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Acute Sinusitis: A Cost-Effective Approach to

Diagnosis and Treatment


L.J. FAGNAN, M.D., Oregon Health Sciences University, Portland, Oregon
Am Fam Physician. 1998 Nov 15;58(8):1795-1802.
See related patient information handout on caring for acute sinusitis, written by Elizabeth
Smoots, M.D.
Acute bacterial sinusitis usually occurs following an upper respiratory infection that results in
obstruction of the osteomeatal complex, impaired mucociliary clearance and overproduction of
secretions. The diagnosis is based on the patient's history of a biphasic illness (double
sickening), purulent rhinorrhea, maxillary toothache, pain on leaning forward, pain with a
unilateral prominence and a poor response to decongestant therapy. Radiographs and computed
tomographic scans of the sinuses generally are not useful in making the initial diagnosis. Since
sinusitis is self-limited in 40 to 50 percent of patients, the expensive, newer-generation
antibiotics should not be used as first-line therapy. First-line antibiotics such as amoxicillin or
trimethoprimsulfamethoxazole are as effective in the treatment of sinusitis as the more expensive
antibiotics. Little evidence supports the use of adjunctive treatments such as nasal corticosteroids
and systemic decongestants. Patients with recurrent or chronic sinusitis require referral to an
otolaryngologist for consideration of functional endoscopic sinus surgery.
Sinusitis is a common ailment: 16 percent of the U.S. population reports a diagnosis of sinusitis
annually, accounting for 16 million office visits.1 Public interest in sinusitis is exemplified by a
1997 Internet search using Alta Vista, which found 4,960 matches. Furthermore, sinusitis is a
costly disorder: about $2 billion is spent annually on medications to treat nasal and sinus
problems.1 The National Ambulatory Medical Care Survey (NAMCS) lists sinusitis as the fifth
most common diagnosis for which an antibiotic is prescribed.2
Sinus Anatomy and Function
The function of the paranasal sinuses is not clear, but theories include humidification and
warming of inspired air, lightening of the skull, improvement of vocal resonance, absorption of
shock to the face or skull, and secretion of mucus to assist with air filtration. The four paranasal
sinuses (maxillary, frontal, ethmoid and sphenoid) develop as outpouchings of the nasal mucosa.
They remain connected to the nasal cavity via narrow ostia with a lumen diameter of 1 to 3 mm
(Figure 1). The sinuses are lined with mucoperiosteum, which is thinner and less richly supplied
with blood vessels and glands than the mucosa of the nasal cavity. Cilia sweep mucus toward the
ostia. The ostia of the frontal, maxillary and anterior ethmoid sinuses open into the osteomeatal
complex, which lies in the middle meatus lateral to the middle turbinate. The posterior ethmoid
and sphenoid sinuses open into the superior meatus and sphenoethmoid recess. The osteo-meatal
complex is important because the frontal, ethmoid and maxillary sinuses drain through this area.




FIGURE 1.
Anatomy of the nose (top) and paranasal sinuses (bottom).
Pathophysiology
Failure of normal mucus transport and decreased sinus ventilation are the major factors
contributing to the development of sinusitis. Obstruction of the sinus ostia occurs with mucosal
edema or any anatomic abnormality that interferes with drainage. Bacterial and viral infections
also impair the mucus transport system. The frequency of ciliary beats (normally 700 per minute)
decreases to less than 300 per minute during periods of infection. Inflammation causes 30
percent of the ciliated columnar cells to undergo metaplastic changes to mucus-secreting goblet
cells. The obstruction and decreased transport results in stagnation of secretions, decreased pH
and lowered oxygen tension within the sinus, creating an excellent culture medium for bacteria.
A number of factors can contribute to the development of sinusitis (Table 1). The most common
cause of acute bacterial sinusitis is a viral upper respiratory infection. Up to 0.5 percent of upper
respiratory infections in adults develop into documented sinusitis.3,4 Children experience six to
eight colds per year, and approximately 5 to 10 percent of these infections are complicated by
sinusitis.5 Allergic rhinitis has also been considered a contributing factor to sinusitis; however,
no causal relationship has been proved, and it is now believed to be a rare initiating factor.6
Iatrogenic factors include mechanical ventilation, nasogastric tubes, nasal packing and dental
procedures. Pregnancy, hormone changes associated with puberty, and senile rhinorrhea may be
contributing factors. Anatomic variations include tonsillar and adenoid hypertrophy, deviated
septum, nasal polyps and cleft palate.
TABLE 1
Predisposing Factors for Sinusitis

