Acute Sinusitis: The Right Clinical Information, Right Where It's Needed

Acute sinusitis
The right clinical information, right where it's needed
Last updated: Feb 02, 2018

Table of Contents
Summary 3
Basics 4
Definition 4
Epidemiology 4
Aetiology 4
Pathophysiology 4
Classification 5
Prevention 6
Primary prevention 6
Secondary prevention 6
Diagnosis 7
Case history 7
Step-by-step diagnostic approach 7
Risk factors 9
History & examination factors 10
Diagnostic tests 11
Differential diagnosis 13
Treatment 14
Step-by-step treatment approach 14
Treatment details overview 17
Treatment options 20
Follow up 35
Recommendations 35
Complications 35
Prognosis 36
Guidelines 38
Diagnostic guidelines 38
Treatment guidelines 38
Online resources 40
References 41
Images 45
Disclaimer 52
Summary
◊ Majority of cases in adults and children are of viral aetiology.
◊ Duration of symptoms more than 10 days often indicates bacterial cause.
◊ Imaging is not required for diagnosis unless complications are suspected.
◊ Condition is usually self-limiting; however, symptomatic therapy is recommended.
◊ Antibiotics are only recommended in select patient groups (e.g., immunocompromised or with severe
disease).
Acute sinusitis Basics
Definition
Acute sinusitis (also commonly known as acute rhinosinusitis) is a symptomatic inflammation of the mucosal
lining of the nasal cavity and paranasal sinuses, where clinical symptoms have been present for 4 weeks or
BASICS
less. It can be caused by either a viral or a bacterial infection.[1]
Epidemiology
More than 20 million cases of acute sinusitis of viral or bacterial aetiology are diagnosed in the US each year
across all age groups,[6] affecting an estimated 16% of the adult population[6] and resulting in almost 12
million surgery visits per year.[7] [8]
Approximately 0.5% to 13% of viral upper respiratory tract infections progress to acute bacterial sinusitis.[9]
[10]
It is estimated that 6% to 13% of children will have had one case of acute sinusitis by the age of 3 years.[9]
School-age children on average contract 6 to 8 upper respiratory tract infections per year, and of these, 5%
to 10% will be complicated by sinusitis.[9]
Prevalence is slightly higher in females compared with males,[11] and there is no clear ethnic
predominance.[12]
Aetiology
The most common cause of acute sinusitis is a viral infection.[13] Following an episode of viral sinusitis,
0.5% to 2% of cases of acute viral sinusitis will progress to acute bacterial sinusitis.[9] The 3 most common
bacteria are Streptococcus pneumoniae (20% to 43% of cases), Haemophilus influenzae (22% to 35%
of cases), and Moraxella catarrhalis (2% to 10% of cases). M catarrhalis is less common in the adult
population.[14] [15]
Although the bacterial pathogens have not changed over time, their antibiotic-resistance patterns have
altered.[16] The prevalence of penicillin-resistant S pneumoniae has increased from 24% to 35%, and the
prevalence of macrolide-resistant S pneumoniae has increased 9% to 39%, both over a 10-year period.[16]
Penicillin resistance is much higher for H influenzae and M catarrhalis , sometimes approaching 100%
in certain study populations.[16] Antibiotic resistance depends on the geographic location; therefore, an
understanding of local antibiotic resistance patterns is important.
Pathophysiology
Acute rhinosinusitis is most likely to be caused by the interaction of a predisposing condition (such as
environmental triggers), a viral infection, and a consequent inflammatory response within the sinonasal
mucosa.[17] With increased oedema and mucus production, the sinus ostium is obstructed, blocking
normal ventilation and drainage of the sinus. With decreased mucociliary clearance, stasis of secretions
occurs and a secondary bacterial infection can take place. From an inflammatory standpoint, high levels of
tumour necrosis factor-beta and interferon-gamma are associated with release of various pro-inflammatory
cytokines.
4 This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 02, 2018.
BMJ Best Practice topics are regularly updated and the most recent version
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subject to our disclaimer. © BMJ Publishing Group Ltd 2018. All rights reserved.
Acute sinusitis Basics
Classification
Types of sinusitis
BASICS
Duration of symptoms:[2]
• Acute: 4 weeks or less

