Acute sinusitis Overview

Acute sinusitis also known as acute rhinosinusitis is a symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal sinuses, presenting with purulent nasal drainage accompanied by nasal obstruction, facial pain/pressure/fullness, or both for 4 weeks or less. Often caused by either a viral or a bacterial infection.

Epidemiology

More than 20 million cases of acute sinusitis of viral or bacterial etiology are diagnosed in the US each year across all age groups, affecting an estimated 16% of the adult population and resulting in almost 12 million office visits per year.^1,2,3

Approximately 0.5% to 2.0% of viral upper respiratory tract infections progress to acute bacterial sinusitis. About 20 million cases of presumed acute bacterial sinusitis occur each year in the United States alone.⁴

It is estimated that adults will experience 1 to 3 episodes of viral acute rhinosinusitis annually. Acute sinusitis accounts for 2% to 10% of primary care and otolaryngology visits.⁵

Prevalence is slightly higher in females compared with males, and there is no clear ethnic predominance.^6,7

Etiology

The most common cause of acute sinusitis is a viral infection.⁸ Following an episode of viral sinusitis, 0.5% to 2.0% of cases of acute viral sinusitis will progress to acute bacterial sinusitis.⁵ The most common bacteria include Streptococcus pneumoniae (up to 35% of cases), Haemophilus influenzae (up to 40% of cases), Moraxella catarrhalis (up to 20% of cases), and beta-hemolytic streptococci such as S pyogenes (up to 8% of cases).⁹

Although the bacterial pathogens have not changed over time, their antibiotic-resistance patterns have altered.¹⁰ Antibiotic resistance depends on the geographic location; therefore, an understanding of local antibiotic resistance patterns is important.^4,5,10 Although the majority of acute sinusitis infections are from viral infection, antibiotics are often prescribed for suspected bacterial infection. However, this is inappropriate for viral upper respiratory infections, rhinitis, or bronchitis. There is a risk that these may be incorrectly categorized as sinusitis in order for prescribers to avoid scrutiny when treating colds, therefore overrepresenting the volume of sinusitis cases.

Prevention

Primary Prevention

Good hand washing practices (i.e., using soap or alcohol-based rubs) are recommended, especially when in contact with people who currently have an upper respiratory tract infection.

Exposure to environmental irritants, such as cigarette smoke, pollutants, and allergens, should be avoided where possible.

Treatment for upper respiratory tract infections (the common cold) is typically focused on reducing symptom duration and severity, though symptoms are usually self-limiting.¹¹

Secondary Prevention

Secondary prevention measures may be useful for patients who have recurrent acute sinusitis.

Good hand washing practices (i.e., using soap or alcohol-based rubs) are recommended, especially when in contact with people who are ill. Exposure to environmental irritants, such as cigarette smoke, pollutants, and allergens, should be avoided where possible.

Any underlying conditions should be assessed and treated appropriately. If recurrent episodes are due to the presence of allergies, consultation and evaluation with an otolaryngologist or allergist is considered beneficial.

Treatment

The goals of treatment are to relieve symptoms, eradicate infection, and prevent complications.¹² Management varies depending on whether the etiology is viral or bacterial, and should involve shared decision-making with the patient.⁴ In most cases the diagnosis is made presumptively.

Acute viral sinusitis

This is generally a self-limiting disease, and treatment is primarily symptomatic. The disease course is usually less than 10 days, but symptoms tend to improve after approximately 5 days.

Adequate rest and hydration, warm facial packs, and nasal saline irrigation may be useful, as well as use of vitamin C, zinc, or over-the-counter medications, depending on the specific symptoms.¹³

Treatments should be tried for 5 to 10 days before reassessing the patient. Antibiotics should not be given to patients with suspected acute viral sinusitis.^5,14

Analgesics/antipyretics

• Recommended for pain and/or fever.
• Examples include acetaminophen, ibuprofen, or acetaminophen/codeine. Selection of agent depends on the subjective level of pain the patient is experiencing.

Codeine is contraindicated in children younger than 12 years of age, and it is not recommended in adolescents 12 to 18 years of age who are obese or have conditions such as obstructive sleep apnea or severe lung disease as it may increase the risk of breathing problems.¹⁵

Codeine is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children 12 years of age and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.^16,17

Decongestants

• May restore sinus ostial patency and provide symptomatic relief of nasal congestion.^4,18 However, evidence is lacking.¹⁹
• Topical agents (e.g., oxymetazoline) are often preferred over systemic agents (e.g., pseudoephedrine) because of increased potency and less risk of adverse effects.
• Topical agents should only be used for up to 3 to 5 days, to prevent the occurrence of rebound congestion.