Allergic rhinitis
Anatomic variations
Barotrauma
Dental infections and procedures, trauma
Hormone factors
Immunodeficiency disease
Inhalation of irritants
Mechanical ventilation
Nasal dryness
Nasotracheal and nasogastric tubes
Upper respiratory infections
Microbiology
Studies have shown that 70 percent of cases of community-acquired acute sinusitis in adults and
children are caused by Streptococcus pneumoniae and Haemophilus influenzae.5,7 Branhamella
(Moraxella) catarrhalis causes 25 percent of pediatric acute sinus infections. Other pathogens
less frequently documented include other streptococcal species (8 percent of adult cases),
Staphylococcus aureus (6 percent of adult cases), Neisseria species, anaerobes and gram-
negative rods. Viruses are identified in fewer than 10 percent of childhood sinus infections.
Infections with beta-lactamaseproducing H. influenzae or B. catarrhalis are unusual in adults
who have not recently undergone treatment with an antibiotic.8 Nasal cultures are of limited
value because the mixed flora does not correlate with bacteria aspirated directly from the
sinuses.9 Nasal swabs of 30 percent of the asymptomatic population grow S. aureus, which
rarely causes acute sinusitis.10
Fungi are normal flora of the upper airway, but they can cause acute sinusitis in
immunocompromised and diabetic patients. Aspergillus species are the most common causes of
noninvasive fungal sinusitis.
Diagnosis
One half to two thirds of patients with sinus symptoms who visit primary care physicians are
unlikely to have bacterial sinusitis.11,12 Certain diagnostic tools may be useful to the family
physician to differentiate a common cold from bacterial sinusitis. Determination of the organism
causing acute sinusitis requires puncture, aspiration and culture, but that procedure is rarely
appropriate in the family physician's office. Another tool is four-view sinus radiographic
studies.9,1315 Also gaining popularity is endoscopic evaluation of the nasopharynx to identify
anatomic abnormalities, determine the presence of purulence around the osteo-meatal complex,
and evaluate swelling and inflammation. However, most clinicians now agree that the most
appropriate diagnostic approach is a good history and a thorough physical examination.1618
Studies performed in primary care settings indicate that no single symptom or sign is both
sensitive and specific for diagnosing acute sinusitis. Predictive power is improved by combining
signs and symptoms into a clinical impression. The accuracy rate of clinical impression ranges
from 55 to 75 percent, compared with punctures and radiographs.11,1618 Among the signs and
symptoms used to increase the likelihood of a correct diagnosis of acute sinusitis are double
sickening (biphasic illness), pain with unilateral prominence, purulent rhinorrhea by history,
purulent secretions in the nasal cavity on examination, a lack of response to decongestant or
antihistamine therapy, facial pain above or below both eyes on leaning forward, and maxillary
toothache. The term double sickening refers to patients who start with a cold and begin to
improve, only to have the congestion and discomfort return (Table 2).
TABLE 2
Clinical Indicators of Acute Sinusitis

