Rhinosinusitis - ClinicalKey PDF

4/1/2020 Rhinosinusitis- ClinicalKey
CLINICAL OVERVIEW
Rhinosinusitis
Elsevier Point of Care (see details)
Updated January 7, 2020. Copyright Elsevier BV. All rights reserved.
Synopsis Urgent Action

Key Points Hospitalization, urgent imaging,
Rhinosinusitis is inflammation of the mucous membranes subspecialist referral, and
lining 1 or more of the paranasal sinuses; almost always treatment with IV antibiotics is
involves contiguous nasal mucosa as well required for complications such
as periorbital or orbital cellulitis
Classified according to duration, with acute or intracranial involvement
rhinosinusitis persisting less than 4 weeks and chronic
rhinosinusitis lasting more than 12 weeks
Viral infection accounts for most cases of acute rhinosinusitis, while bacterial cause is less common
Acute bacterial rhinosinusitis can be classified as uncomplicated rhinosinusitis that has no evidence of
extension of inflammation outside paranasal and nasal cavity, and complicated rhinosinusitis with
neurologic, ophthalmologic, or soft tissue involvement
Characterized by purulent nasal drainage accompanied by nasal obstruction; or facial pain, fullness,
or pressure; or both
Diagnosis of acute rhinosinusitis is generally based on clinical history and physical examination 1
Imaging studies are not required in most cases of acute uncomplicated rhinosinusitis 2 3
CT and/or MRI is indicated if complications or alternative diagnosis is suspected
In most patients, symptoms of acute rhinosinusitis are self-limited and will resolve within 1 to 2
weeks; symptomatic therapy (eg, analgesics, topical intranasal steroids, nasal saline irrigation) is
recommended in most cases 3
If acute bacterial rhinosinusitis is suspected, empiric antibiotic therapy with amoxicillin or preferably
amoxicillin–clavulanic acid may be considered 4 5
https://www.clinicalkey.com/#!/content/clinical_overview/67-s2.0-50ef9b00-ea3c-4e85-9226-49c613085072 1/24
Diagnosis of chronic rhinosinusitis is based on clinical presentation and findings on nasal endoscopy
or sinus CT
Patients with chronic or recurrent acute rhinosinusitis should be assessed for predisposing conditions
(eg, asthma, cystic fibrosis, immunocompromised status)
Initial management consists of prolonged antibiotic therapy in conjunction with smoking cessation,
nasal saline irrigation, and intranasal corticosteroids
Patients with chronic or recurrent rhinosinusitis who have nasal polyps or other structural
abnormalities may require endoscopic sinus surgery to relieve obstruction and promote drainage 1 6
Terminology
Clinical Clarification
Rhinosinusitis is inflammation of the mucous membranes lining 1 or more of the paranasal sinuses
Inflammation almost always involves contiguous nasal mucosa 3
Classification
Acute rhinosinusitis
Duration less than 4 weeks 3 7
Further classified based on presumed cause 3
Acute viral rhinosinusitis
Acute bacterial rhinosinusitis
Acute bacterial rhinosinusitis can be subclassified further as: 3
Uncomplicated
Rhinosinusitis without clinical evidence of inflammation extending outside paranasal and nasal
cavity (ie, no neurologic, ophthalmologic, or soft tissue involvement)
Complicated
Rhinosinusitis with evidence of inflammation extending outside paranasal and nasal cavity (ie,
neurologic, ophthalmologic, or soft tissue involvement present at time of diagnosis)
Chronic rhinosinusitis
Duration more than 12 weeks, with or without acute exacerbations 3 7
Subclassified based on cause
Associated with nasal polyposis
Without nasal polyposis
Allergic fungal rhinosinusitis
Subacute rhinosinusitis
Duration between 4 and 12 weeks 3 7
Limited data exist for this entity; decision to manage as acute or chronic illness are individualized 3
Recurrent acute rhinosinusitis
4 or more episodes of acute bacterial rhinosinusitis per year, without persistent symptoms in
between 3
Diagnosis
Clinical Presentation
History
Nasal congestion
Purulent rhinitis
Facial pain or pressure
Headache
Maxillary toothache
Persistent cough (usually with a more severe nocturnal component)
Postnasal drip
Hyposmia
Ear pain, pressure, or fullness
Hearing loss
Poor response to decongestants
Less common symptoms include:
Fever (more common in children)
Nausea
Malaise
Fatigue
Halitosis
Sore throat
In children, increased irritability and vomiting may be present as a result of gagging on mucus and
prolonged cough
The following symptoms are suggestive of complicated rhinosinusitis with extension beyond the
paranasal sinuses:
High fever
Diplopia or abnormal eye movement
Proptosis or marked periorbital edema
Severe headache
Physical examination
Patients are typically afebrile
Examination of head and neck may show the following:
Tenderness over the involved sinus cavities or tenderness to percussion of upper teeth 3
Dark circles under eyes (however, may reflect allergic diathesis more than infection)
Increased posterior pharyngeal secretions
Swelling, erythema, or edema over cheekbone or periorbital region 3
Rhinoscopy with an otoscope or nasal speculum may show:
Mucous membrane edema
Purulent secretions from middle meatal region
Inferior turbinate hypertrophy
Complicated cases may be associated with orbital or facial cellulitis, orbital protrusion, eye movement
abnormalities, or papilledema 3 8
Causes and Risk Factors

