared with nasopharyngeal swabs or cultures of the middle meatus obtained endoscopically; however, cultures of the middle meatus are easier to obtain and less invasive and hence better tolerated by patients. Middle meatus cultures may not correlate with an infection of the sphenoidal sinuses but still would be expected to correlate with infection of the ethmoid or frontal sinuses because the latter primarily drain through the middle meatus.

In contrast, a maxillary sinus tap would not be expected to identify pathogens from the ethmoid, frontal, or sphenoidal sinuses. More data are needed to validate the use of cultures of the middle meatus for assessing microbiological eradication rates and efficacy of antimicrobial therapy.

In patients with ABRS suspected to have suppurative complications, obtaining axial and coronal views of contrast-enhanced CT rather than MRI is recommended for localization of infection and to guide further treatment weak, low. Most cases of ABRS do not require radiographic evaluation because findings on plain radiographs or CT are nonspecific and do not distinguish bacterial from viral infection.

The usefulness of imaging is in determining disease location and the extent of involvement beyond the original source. Occasionally, imaging studies may be useful to support the diagnosis or provide evidence of the degree of mucosal involvement, potentially guiding a more aggressive approach to therapy [ 23 ]. In general, more advanced imaging modalities such as CT or MRI should be reserved for recurrent or complicated cases or when suppurative complications are suspected.

Suppurative complications of ABRS are rare, estimated to be 3. Only approximately 1 of 95 hospital admissions in the United States is due to sinusitis-associated brain abscess [ ]. Overall, the evidence supporting a superiority of CT vs MRI for the diagnosis of suppurative complications of ABRS is very poor, consisting primarily of case reports and small retrospective observational studies.

In general, CT is considered the gold standard for assessing bony and anatomical changes associated with acute or chronic sinusitis, whereas MRI is useful to further delineate the extent of soft tissue abnormalities and inflammation [ — ]. CT is also necessary for surgical planning and for intraoperative image-guided surgical navigation.

Younis et al [ ] evaluated the diagnostic accuracy of clinical assessment vs CT or MRI in the diagnosis of orbital and intracranial complications arising from sinusitis and confirmed by intraoperative findings. A total of 82 adults and children were studied retrospectively from a single medical center during — Thus, MRI appears more sensitive than CT for detecting soft tissue involvement in patients with suspected intracranial complications and is not associated with ionizing radiation [ , ]. In a retrospective descriptive study of 12 children with sinogenic intracranial empyema SIE , Adame et al [ ] reported that the diagnosis was missed in 4 patients who underwent nonenhanced CT.

Axial imaging alone was unable to demonstrate SIE in 1 child with sphenoidal and ethmoid sinusitis, and coronal images were needed to demonstrate its presence and extent. Thus, the recommendation of the IDSA panel in favor of contrast-enhanced CT over MRI places greater value on relative availability and speed of diagnosis by CT, and a lack of need for sedation, which is frequently required for MRI studies in infants and children.

There are definite risks associated with these procedures. CT scanning results in low levels of radiation exposure, which may lead to radiation-induced illnesses if multiple scans are obtained [ ]. With either CT or MRI, there is a potential risk of allergic reactions to the contrast material, and appropriate precaution should be undertaken in patients with renal impairment. Because most of our knowledge in this area is based on retrospective case series or reports, the overall quality of evidence is weak.

As technology continues to evolve, more studies are needed to clarify the indications of these imaging techniques in the management of ABRS. Patients who are seriously ill, immunocompromised, continue to deteriorate clinically despite extended courses of antimicrobial therapy, or have recurrent bouts of acute rhinosinusitis with clearing between episodes should be referred to a specialist such as an otolaryngologist, infectious disease specialist, or allergist for consultation.

Most patients with ABRS will respond to empiric antimicrobial therapy, usually within 3—5 days after initiation of treatment. However, when such patients fail to respond despite a change in antimicrobial therapy to broaden coverage for presumed bacterial resistance, prompt referral to a specialist such as an otolaryngologist, allergist, or infectious disease specialist should be considered.

A confirmation of diagnosis is probably best determined by an otolaryngologist, who may assist in obtaining cultures by sinus puncture or middle meatus endoscopy. Severe infection, particularly in the immunocompromised host, or patients with multiple medical problems that may complicate appropriate dosing or predispose to unusual microorganisms, should be referred to an infectious disease specialist.

Patients with recurrent infection or suspected to have an underlying hypersensitivity or immunologic disorder should be referred to an allergist. Patients with rapid deterioration and manifestations suggestive of orbital or intracranial suppurative complications require urgent consultation and a multidisciplinary approach. Delay in appropriate referral to specialists may prolong illness, result in chronic disease, and occasionally lead to catastrophic consequences if life-threatening complications are not recognized.

Unnecessary referral adds to the burden of healthcare costs. Early access to critical diagnostic facilities such as imaging studies, endoscopy, surgical biopsies, and immunologic testing is needed to improve healthcare and prevent the development of chronic sequelae. Examples of suitable performance measures include:.

Percentage of patients treated for sinusitis who met the criteria for therapy based on question I.

A practical guide for the diagnosis and treatment of acute sinusitis.

Percentage of patients treated for sinusitis for which the appropriate antimicrobial is used as listed in Tables 9 and Percentage of patients who fail initial therapy and have an appropriate culture obtained based on question XVI. Barlam as liaison of the IDSA Standards and Practice Guidelines Committee; Jennifer Padberg for overall guidance and coordination; and Vita Washington and Genet Demisashi for their capable assistance in all aspects of the development of this guideline. Guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations.

The Infectious Diseases Society of America considers adherence to this guideline to be voluntary, with the ultimate determination regarding their application to be made by the physician in light of each patient's individual circumstances. All other authors report no potential conflicts.

Conflicts that the editors consider relevant to the content of the manuscript have been disclosed. Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide. Sign In or Create an Account. Close mobile search navigation Article navigation. Abstract Evidence-based guidelines for the diagnosis and initial management of suspected acute bacterial rhinosinusitis in adults and children were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America comprising clinicians and investigators representing internal medicine, pediatrics, emergency medicine, otolaryngology, public health, epidemiology, and adult and pediatric infectious disease specialties.

View large Download slide. Further research is unlikely to change our confidence in the estimate of effect. Further research if performed is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Further research if performed is likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Any estimate of effect, for at least 1 critical outcome, is very uncertain. RCT, randomized controlled trial. CI, confidence interval; OR, odds ratio.

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