Double sickening
Unilateral pain
Pain above or below the eyes on leaning forward
Maxillary toothache
Purulent rhinorrhea by history
Purulent secretions in the nasal cavity on examination
Poor response to decongestants or antihistamines
In cases of acute inflammation, palpation and percussion of the involved sinus may elicit
tenderness. The following areas should be palpated: the maxillary floor, palpated from the palate;
the anterior maxillary wall, from the cheek; the lateral ethmoid wall, from the medial canthus;
the frontal floor, from the roof of the orbit; and the anterior frontal wall, from the supraorbital
skull.
Transillumination is commonly used to assess the maxillary and frontal sinuses, although poor
reproducibility between observers and a lack of correlation with maxillary sinusitis limits the
usefulness of transillumination as a diagnostic tool.19
In children, the symptoms of sinusitis are less specific than in adults.5,20 Symptoms include
persistent nasal congestion and cough lasting for more than 10 days, high fever and purulent
nasal discharge. Children are less likely to present with facial pain or headache.
The differential diagnosis of acute sinusitis includes protracted upper respiratory infection, dental
disease, nasal foreign body, migraine or cluster headache, temporal arteritis, tension headache
and temporomandibular disorders.
Imaging
Imaging studies are not cost effective in the initial assessment and treatment of patients with
clinical findings suggestive of acute sinusitis. Radiographs, however, may be helpful in uncertain
or recurrent cases. A normal sinus x-ray series has a negative predictive value of 90 to 100
percent, particularly for the frontal and maxillary sinuses. The positive predictive value of x-rays
using opacification and air-fluid levels as end points is 80 to 100 percent, but the sensitivity is
low since only 60 percent of patients with acute sinusitis have opacification or air-fluid levels.21
The traditional standard study has been a four-view sinus series that includes: (1) the Waters
view, in which the occiput is tipped down (patient's chin and tip of the nose are against the film
surface) to facilitate viewing of the maxillary and frontal sinuses; (2) the Caldwell view, in
which the forehead and tip of the nose are placed in contact with the film (this offers superior
visualization of the frontal and ethmoid sinuses); (3) the lateral view, in which the sphenoid sinus
and the posterior frontal sinus wall are visualized; and (4) the submentovertex view, in which the
sphenoid sinuses and posterior ethmoid cells are visualized.
A Veterans Affairs general medicine clinic study,22 using the standard criteria of air-fluid level,
sinus opacity or mucosal thickening (greater than 6 mm) to diagnose sinusitis, demonstrated that
a single Waters view had a high level of agreement with the complete sinus series. In this study,
88 percent of patients with sinusitis had maxillary disease. A single occipitomental (Waters)
view in children has an overall accuracy of 87 percent in diagnosing acute sinusitis.23 In those
few situations where x-rays are indicated, utilizing a single Waters view is preferred over the
traditional four-view study.
Computed tomographic (CT) scanning of the sinuses has no place in the routine evaluation of
acute sinusitis. Limited sinus CT studies are useful in delineating the osteomeatal complex in
anticipation of an otolaryngology consultation and functional endoscopic sinus surgery to
evaluate and treat chronic sinus inflammation. Sinus CT scanning has a high sensitivity but a low
specificity for demonstrating acute sinusitis.24,25 Forty percent of asymptomatic patients and 87
percent of patients with community-acquired colds have sinus abnormalities on sinus CT.26
Therapy
Adjunctive Treatment
In addition to considering antibiotic therapy in patients who present with acute sinusitis, family
physicians may make recommendations regarding adjunctive therapies such as diet, steam, saline
nasal rinses, topical decongestants, oral decongestants, mucolytic agents, antihistamines and
intranasal corticosteroids. These adjunctive therapies are designed to promote ciliary function
and decrease edema to improve drainage through the sinus ostia. Unfortunately, few randomized
controlled trials have investigated the effectiveness of these approaches.27,28
Sipping hot fluids, applying moist heat with a hot towel and inhaling steam may improve ciliary
function and decrease congestion and facial pain. Salt water nasal rinses provide short-term relief
of congestion by removing crusts and secretions. A normal saline solution can be made by
adding one-fourth teaspoon of table salt to 8 oz of warm water to be delivered with a squeeze
bottle or pump spray bottle.
Decongestants may provide temporary relief of nasal congestion. Nasal spray or drops act by
constricting the sinusoids in the nasal mucosa (Table 3). These sinusoids are regulated by both
alpha1 and alpha2 adrenoreceptors.29 The nasal mucosal blood flow is not significantly affected
by the alpha1 agonists, but recent studies suggest that oxymetazoline (Afrin), a selective alpha2
adrenoreceptor agonist, interferes with the healing of maxillary sinusitis by decreasing nasal
mucosal blood flow.30 As a result, alpha1 agonists, such as phenylephrine (Neo-Synephrine), are
the preferred topical mucosal decongestants. Because of the risk of rebound rhinitis (rhinitis
medicamentosa), the use of topical decongestants should be restricted to three to four days or
less.
TABLE 3
Vasoconstrictors for Decongestion of the Nasal Mucosa