Causes
Most cases involve extension of a viral upper respiratory tract infection into the paranasal sinuses;
subsequent secondary bacterial infection may follow 3
Acute viral rhinosinusitis
Most cases (up to 90%) of acute rhinosinusitis are viral 9
Common pathogens include: 10
Rhinovirus
Adenovirus
Influenza virus
Parainfluenza virus
Acute bacterial rhinosinusitis
Only 0.5% to 2% of episodes are caused by bacterial infection 9
Most common community-acquired organisms are:
Streptococcus pneumoniae and other Streptococcus species 7 11
Nontypable Haemophilus influenzae 7 11
Moraxella (Branhamella) catarrhalis 7 11
Nosocomial infections occur in patients with nasogastric tubes, nasotracheal intubation, cystic
fibrosis, and immunocompromise; typical organisms include: 11
Staphylococcus aureus (including MRSA)
Pseudomonas aeruginosa
Klebsiella pneumoniae
Gram-negative enteric organisms
Streptococcus pneumoniae
11
Complex pathophysiology involving dysregulation of inflammatory pathways; may be associated

with nasal polyposis 12
Concurrent inflammation in lower airways (eg, asthma) may be present

Isolated organisms include:
Staphylococcus aureus
Streptococcus pneumoniae
Haemophilus influenzae
Anaerobes
Gram-negative enteric organisms
Risk factors and/or associations

Age
Most common in adults between ages 45 and 65 years 13
Sex
Diagnosed more frequently in women than men (1.8:1) 11
Other risk factors/associations

Allergic rhinitis 7
Asthma 11
Nasal obstruction due to: 10 11
Polyps
Foreign body
Deviated nasal septum
Tumor
Trauma
Structural defects (eg, cleft palate) 11
Immunodeficiencies 11
Functional disorders of mucociliary clearance (eg, ciliary dyskinesia, cystic fibrosis) 11
Cigarette smoke exposure 7
Swimming 11
Air travel 14
Diving 14
Dental infections and procedures 10
Mechanical ventilation 10
Nasogastric tube 10
Nasal packing 10
Previous sinus surgery 10
Diagnostic Procedures
Primary diagnostic tools
11
Diagnosis is based primarily on clinical history
Acute rhinosinusitis is defined as up to 4 weeks of purulent nasal drainage accompanied by nasal

obstruction; facial pain, fullness, or pressure; or both
Presence of purulent nasal discharge alone does not indicate bacterial infection; coloration is
due to the presence of neutrophils, a sign of inflammation, and not specific for infection
Distinguish between acute rhinosinusitis from viral or noninfectious conditions and acute
bacterial rhinosinusitis 3
Presume diagnosis of viral rhinosinusitis when signs and symptoms of acute rhinosinusitis are
present for less than 10 days and not worsening
Presume diagnosis of acute bacterial rhinosinusitis in the following:
Adults with signs and symptoms of acute rhinosinusitis that persist for at least 10 days
without improvement or worsen within 10 days after initial improvement 9
Children with: 1 15
Persistent symptoms of upper respiratory tract infection, including nasal discharge and
cough, for longer than 10 days without improvement
Worsening course, such as worsening or new onset of nasal discharge, daytime cough, or
fever after initial improvement
Severe onset, including temperature of at least 39°C and purulent nasal discharge for at
least 3 consecutive days
Imaging studies are not required in most cases of acute uncomplicated rhinosinusitis 1 2 3
If complications or an alternative diagnosis is suspected (eg, severe headache, proptosis, cranial

nerve palsies, facial swelling), contrast-enhanced CT and/or MRI are indicated 2 16
Sinus radiographs are often inaccurate and have been largely supplanted by CT when imaging
is necessary 2
Chronic rhinosinusitis 8
Chronic rhinosinusitis is defined as follows:
2 or more of the following symptoms persisting for 12 weeks or longer:
Mucopurulent nasal discharge
Nasal obstruction
Facial pain, pressure, or fullness
Decreased sense of smell, plus
1 or more of the following signs of inflammation:
Purulent mucus or edema in the middle meatus or ethmoid region
Polyps in the nasal cavity or middle meatus
Signs of sinus inflammation on imaging
Presence of facial pressure alone in the absence of other nasal symptoms is not sufficient for
diagnosis
Confirm diagnosis with anterior rhinoscopy, nasal endoscopy, or sinus CT 3
Provides objective documentation of sinonasal inflammation
Shows nasal polyps or septal deviation; may require different management strategies 3
Paranasal sinus biopsy can be used to determine whether any visible lesions are neoplastic, to
confirm presence of suspected fungal disease, or to assess the possibility of granulomatous
disease
Sinus cultures are advisable for patients with persistent purulence despite earlier antibiotic
treatment
Assess patients with chronic or recurrent acute rhinosinusitis for conditions that could modify
management (eg, asthma, cystic fibrosis, immunocompromised status) 3
Obtain sweat chloride test in children with nasal polyps 1
Gold standard for identifying patients with cystic fibrosis
Consider allergy and immune function testing in a patient with chronic rhinosinusitis or
recurrent acute rhinosinusitis
Laboratory
Sinus culture 3
Recommended for patients with persistent purulence despite previous antibiotics
Sample is obtained endoscopically or via aspiration from the sinus ostia; nasal swabs are not
sufficient to guide treatment
Imaging
CT 6 11
Sinus CT without contrast enhancement is the preferred modality for evaluating chronic
rhinosinusitis; obtain CT with contrast enhancement if complications of acute rhinosinusitis are
suspected 2
Indications include: 2
Evaluation of patients with clinical concern for intraorbital or intracranial complications of