Topical anticholinergics (e.g., ipratropium)

• Recommended in adults with rhinorrhea.²⁰

Intranasal saline irrigations/sprays

• May also be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing medication use.
• Saline nasal irrigations may be helpful in relieving nasal symptoms; however, they should be used cautiously as patients who have not had an endoscopic sinus surgery may develop facial pressure or discomfort when the saline irrigations get trapped in the nonoperated sinuses.²¹
• The following instructions for a home-prepared saline irrigation may be helpful for patients: University of Michigan Health System: saltwater washes (nasal saline lavage or irrigation) for sinusitis
  • Add 1 cup (240 mL) of distilled water to a clean container. If using tap water, boil it first to sterilize it, and then let it cool down.
  • Add half a teaspoon (2.5 g) of salt to the water.
  • Add half a teaspoon (2.5 g) of baking soda.
  • This solution can be stored at room temperature for 3 days.
  • To use the homemade solution, fill a large medical syringe, squeeze bottle, or nasal cleansing pot with the solution, insert the tip into the nostril, and squeeze gently.
  • Aim the stream of solution toward the back of the head.
  • The solution should go through the nose and out of the mouth or the other nostril.
  • Gently blow the nose after using the solution, unless instructed otherwise.
  • Repeat several times every day.
  • Clean the syringe or bottle after each use.

Acute bacterial sinusitis

For nonsevere symptoms in immunocompetent people, some guidelines recommend watchful waiting for up to 10 days with symptomatic therapy before instituting subsequent antibiotic therapy, as the majority of nonsevere cases will resolve without them.^4,22

However, immediate antibiotic therapy can shorten the duration of symptoms, so may be used if the benefits (i.e., eradication of infection, improvement in symptoms, reduced duration of illness) outweigh the risks (i.e., adverse effects, cost, need for follow-up, increased bacterial resistance) of therapy.^4,14,23

Patients with severe symptoms or worsening symptoms are more likely to have bacterial infection compared with patients with mild symptoms, particularly if the symptoms have lasted for more than 10 days.¹⁴

In this context, current guidelines recommend more broad-spectrum first-line therapy for acute bacterial rhinosinusitis (ABRS).^4,14 There are several sets of guidelines in existence, and practices may vary.

Antibiotic therapy

• Amoxicillin or amoxicillin/clavulanate has generally been recommended as a first-line agent for nonsevere disease in immunocompetent people, owing to its safety, efficacy, and low cost.⁴ A pharmacokinetically-enhanced extended-release formulation of amoxicillin/clavulanate can be used for the treatment of acute bacterial sinusitis caused by penicillin-resistant Streptococcus pneumoniae.²⁴ High-dose amoxicillin/clavulanate is recommended as first-line therapy for patients who have severe disease or are immunocompromised.⁴
• For penicillin-allergic patients, a reasonable alternative is therapy with clindamycin plus a second- or third-generation cephalosporin (e.g., cefuroxime, cefpodoxime, cefprozil). There is a risk of cross-sensitivity with cephalosporins in these patients, although this risk is low if the allergic manifestation is simply a rash without respiratory involvement.²⁵
• Doxycycline is a suitable alternative in adults with allergies to beta-lactam antibiotics; however, it is not recommended in children due to risks of tooth discoloration and dental enamel hypoplasia.²⁶
• Trimethoprim/sulfamethoxazole or a macrolide (e.g., azithromycin) have been used in patients with an allergy to penicillins, but in some areas there are now relatively high rates of resistance to these drugs that limit their usefulness.
• Fluoroquinolones should only be used in patients with acute bacterial sinusitis who do not have other treatment options.²⁷ They may be tried in adults if treatment with a penicillin or cephalosporin is not possible. Fluoroquinolones should be used with caution in children due to risk of musculoskeletal adverse effects.²⁸

Doctor’s Advice

Patients should be instructed to notify their physician if symptoms do not improve as expected. Pain and fever should begin to improve within 2 to 3 days without treatment in patients with acute viral sinusitis.⁴

Nasal obstruction and drainage may take a week or more to improve. Patients should be advised to avoid cigarette smoke, environmental pollutants and allergens, alcohol, air travel, and diving in deep water. Warm facial packs and nasal saline irrigation may be useful. Adequate sleep and hydration should be encouraged.

If air travel is unavoidable, advise patients to avoid stress, ensure a good night’s sleep before traveling, stay well hydrated, avoid alcohol and caffeine, and consider using intranasal decongestant spray just before boarding the flight.

 

References

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