Vasoconstrictors*
Adrenoceptor
activity
Onset
(minutes)
Duration of
action
(hours) Dosage
Topical agents
Sympathomimetic amines
Phenylephrine (Neo-
Synephrine)
Alpha1 1 to 3 1 to 4 2 to 3 sprays in each
nostril every 3 to 4
hours
Imidazoline derivatives
Naphazoline (Naphcon
Forte)
Alpha2 1 to 3 2 to 6 1 to 2 sprays in each
nostril no no more
than every six hours
Oxymetazoline (Afrin 12-
Hour)
Alpha2 1 to 3 5 to 12 2 to 3 sprays twice
daily
Xylometazoline (Otrivin) Alpha2 1 to 3 6 to 12 2 to 3 drops or 2 to 3
sprays every 8 to 10
hours
Systemic agents
Phenylpropanolamine
(Tavist-D [timed release])
Alpha1 and alpha2,
beta1 and beta2
15 to 30 8 to 12 1 tablet every 12
hours
Pseudoephedrine (Sudafed) Alpha1 and alpha2, 15 to 30 4 to 8 60 mg every 4 to 6
hours
(Novafed [timed release]) Beta1 and beta2 8 to 12 120 mg every 12
hours

*Trade names given are for fast-acting formulations, except where otherwise noted.
Dosage recommendations may vary. The dosages given are those listed in Drug facts and
comparisons. St. Louis: Wolters Kluwer, 1998.
Oral decongestants such as pseudoephedrine (Novafed), taken in a dosage of 60 to 120 mg, will
reduce nasal congestion within 30 minutes, and the effect persists for up to four hours. Side
effects include nervousness, insomnia, tachycardia and hypertension. No clinical trials
demonstrate the effectiveness of oral decongestants in treating acute sinusitis.
The mucolytic agent guaifenesin, which is usually given in decongestant combinations (e.g.,
Entex L.A.) is widely prescribed to thin secretions despite its lack of demonstrated effectiveness.
The recommended dosage of 2,400 mg is just below the level that may cause emesis. A recent
study comparing the effects of guaifenesin and placebo on nasal mucociliary clearance and
ciliary beat frequency failed to show any measurable effect.31
There is no rationale for using antihistamines in treating acute sinusitis, since histamine does not
play a role in this condition and these agents dry the mucous membranes with crusts that block
the osteo-meatal complex. The newer, nonsedating, second-generation antihistamines do not
cause excessive dryness and crusting; however, no evidence supports the use of these expensive
agents.
Although widely prescribed for acute sinusitis, intranasal steroids are of questionable benefit.
Given the limited role of allergic rhinitis in the etiology of acute sinusitis and the limited
effectiveness of steroid agents in clinical trials, topical steroids should not routinely be used in
the management of acute sinusitis.
Antibiotics
The appropriate role of antibiotics in the treatment of acute sinusitis is not clear. A recent
study32 of adult patients with acute maxillary sinusitis diagnosed by using clinical and
radiographic examinations and treated with amoxicillin (in a dosage of 250 mg three times daily
for seven days) or placebo showed no significant difference in outcomes. After two weeks, 83
percent of the amoxicillin group and 77 percent of the placebo group had greatly reduced
symptoms, and 65 percent and 53 percent, respectively, were cured. In contrast, other
randomized controlled trials33,34 have demonstrated the effectiveness of antibiotic treatment of
acute sinus infections in adults and children. A study34 in a Norwegian general practice
compared amoxicillin, penicillin and placebo in the treatment of adult patients with acute
sinusitis. Eighty-six percent of the antibiotic group considered themselves cured or much better,
compared with 57 percent of the placebo group. The median duration of sinusitis in the
amoxicillin, penicillin and placebo groups was nine, 11 and 17 days, respectively. In a study of
children two to 16 years of age with acute maxillary sinusitis, the overall cure rate on day 10 was
67 percent for amoxicillin, 64 percent for amoxicillin-clavulanate potassium (Augmentin) and 43
percent for placebo.33 Acute sinusitis is caused by the same organisms that cause otitis media,
and drug choices are similar.
Although the incidence of beta-lactamaseproducing organisms causing maxillary sinusitis is 25
percent in some communities, there has been no superior outcome with the use of broad-
spectrum antibiotics compared with amoxicillin. A number of studies evaluating antibiotic
treatment of sinusitis have shown that amoxicillin, trimethoprim-sulfamethoxazole (Bactrim),
penicillin V (V-Cillin K), minocycline (Minocin), doxycycline (Vibramycin), cefaclor (Ceclor),
azithromycin (Zithromax), amoxicillin-clavulanate potassium, loracarbef (Lorabid),
bacampicillin (Spectrobid), cefuroxime (Ceftin) and clarithromycin (Biaxin) are similarly
effective in producing symptomatic and bacteriologic improvement in 80 to 90 percent of
patients.3543 Most of the studies used seven to 14 days of antibiotic therapy.
A recently reported study44 of adult male patients in a general medicine Veterans Affairs clinic
with sinus symptoms and radiographic evidence of maxillary sinusitis compared the
effectiveness of trimethoprim-sulfamethoxazole twice daily for three days and 10 days. By 14
days, 77 percent of the three-day group and 76 percent of the 10-day treatment group rated their
symptoms as cured or much improved, suggesting that shorter courses of therapy than the
traditional 10- to 14-day course may be effective. However, some have argued against the
validity of this study, so standard therapy is preferred until further data are available.
Most patients (90 percent) with a diagnosis of acute sinusitis expect to receive a prescription for
antibiotics, along with adjunctive treatment recommendations.45 Treatment considerations
include patient expectations, the natural course of untreated disease, time lost from work,
documented effectiveness, adverse effects, and duration and cost of therapy. Use of broad-
spectrum antibiotics, nasal corticosteroids and antihistamines adds to the expense of treatment
with little additional benefit. More controlled trials are needed to clarify the effectiveness of
these various treatment options (Table 4).
TABLE 4
Cost of Antibiotic Treatment for Community-Acquired Acute Sinusitis