rhinosinusitis
Evaluation of recurrent acute rhinosinusitis before surgical intervention
Confirmation of chronic rhinosinusitis
Providing preoperative anatomical information
Findings in rhinosinusitis include mucosal thickening, loss of air-space volume, air-fluid levels,
opacification, and sinus ostial obstruction
MRI 2
Not first line modality for routine sinus imaging
Lacks bone detail and has longer imaging times
May be useful in aggressive sinus infection to better depict intraorbital and intracranial
complications
Best delineates orbital, skull base, or intracranial involvement
Aids differentiation of soft tissue masses from adjacent inflammatory mucosal disease
Study of choice for suspected invasive fungal rhinosinusitis
Differential Diagnosis
Most common
Upper respiratory tract

Acute viral respiratory illness with incubation period of 24 to 72
infection
hours; lasting from a few days to a few weeks
Generally mild and self-limiting
Features include mild upper respiratory symptoms, such as throat

irritation and nasal congestion (heralding symptoms), followed by
rhinorrhea and sneezing
Other associated symptoms, such as sore throat, cough, fever, or

lacrimation, may occur
Differentiated by history and physical examination
Allergic rhinitis
Often associated with a history of allergies and may be caused by
an inflammatory response to a particular inhalant allergen (eg,
tree, grass, weed pollen)
Characterized by inflammation of the nasal passages
Symptoms such as nasal congestion and rhinorrhea exhibit a

seasonal pattern
Can be distinguished from viral rhinorrhea by skin test

hypersensitivity to specific antigens and by a positive
radioallergosorbent test; however, allergy testing is rarely
necessary in an acute setting
Differentiated by history and physical examination; skin test

hypersensitivity to specific antigens can provide confirmation of
allergy
Nonallergic rhinitis
Nonallergic rhinitis (also known as irritant rhinitis, vasomotor
rhinitis, or perennial nonallergic rhinitis) results from
hyperreactivity to environmental triggers (eg, temperature

change)
Caused by increased parasympathetic tone involving the nasal

mucosa
Symptom complex is similar to that of allergic rhinitis
Negative results on skin testing and radioallergosorbent tests
Nasal polyposis
Most often associated with allergic rhinitis
Some patients with nasal polyposis have Samter triad (asthma,

nasal polyps, and acute hypersensitivity reactions to aspirin or
NSAIDs)
Patients with polyps may present with few symptoms or have

rhinorrhea, obstruction, and anosmia
Polyps can be visualized on direct intranasal examination
Granulomatosis with Granulomatosis with polyangiitis (Wegener granulomatosis)

polyangiitis (Related: )
Granulomatous condition that can affect multiple systems
Chronic granulomatous inflammatory disease of the upper and

lower respiratory tracts occurs simultaneously with
glomerulonephritis
Granulomatous invasion destroys the nasal septum, erodes nasal

cartilage, and can cause proptosis in advanced cases
Patient typically presents with sinus pain and a purulent nasal

discharge
Most common chest radiography findings are single or multiple

nodules/masses; nodules are typically diffuse and often cavitated
Confirmed with tissue biopsy from site of active disease; renal and
lung biopsies are most specific
Differentiated based on biopsy and clinical, serologic (eg,

markedly elevated erythrocyte sedimentation rate and C-reactive
protein level, autoantibodies), and radiographic findings
Treatment
Goals
Relieve symptoms, restore patency of nasal passages, and aid sinus drainage
Eradicate bacterial infection, when present
Disposition
Admission criteria
Admit patients who exhibit signs of postseptal orbital rhinosinusitis; some cases of preseptal orbital
rhinosinusitis may require admission, but many cases can be managed on outpatient basis
Immediately hospitalize patients who have intracranial involvement as a complication of bacterial

rhinosinusitis and treat with appropriate antibiotic therapy
Immediately hospitalize patients who have osteomyelitis as a complication of frontal rhinosinusitis and
treat with appropriate antibiotic therapy
Criteria for ICU admission

May be necessary in some patients with complications
Recommendations for specialist referral

Refer patients with chronic or recurrent rhinosinusitis to an allergist or immunologist for further
evaluation of underlying risk factors and to an otolaryngologist for evaluation of suspected structural
abnormalities
Refer patients who are seriously ill, are immunocompromised, or who continue to deteriorate despite
extended courses of antimicrobial therapy to a specialist (eg, otolaryngologist, infectious disease
specialist)
Patients exhibiting signs of preseptal or postseptal orbital rhinosinusitis should be evaluated by an

ophthalmologist immediately
Treatment Options
In most patients the cause is viral and symptoms will resolve within 1 to 2 weeks with supportive
therapy
The following agents may provide symptomatic relief: 3
Analgesics (eg, acetaminophen, NSAIDs) can relieve pain and fever
Nasal saline irrigation with either physiologic or hypertonic saline 3