• Subacute: 4 to 12 weeks
• Chronic: 12 weeks or more
• Recurrent acute: 4 or more episodes per year.
Severity:[3] [4]
• Characterised according to the presence of fever with purulent nasal discharge, moderate to severe
facial or dental pain, or periorbital swelling lasting for at least 3 to 4 days.
This PDF of the BMJ Best Practice topic is based on the web version that was last updated: Feb 02, 2018.
5
Acute sinusitis Prevention
Primary prevention
Good hand washing practices (i.e., using soap or alcohol-based rubs) are recommended, especially when in
contact with people who are unwell. Exposure to environmental irritants, such as cigarette smoke, pollutants,
and allergens, should be avoided where possible. Viral upper respiratory tract infections should be treated
promptly as they can often progress to acute bacterial sinusitis. Treatment will depend on the type of
infection.
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 unwell. Exposure to environmental irritants, such as cigarette smoke, pollutants,
and allergens, should be avoided where possible.
PREVENTION
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.
Acute sinusitis Diagnosis
Case history
Case history #1
A 19-year-old woman presents with a 12-day history of purulent nasal drainage and nasal congestion,
and reports a history of fever, myalgia, and facial pressure. She is otherwise healthy and works as a
teacher. After 5 days of illness, the patient's symptoms started to improve; however, they have worsened
in the last few days, despite the use of over-the-counter medications. Physical examination shows
oedematous mucosa of the inferior turbinate. There is also thick mucus in the nasal cavity. Nasal
endoscopy demonstrates purulent drainage and a small polyp in the ostiomeatal complex. The adenoids
are small and erythematous.
Case history #2
A 33-year-old man with a medical history of paediatric-onset asthma, atopic dermatitis, and allergic rhinitis
presents with a 7-day history of facial pressure, dental pain, nasal blockage, and hyposmia. The patient
developed these symptoms after recently mowing his lawn. The symptoms have not improved despite
use of an intranasal corticosteroid, an antihistamine, and intranasal saline washes. Physical examination
shows a septum deviated to the left side, and a large concha bullosa on the right side. There are no
polyps, but there are swollen turbinates and thin, clear mucus present.
Other presentations
Other symptoms may include sore throat or clear nasal discharge, which usually indicates a viral
cause.[5] Patients may also present with a cough secondary to post-nasal drainage or exacerbation of
asthma.
DIAGNOSIS
Step-by-step diagnostic approach
Diagnosis is primarily based on the history and physical examination. There is usually no need for further
investigations unless there are complications present. In most cases the diagnosis is made presumptively.
Complications, although rare, are more common in children.
History
Key risk factors include a history of viral upper respiratory tract infection or allergic rhinitis. Acute sinusitis
may cause acute exacerbation of asthma or migraine in patients with these conditions.
The most important factors in differentiating viral from bacterial sinusitis are the overall symptom duration
and the symptom trajectory. Symptoms of viral infection tend to peak early and gradually resolve.[2] [5]
Thus symptoms present for less than 10 days point to a viral infection, whereas symptoms present for
more than 10 days without an improvement suggest a bacterial infection.[2] Symptoms that worsen after
an initial improvement (so-called 'double sickening') also suggest secondary bacterial infection.[2]
Specific symptoms may help distinguish between viral and bacterial sinusitis. Purulent nasal discharge,
nasal obstruction, dental pain, or facial pain/pressure/headache are more common with acute bacterial
7
sinusitis. Fever, sore throat, myalgia, or a clear nasal discharge usually indicate viral sinusitis. However,
the colour of the mucus, as a sole indicator, does not distinguish bacterial from viral aetiology.
Cough is a common symptom in acute viral and bacterial sinusitis.[5] Cough may occur secondary to
post-nasal drainage or asthma exacerbation.
Physical examination
Examination should include a thorough head and neck examination, with particular attention paid to the
presence of facial tenderness to gentle palpation, post-nasal pharyngeal secretions or exudate, tender
maxillary dentition, and middle ear effusion.
The nasal cavity should be examined for the presence of mucosal erythema or purulent discharge.
Optimal examination is performed after topical decongestant spray,[18] with either an otoscope or a
nasal speculum and head light. Unilateral purulent secretions, mucosal oedema or erythema, and
facial tenderness are suggestive of bacterial sinusitis. Non-purulent secretions are suggestive of
viral or allergic inflammation. However, because nasal examination may be difficult or the signs non-
specific, nasal endoscopy is recommended in selected patients, including patients refractory to empirical
antibiotic therapy or where there is concern for antibiotic resistance, or in immunocompromised patients.
Endoscopy can provide excellent visualisation of the nasal cavity and sinus drainage paths. There are 2
types of endoscope: rigid and flexible. A rigid nasal endoscope has superior resolution and only requires
the use of one hand. This easily allows cultures of the nasal cavity or sinus to be obtained if necessary. A
flexible nasal endoscope is more comfortable for patients, but requires both hands to use. It is preferred
in children as it is better tolerated; however, either type may be used in adults and children. Choice
will depend on the practitioner's familiarity with the procedure, and most will be performed by an ENT
specialist.
Peri-orbital or malar oedema, orbital proptosis, visual disturbances, abnormal extra-ocular movements,
or abnormal neurological signs may indicate the presence of complications, and urgent otolaryngology
consultation is required.
[Fig-1]
DIAGNOSIS
[Fig-2]
[Fig-3]
[Fig-4]
[Fig-5]
Investigations
Laboratory testing is rarely required for diagnosis; however, culture can be an important aid in antibiotic
selection if the infection has been refractory to empirical antibiotic therapy, if there is a concern for
antibiotic resistance, or if the patient is immunocompromised.
Endoscopic sinus culture is much less painful than sinus puncture. The two culture methods correlate
well, especially when there is purulence within the middle meatus (i.e., within the sinus drainage
path).[19] [20] Cultures taken from the nasal cavity or the nasopharynx, such as with a swab and without
endoscopic visualisation, are discouraged because they do not correlate with the causative pathogen.
Imaging
Radiographic studies are not recommended for evaluation of routine acute sinusitis. They cannot
differentiate viral from bacterial sinusitis. Clinical diagnosis is essential in this regard.[21] However,
radiographic studies are recommended in patients with complications of sinusitis, such as facial cellulitis,
or suspected orbital or intracranial infection. Radiographic studies are also recommended in the
evaluation of patients with suspected recurrent acute or chronic sinusitis. In this setting the study may
be used to confirm the diagnosis of sinusitis or rule out an alternative diagnosis.[2] Recurrent acute and
chronic sinusitis are beyond the scope of this review.
CT scan
• Non-contrast CT scan is the imaging study of choice.[21]