Antibiotic Usual adult dosage* Cost
First-line therapy
Trimethoprim-sulfamethoxazole, double-
strength (Bactrim DS)
160/800 mg twice daily $ 25.00; generic: 8.00
Amoxicillin 500 mg three times daily 12.00; generic: 10.00
to 14.00
Second-line therapy
Amoxicillin-clavulanate potassium
(Augmentin)
500/125 mg three times daily 94.00
Cefaclor (Ceclor) 500 mg three times daily 128.00; generic:
115.00 to 117.00
Cefuroxime (Ceftin) 500 mg twice daily 132.00
Cefixime (Suprax) 400 mg twice daily 135.00
Clarithromycin (Biaxin) 500 mg twice daily 65.00
Doxycycline (Vibramycin) 200 mg on day 1, then 100 mg
on days 2 through 10
21.00; generic: 2.00
to 6.00

*These medications are always prescribed in 10-day courses.
Estimated cost to the pharmacist for one month's therapy at the usual adult dosage, rounded
to the nearest dollar, based on average wholesale prices in Red book. Montvale, N.J.: Medical
Economics Data, 1998. Cost to the patient will be higher, depending on prescription filling fee.
Treatment Failure and Complications
Despite the use of antibiotics and selected adjunctive therapy, 10 to 25 percent of primary care
patients continue to have symptoms. The office re-evaluation of these patients, two to three
weeks after the first visit, should include a careful history and physical examination, and a single
Waters view of the sinuses should be taken to confirm the diagnosis. Empiric therapy may
include a two-week course of a second-line antibiotic (Table 4).
Antibiotics appear to be of little benefit in the treatment of chronic sinusitis. Recurrent or chronic
sinusitis often requires otolaryngology consultation. CT imaging of the osteomeatal complex
followed by functional endoscopic sinus surgery (FESS) often successfully restores the
physiology of sinus aeration and drainage. Between 80 and 90 percent of FESS patients
experience significant improvement of symptoms.21
In the era of antibiotic therapy and adequate access to primary care, major complications of
sinusitis are rare. However, 75 percent of all orbital infections are the direct result of sinusitis.46