Topical intranasal corticosteroids 3 6
Decongestants (oral or intranasal), while frequently used, are not specifically recommended as
3 6
adjunct treatment in patients with acute bacterial rhinosinusitis
Topical decongestant use may be palliative by reducing congestion of sinus and nasal mucosa;
duration of use should not exceed 3 to 5 days to avoid rebound congestion and medicamentous
rhinitis
Oral decongestants may provide symptomatic relief; can be considered if no medical

contraindications exist
Antihistamines have no role in symptomatic relief of acute rhinosinusitis; no studies support their
use in an infectious setting, and they may worsen congestion by drying nasal mucosa 3
Guaifenesin is an expectorant often used to loosen phlegm and bronchial secretions; evidence of
clinical efficacy is lacking and decisions regarding use are based on patient and provider preference
3
Antibiotic therapy 4 5
Initiate antibiotic treatment at time of diagnosis in patients who are unlikely to attend follow-up,
and in patients initially managed with observation who worsen or who do not improve within 7
days
First line empiric therapy is amoxicillin (amoxicillin–clavulanic acid may be preferable), which is
generally effective, inexpensive, and well tolerated 3 6
High-dose amoxicillin-clavulanate therapy is recommended as initial empiric therapy in the

following settings: 6
Severe infection (eg, systemic toxicity with fever 39°C or higher)
Risk factors for pneumococcal resistance (eg, day care attendance, age younger than 2 years
or older than 65 years, recent hospitalization, antibiotic use within past month,
immunocompromised status, multiple comorbidities)
High endemic rate (10% or higher) of penicillin-nonsusceptible Streptococcus pneumoniae
Penicillin-allergic patients
For penicillin-allergic adults, alternatives for empiric treatment include doxycycline (preferred)
9 or a respiratory fluoroquinolone; 6 combination therapy with clindamycin plus a third-
generation oral cephalosporin (eg, cefixime, cefpodoxime) is recommended in adults with a
history of non–type I hypersensitivity to penicillin 3
For penicillin-allergic children, combination therapy with a third-generation oral

cephalosporin (eg, cefixime, cefpodoxime) plus clindamycin may be used as alternative for
children with non–type I penicillin allergy 6
FDA has determined that fluoroquinolones should be reserved for use in patients who have no
other treatment options for acute bacterial rhinosinusitis (eg, severe allergic reaction precludes
the use of standard therapy) 17
Note that macrolides (eg, clarithromycin, azithromycin), and trimethoprim-sulfamethoxazole are

not recommended for empiric therapy owing to high rates of resistance 6
Second- and third-generation oral cephalosporins are no longer recommended for empiric
monotherapy owing to variable rates of resistance among Streptococcus pneumoniae 6
If an oral cephalosporin is to be used (eg, for patients from geographic areas with high endemic
rates of penicillin-nonsusceptible Streptococcus pneumoniae or with non–type I penicillin
allergy), a third-generation cephalosporin (eg, cefixime, cefpodoxime) in combination with
clindamycin is recommended
Duration of therapy is inconsistent in the literature; recommendations based on clinical

observations vary widely
In adults, treatment can range from 5 to 10 days 3
No consistent benefit demonstrated in 10 days of therapy versus shorter courses 3
Consider longer course for more severe illness or when symptoms persist despite shorter
course
In children, treatment duration ranges from 10 to 28 days (often 10-14 days 6 ) 1
Consider an individualized approach, with treatment recommended for a minimum of 10

days, or 7 days after resolution of symptoms 7
Treatment failure 1 3
The Infectious Diseases Society of America suggests choosing an alternative treatment strategy
for adults or children if symptoms worsen after 72 hours or condition fails to improve despite 3
to 5 days of initial empiric antimicrobial therapy 6
The American Academy of Otolaryngology-Head and Neck Surgery recommends reassessing

