Evidence-Based Practice / Vol. 17, No.

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What are effective treatments
for acute maxillary sinusitis?
Evidence-Based Answer
Antibiotics and intranasal corticosteroids are effective
for acute maxillary sinusitis (SOR: A, meta-analysis
of consistent RCTs). Systemic corticosteroids may be
effective. Nasal irrigation does not appear to be effective
(SOR: B, meta-analysis of moderate quality RCTs).
A 2011 Cochrane review of 59 RCTs evaluated the
effectiveness of antibiotic treatment in acute sinusitis.
1

Fifty-three studies compared antibiotics from different
classes head-to-head in nearly 16,000 patients. The
remaining 6 trials compared antibiotics with no
treatment in 747 patients. Sinusitis was defned as
upper respiratory infection (URI) symptoms 7 to
30 days and at least 2 typical clinical signs or positive
imaging results. Clinical signs included sinus pain on
palpation, postnasal drip, purulent nasal discharge,
nasal obstruction, unilateral facial pain, maxillary
toothache, or impaired sense of smell.
In the 6 studies comparing antibiotics with placebo,
patients in the antibiotic group (penicillin V, amoxicillin,
or azithromycin) had a statistically signifcant reduction
in symptoms or cure at 1 to 15 days (5 trials, N=631;
risk ratio [RR] 0.66; 95% CI, 0.440.98). However, the
clinical beneft was small. There was a 90% versus 80%
symptom improvement or cure rate with antibiotics
versus placebo, respectively. The remaining 53 studies
comparing antibiotics head-to-head failed to show
superiority of any agent.
1
A 2012 meta-analysis of 6 studies including
2,495 patients with acute sinusitis examined the effcacy
of high-dose intranasal corticosteroids compared
with placebo.
2
Corticosteroids were associated with a
signifcant reduction in symptoms including facial pain,
rhinorrhea, nasal congestion, and cough (risk difference
[RD] 0.08; 95% CI, 0.030.13; NNT=13). However, 5
of the 6 studies had all patients taking antibiotics, and
therapeutic beneft was low with a relatively high cost
of treatment.
A 2011 Cochrane review of systemic corticosteroids
looked at 4 RCTs of moderate quality (N=1,008).
3

Sinusitis was defned clinically and all participants
received oral antibiotics. In addition, they were
assigned to oral corticosteroids (betamethasone 1 mg
for 5 days or prednisone 2480 mg PO daily for 3, 5,
and 7 days) or control (placebo in 3 trials, NSAIDs in
1 trial). Participants treated with oral corticosteroids
had a small increase in improvement of patient-reported
symptom severity (facial pain, congestion, headache) at
days 3 through 10 of illness (RR 1.3; 95% CI, 1.01.7).
A 2010 Cochrane review of 3 heterogeneous
RCTs (N= 92) evaluating saline nasal irrigation for
acute URI found no signifcant difference in symptom
improvement between saline treatments and control.
4
Brett Eckenrod, MD
Tyler J. Baker, MD
Gary Newkirk, MD
Barry Linehan, PA-C
Providence FMR of Spokane
Spokane WA
1. Ahovuo-Saloranta A, et al. Cochrane Database Syst Rev. 2008; (3):CD000243. [STEP 1]
2. Hayward G, et al. Ann Fam Med. 2012; 10(3):241249. [STEP 1]
3. Venekamp RP, et al. Cochrane Database Syst Rev. 2011; (12):CD008115. [STEP 1]
4. Kassel JC, et al. Cochrane Database Syst Rev. 2010; (3):CD006821. [STEP 1]
What are the indications
for pediatric bariatric surgery?
Evidence-Based Answer
Bariatric surgery in the pediatric age group results in
signicant weight loss. Current indications for bariatric
surgery in adolescents include a body mass index (BMI)
of 35 kg/m
2
with type 2 diabetes mellitus, moderate
to severe sleep apnea, pseudotumor cerebri, or severe
steatohepatitis; or a BMI 40 kg/m
2
with less severe
comorbidities (SOR: C, expert opinion).
A 2008 systematic review and meta-analysis of bariatric
surgery for pediatric obesity reviewed 17 case series and
1 prospective study comprising a total of 641 patients.
1

To be a part of the meta-analysis, the studies needed
to include procedures currently performed in the
United States, and report outcome data for at least 3
patients younger than 21 years regarding weight, BMI,
comorbidity resolution, quality of life, and/or survival.
The meta-analysis for each procedure demonstrated
a signifcant decrease in BMI, ranging from an 11- to
14-unit change with lap banding (8 trials; N=352;
mean initial BMI 46 kg/m
2
) to an 18- to 22-unit change
with the Roux-en-Y procedure (6 trials; N=131; mean
initial BMI 52 kg/m
2
). Comorbidity resolution was
sparsely reported with some studies showing resolution
of diabetes and hypertension. There was also limited