patient to confirm diagnosis, exclude other causes, and detect complications if condition
worsens or fails to improve with initial therapy within 7 days after diagnosis, or if it worsens
during initial management 3
If rhinosinusitis remains the best diagnosis, change antimicrobial agent
Fluctuations of signs and symptoms during first 48 to 72 hours of initial therapy are not
uncommon and do not necessarily indicate treatment failure
The American Academy of Pediatrics recommends changing the antibiotic therapy if there is
worsening or failure to improve within 72 hours of initial treatment when diagnosis of acute
bacterial rhinosinusitis is confirmed 1
Patients with complicated bacterial rhinosinusitis require hospitalization and treatment with IV
antibiotics; treat for specific complication; emergency surgical treatment may be necessary
In severe cases requiring hospitalization, antibiotic coverage can include the following: 6
Adults: ampicillin-sulbactam, ceftriaxone, cefotaxime, levofloxacin, moxifloxacin
Children: ampicillin-sulbactam, ceftriaxone, cefotaxime, levofloxacin
Note: fluoroquinolones are reserved for patients who do not have other treatment options 17
Surgical intervention is rarely required in cases of acute rhinosinusitis unless there are complications
or structural abnormalities predisposing to recurrent episodes 12
Treatment is aimed at reducing symptoms; however, a complete cure is unlikely
Initial management may include: 3
Smoking cessation
Nasal saline irrigation 18 19
Intranasal corticosteroids 20
Antibiotic therapy at initial diagnosis and intermittently for any acute exacerbations 21 22
Amoxicillin–clavulanic acid is the recommended first line agent
Treatment may be prolonged (up to 6 weeks) 21
Antileukotriene agents may have a role in patients with allergic rhinitis or nasal polyposis
Surgical intervention may be required in patients with nasal polyps or other structural abnormalities
23 24
Functional endoscopic sinus surgery restores sinus ventilation and drainage; however, medical
therapy is typically still required to prevent recurrence
Drug therapy
Amoxicillin–clavulanic acid
First line therapy
Standard dose
Amoxicillin Trihydrate, Clavulanate Potassium Oral suspension; Neonates and Infants 1 to 2

months: 30 mg/kg/day amoxicillin component PO divided every 12 hours; only 125 mg/5 mL
suspension recommended in this age group. IDSA recommends to treat for 10 to 14 days.
Amoxicillin Trihydrate, Clavulanate Potassium Oral suspension; Infants 3 months and older,
Children, and Adolescents weighing less than 40 kg: 45 mg/kg/day amoxicillin component PO
divided every 12 hours (using 200 mg/5 mL or 400 mg/5 mL suspension; 200 mg or 400 mg
chewable tablets) or 40 mg/kg/day amoxicillin component PO divided every 8 hours (using 125
mg/5 mL or 250 mg/5 mL suspension; 125 mg or 250 mg chewable tablets; or 500 mg regular
tablets) for 10 to 14 days; every 12 hour regimen preferred because it causes less diarrhea.
Amoxicillin Trihydrate, Clavulanate Potassium Oral suspension; Children and Adolescents

weighing 40 kg or more: 875 mg amoxicillin with 125 mg clavulanic acid PO every 12 hours (using
875 mg tablet or 200 mg/5 mL or 400 mg/5 mL suspension) or 500 mg amoxicillin with 125 mg
clavulanic acid PO every 8 hours (using 500 mg regular tablets; 125 mg or 250 mg chewable
tablets; or 125 mg/5 mL or 250 mg/5 mL suspension) for 10 to 14 days.
High dose (for treatment failure or areas of resistance or severe infection) 6
Amoxicillin Trihydrate, Clavulanate Potassium Oral suspension; Infants, Children, and

Adolescents: 90 mg/kg/day amoxicillin component PO divided twice daily for 10 to 14 days (Max:
2000 mg amoxicillin/125 mg clavulanic acid twice daily).
Amoxicillin Trihydrate, Clavulanate Potassium Oral tablet, extended-release; Children and

Adolescents weighing 40 kg or more: 2000 mg amoxicillin with 125 mg clavulanic acid PO every
12 hours for 10 to 14 days.
Amoxicillin Trihydrate, Clavulanate Potassium Oral tablet, extended-release; Adults: 2000 mg

amoxicillin with 125 mg clavulanic acid PO every 12 hours for 10 days per FDA-approved labeling.
IDSA recommends to treat for 5 to 7 days.
Amoxicillin
Standard dose
Amoxicillin Trihydrate Oral suspension; Children and Adolescents 2 years and older (standard-
dose therapy): 45 mg/kg/day PO divided every 12 hours is standard dose for children with
mild/moderate uncomplicated disease (do not attend daycare, have not had antibiotics in last 4
weeks).
High dose
Amoxicillin Trihydrate Oral suspension; Children and Adolescents 2 years and older (high-dose
therapy): 80 to 90 mg/kg/day PO in divided doses every 12 hours (Max: 2 g/dose) is
recommended for children in areas with high rates of S. pneumoniae resistance (more than 10%,
including intermediate- and high-level resistance). Use high-dose amoxicillin; clavulanic acid for
those with moderate/severe disease, attending daycare, or who have recently been treated with
antimicrobial therapy.
Doxycycline
Alternative for penicillin-allergic patients; second line alternative agent
Doxycycline Monohydrate Oral suspension; Children 8 years and older and Adolescents weighing
less than 45 kg: 2.2 mg/kg/dose PO every 12 hours on day 1, then 2.2 mg/kg/day, or for severe
infections, every 12 hours.
Doxycycline Hyclate Oral tablet; Children 8 years and older and Adolescents weighing 45 kg or
more: 100 mg PO every 12 hours on day 1, then 100 mg/day, or for severe infections, every 12 hours.
Doxycycline Hyclate Oral tablet; Adults: 100 mg PO every 12 hours on day 1, then 100 mg/day, or
for severe infections, every 12 hours. For sinusitis, clinical guidelines recommend 100 mg PO twice
daily or 200 mg/day PO for 5 to 7 days as second line therapy or for beta-lactam allergy.
Quinolones
Alternative for penicillin-allergic patients with no other treatment options
Note: Systemic fluoroquinolones have been associated with disabling and potentially irreversible
serious adverse effects involving the central nervous system, nerves, tendons, muscles, and joints.
Reserve for use in patients who have no other treatment options for acute bacterial rhinosinusitis.
Benefits may outweigh risks for some serious bacterial infections, and it is appropriate for them to
remain available as a therapeutic option. 17
Levofloxacin
Levofloxacin Oral tablet; Adults: 500 mg PO once daily for 5 to 7 days recommended by clinical
guidelines as alternative therapy; FDA-approved dose is 500 mg PO every 24 hours for 10 to 14
days or 750 mg PO every 24 hours for 5 days. Due to the risk for serious and potentially
permanent side effects, only use in cases where alternative treatment options cannot be used.
Cefixime
Used in combination therapy with clindamycin as second line therapy for children with non–type 1
penicillin allergy or from geographic regions with high endemic rates of penicillin nonsusceptible
Streptococcus pneumoniae 6
Cefixime Oral suspension; Infants 6 months and older, Children, and Adolescents: 8 mg/kg/day PO
divided every 12 hours (Max: 400 mg/day) with clindamycin for 10 to 14 days; IDSA does not
recommend as monotherapy, but may be given as second-line therapy with clindamycin.
Cefixime Oral capsule; Adults: 400 mg PO once daily with clindamycin for 10 days; not recommend
as monotherapy. 9
Cefpodoxime
Used in combination with clindamycin as second line therapy for children with non–type 1
penicillin allergy or for patients from geographic regions with high endemic rates of penicillin
nonsusceptible Streptococcus pneumoniae 6
Cefpodoxime Proxetil Oral suspension; Infants 2 months and older and Children: 5 mg/kg PO every
12 hours for 10 days (Max: 200 mg/dose). Guidelines do not recommend as monotherapy; may be
used second-line with clindamycin for 10 to 14 days.
Cefpodoxime Proxetil Oral tablet; Adolescents and Adults: 200 mg PO every 12 hours for 10 days.
Guidelines do not recommend as monotherapy. 9
Clindamycin
Used to treat rhinosinusitis caused by both staphylococci and anaerobes
May be added to a broad-spectrum antibiotic agent for anaerobic coverage in chronic rhinosinusitis
Used in combination therapy with cefixime as second line therapy for children with non–type 1
penicillin allergy or for patients from geographic regions with high endemic rates of penicillin
nonsusceptible Streptococcus pneumoniae 6
Clindamycin Hydrochloride Oral capsule; Infants, Children, and Adolescents: 30 to 40 mg/kg/day

PO divided every 8 hours (Max: 1,800 mg/day) in combination with cefixime (4 mg/kg/dose PO
twice daily) or cefpodoxime (5 mg/kg/dose PO twice daily) for 10 to 14 days; recommended as
second-line therapy for children with a non-type I penicillin allergy or from regions with high rates
of penicillin-nonsusceptible S. pneumoniae.
Clindamycin Hydrochloride Oral capsule; Adults: 300 mg PO 3 times per day in combination
therapy with cefixime or cefpodoxime. 9
For severe infection requiring hospitalization
Ampicillin-sulbactam
Ampicillin Sodium, Sulbactam Sodium Solution for injection; Infants, Children, and Adolescents:
IDSA recommends 200 mg/kg/day ampicillin component (300 mg/kg/day ampicillin;
sulbactam) IV divided every 6 hours (Max: 8 g/day ampicillin [12 g/day ampicillin; sulbactam])
for 10 to 14 days as alternative for severe infection requiring hospitalization; higher doses (up to
400 mg/kg/day ampicillin component [600 mg/kg/day ampicillin; sulbactam]) may be used for
more severe or resistant infections.
Ampicillin Sodium, Sulbactam Sodium Solution for injection; Adults: IDSA recommends 1.5 g (1
g ampicillin and 0.5 g sulbactam) or 3 g (2 g ampicillin and 1 g sulbactam) IV every 6 hours for 5
to 7 days as alternative for severe infection requiring hospitalization.
Ceftriaxone
Ceftriaxone Sodium Solution for injection; Infants, Children, and Adolescents: 50 to 100
mg/kg/day IV divided every 12 to 24 hours for 10 to 14 days (Max: 4 g/day).
Ceftriaxone Sodium Solution for injection; Adults: 1 to 2 g IV every 12 to 24 hours for 5 to 7 days.
Cefotaxime
Cefotaxime Sodium Solution for injection; Infants, Children, and Adolescents: 100 to 200
mg/kg/day (Max: 12 g/day) IV divided every 6 hours for 10 to 14 days as alternative with severe
infection requiring hospitalization.
Cefotaxime Sodium Solution for injection; Adults: 2 g IV every 4 to 6 hours for 5 to 7 days as
alternative with severe infection requiring hospitalization.
Fluoroquinolones
Note: fluoroquinolones are reserved for patients who do not have other treatment options
Levofloxacin
Levofloxacin, Dextrose Solution for injection; Infants†, Children†, and Adolescents†: 10 to 20

mg/kg/day IV divided every 12 to 24 hours (Max: 500 mg/day) for 10 to 14 days recommended
by IDSA as alternative therapy. Due to the risk for serious and potentially permanent adverse
reactions, only use in cases where alternative treatment options cannot be used.
Levofloxacin, Dextrose Solution for injection; Adults: 500 mg IV once daily for 5 to 7 days
recommended by clinical guidelines as alternative therapy; FDA-approved dose is 500 mg IV
every 24 hours for 10 to 14 days or 750 mg IV every 24 hours for 5 days. Due to the risk for
serious and potentially permanent side effects, only use in cases where alternative treatment
options cannot be used.
Moxifloxacin
Moxifloxacin Hydrochloride, Sodium Chloride Solution for injection; Adults: 400 mg IV once
daily for 10 days. Clinical guidelines recommend treating for 5 to 7 days. Due to the risk for
serious and potentially permanent side effects, only use in cases where alternative treatment
options cannot be used.
Nondrug and supportive care

Adjunct therapies to aid mucociliary clearance 1 6 21
Nasal saline irrigation
Humidification therapy: inhaled steam (eg, from a hot shower) may provide symptomatic relief
Application of warm facial packs may provide symptomatic relief
Lifestyle changes (eg, smoking cessation, avoidance of allergens) may help prevent recurrence 1 6 21
Procedures
Functional endoscopic sinus surgery 24 25
General explanation
Endoscopic surgical removal of anatomic structures that block sinus drainage
Endoscopic surgical correction of nasal septum deviation
Indication
To prevent further episodes of rhinosinusitis in patients with a history of recurrent or chronic

rhinosinusitis
Patients with nasal polyps or other structural abnormalities may require surgery to relieve obstruction
and promote drainage
Complications
Bleeding
Synechiae formation
Orbital injury
Diplopia
Orbital hematoma
Blindness
Cerebrospinal fluid leak
Direct brain injury

Nasolacrimal duct injury/epiphora
Comorbidities
Asthma
Patients with recurrent rhinosinusitis and concomitant asthma who do not improve with medical
therapy may benefit from functional endoscopic sinus surgery, which also may improve asthma
symptoms
Complications and Prognosis

Complications
Periorbital cellulitis (preseptal cellulitis)
Orbital cellulitis (postseptal cellulitis)
Brain abscess
Bacterial meningitis (Related: Bacterial meningitis in adults)
Cavernous sinus thrombosis
Osteomyelitis of sinus bones (Related: Osteomyelitis in adults)
Superior orbital fissure syndrome
Prognosis
In acute rhinosinusitis, signs and symptoms most often resolve without antibiotic treatment
About 85% of patients have symptom resolution or reduction within 7 to 15 days without antibiotic
therapy 9
When treated with appropriate antibiotics, acute bacterial rhinosinusitis usually shows prompt
improvement
For chronic rhinosinusitis, up to 6 weeks of appropriate antibiotic medication may be necessary for
complete resolution of symptoms 21
Untreated or inadequately treated rhinosinusitis can result in complications, such as orbital cellulitis,
osteomyelitis, or brain abscess
REFERENCES
1: Wald ER et al: Clinical practice guideline for the diagnosis and management of acute bacterial
sinusitis in children aged 1 to 18 years. Pediatrics. 132(1):e262-80, 2013
| Cross Reference (https://www.ncbi.nlm.nih.gov/pubmed/23796742)
2: Expert Panel on Neurologic Imaging et al: ACR Appropriateness Criteria: sinonasal disease. J Am
Coll Radiol. 14(11S):S550-9, 2017
3: Rosenfeld RM et al: Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg.
152(2 Suppl):S1-S39, 2015
4: Young J et al: Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of
individual patient data. Lancet. 371(9616):908-14, 2008
5: Ahovuo-Saloranta A et al: Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst
Rev. 2:CD000243, 2014
6: Chow AW et al: IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and
adults. Clin Infect Dis. 54(8):e72-e112, 2012
7: Pappas DE et al: Sinusitis. In: Kliegman RM et al, eds: Nelson Textbook of Pediatrics. 21st ed.
Philadelphia, PA: Elsevier; 2020:2188-92.e1
| Cross Reference (https://www.clinicalkey.com/#!/content/book/3-s2.0-B9780323529501004089)
8: Rosenfeld RM et al: Clinical practice guideline (update): adult sinusitis executive summary.
Otolaryngol Head Neck Surg. 152(4):598-609, 2015
9: Rosenfeld RM: Clinical practice. Acute sinusitis in adults. N Engl J Med. 375(10):962-70, 2016
10: Aring AM et al: Current concepts in adult acute rhinosinusitis. Am Fam Physician. 94(2):97-105,
2016
11: DeMuri GP et al: Sinusitis. In: Bennett JE et al, eds: Mandell, Douglas, and Bennett's Principles and
Practice of Infectious Diseases. 9th ed. Philadelphia, PA: Elsevier; 2020:844-54.e3
| Cross Reference (https://www.clinicalkey.com/#!/content/book/3-s2.0-B978032348255400062X?

scrollTo=%23hl0001258)
12: London NR Jr et al: Sinuses and common rhinologic conditions. Med Clin North Am. 102(6):993-
1000, 2018
13: Blackwell DL et al: Summary health statistics for US adults: national health interview survey, 2012.
Vital Health Stat 10. 260:1-161, 2014
14: Wilson JF: In the clinic. Acute sinusitis. Ann Intern Med. 153(5):ITC31-15; quiz ITC316, 2010
15: Arora HS: Sinusitis in children. Pediatr Ann. 47(10):e396-e401, 2018
16: Expert Panel on Pediatric Imaging et al: ACR Appropriateness Criteria: sinusitis-child. J Am Coll
Radiol. 15(11S):S403-S412, 2018
17: FDA: Fluoroquinolone Antibacterial Drugs for Systemic Use: Drug Safety Communication -
Warnings Updated Due to Disabling Side Effects. FDA website. Updated March 8, 2018. Accessed
December 19, 2019. https://www.fda.gov/Drugs/DrugSafety/ucm511530.htm
| Cross Reference (https://www.fda.gov/Drugs/DrugSafety/ucm511530.htm)
18: Casale M et al: Saline nasal irrigations for chronic rhinosinusitis: from everyday practice to
evidence-based medicine. An update. Int J Immunopathol Pharmacol. 32:2058738418802676, 2018
19: Chong LY et al: Saline irrigation for chronic rhinosinusitis. Cochrane Database Syst Rev.
4:CD011995, 2016
20: Chong LY et al: Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis.
Cochrane Database Syst Rev. 4:CD011996, 2016
21: Peters AT et al: Diagnosis and management of rhinosinusitis: a practice parameter update. Ann
Allergy Asthma Immunol. 113(4):347-85, 2014
22: Head K et al: Systemic and topical antibiotics for chronic rhinosinusitis. Cochrane Database Syst
Rev. 4:CD011994, 2016
23: Rimmer J et al: Surgical versus medical interventions for chronic rhinosinusitis with nasal polyps.
Cochrane Database Syst Rev. 12:CD006991, 2014
24: Vlastarakos PV et al: Functional endoscopic sinus surgery improves sinus-related symptoms and
quality of life in children with chronic rhinosinusitis: a systematic analysis and meta-analysis of
published interventional studies. Clin Pediatr (Phila). 52(12):1091-7, 2013
25: Khalil HS et al: Functional endoscopic sinus surgery for chronic rhinosinusitis. Cochrane Database
Syst Rev. 3:CD004458, 2006
Copyright © 2020 Elsevier, Inc. All rights reserved.

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4/1/2020 Rhinosinusitis- ClinicalKey

Synopsis Urgent Action

CT and/or MRI is indicated if complications or alternative diagnosis is suspected

Inflammation almost always involves contiguous nasal mucosa 3

Duration less than 4 weeks 3 7

Further classified based on presumed cause 3

Acute viral rhinosinusitis

Acute bacterial rhinosinusitis

Acute bacterial rhinosinusitis can be subclassified further as: 3

Duration more than 12 weeks, with or without acute exacerbations 3 7

Subclassified based on cause

Associated with nasal polyposis

Without nasal polyposis

Allergic fungal rhinosinusitis

Duration between 4 and 12 weeks 3 7

Recurrent acute rhinosinusitis

Facial pain or pressure

Persistent cough (usually with a more severe nocturnal component)

Ear pain, pressure, or fullness

Poor response to decongestants

Less common symptoms include:

Fever (more common in children)

Diplopia or abnormal eye movement

Proptosis or marked periorbital edema

Examination of head and neck may show the following:

Increased posterior pharyngeal secretions

Swelling, erythema, or edema over cheekbone or periorbital region 3

Rhinoscopy with an otoscope or nasal speculum may show:

Mucous membrane edema

Purulent secretions from middle meatal region

Inferior turbinate hypertrophy

Causes and Risk Factors

Acute viral rhinosinusitis

Most cases (up to 90%) of acute rhinosinusitis are viral 9

Common pathogens include: 10

Acute bacterial rhinosinusitis

Only 0.5% to 2% of episodes are caused by bacterial infection 9

Most common community-acquired organisms are:

Streptococcus pneumoniae and other Streptococcus species 7 11

Nontypable Haemophilus influenzae 7 11

Moraxella (Branhamella) catarrhalis 7 11

Staphylococcus aureus (including MRSA)

Gram-negative enteric organisms

Complex pathophysiology involving dysregulation of inflammatory pathways; may be associated

Concurrent inflammation in lower airways (eg, asthma) may be present

Isolated organisms include:

Gram-negative enteric organisms

Risk factors and/or associations

Other risk factors/associations

Nasal obstruction due to: 10 11

Deviated nasal septum

Structural defects (eg, cleft palate) 11

Functional disorders of mucociliary clearance (eg, ciliary dyskinesia, cystic fibrosis) 11

Cigarette smoke exposure 7

Dental infections and procedures 10

Previous sinus surgery 10

Acute rhinosinusitis is defined as up to 4 weeks of purulent nasal drainage accompanied by nasal

Presume diagnosis of acute bacterial rhinosinusitis in the following:

If complications or an alternative diagnosis is suspected (eg, severe headache, proptosis, cranial

Chronic rhinosinusitis is defined as follows:

2 or more of the following symptoms persisting for 12 weeks or longer:

Mucopurulent nasal discharge

Facial pain, pressure, or fullness