• Findings consistent with, but not diagnostic of, acute rhinosinusitis include sinus opacification, air-
fluid level, or marked or severe mucosal thickening.[2]
MRI
• May be useful if extrasinus complications are suspected.[2]

X-rays
• X-rays of the sinus are not usually appropriate for acute or subacute uncomplicated sinusitis, and
should be supplanted by CT scan if imaging is required.[22]
• Lateral neck x-rays can be helpful in children to evaluate the patient for adenoid hypertrophy in
patients with nasal obstruction. An alternative is a flexible nasal endoscopy, which also can confirm
adenoiditis.
• Plain x-rays of the sinus cavity in various views (anterior-posterior, occipito-mental, lateral) have
76% sensitivity and 79% specificity compared with sinus puncture.[2]
[Fig-6]
Risk factors
DIAGNOSIS
Strong
viral upper respiratory tract infection
• Between 0.5% and 13% of viral upper respiratory tract infections progress to acute bacterial
sinusitis.[9] [10]
allergic rhinitis
• Leads to mucosal inflammation, which can cause blockage of the sinus ostium.[13] Treatment of
allergic rhinitis may reduce this risk.
Weak
GORD
• Gastroesophageal reflux into the nasopharynx can cause symptoms that may be mistaken for
sinusitis. In the paediatric population, it is associated with chronic sinusitis but does not contribute to
acute sinusitis.
9
History & examination factors

Key diagnostic factors
symptoms <10 days (acute viral sinusitis) (common)
• Symptoms that are present for less than 10 days suggest acute viral sinusitis. The symptoms usually
peak early and gradually resolve.[2] [23] [24]
symptoms >10 days but <4 weeks (acute bacterial sinusitis) (common)
• Symptoms present for more than 10 days without improvement may indicate a bacterial infection,
although these patients are less likely to benefit from antibiotic therapy compared with those with
severe symptoms at the onset or those with symptoms that worsen after initial improvement.[2] [4]
symptoms that worsen after an initial improvement (acute bacterial sinusitis)

(common)
• Symptoms that worsen after an initial improvement (so-called 'double sickening') suggest secondary
bacterial infection. The typical scenario is a patient who experiences symptoms of viral sinusitis and
improves after 5 days, only to worsen 2 to 3 days later.[1] [2] [23] [24] [4]
purulent nasal discharge (common)

• Refers to cloudy or discoloured (brown, yellow, green) nasal mucus. May be reported by patient, or
observed on physical examination (e.g., in the nasal cavity, middle meatus, or posterior pharynx). Non-
specific symptom that may be present in viral or bacterial sinusitis.
nasal obstruction (common)

• Refers to congestion, stuffiness, or blockage. Swollen septal or turbinate mucosa may be seen on
examination. Non-specific symptom that may be associated with viral or bacterial sinusitis as well as
allergic rhinitis.
facial pain/pressure (common)

DIAGNOSIS
• Reported by the patient as headache or discomfort in the anterior face or periorbital region.[2] Non-
specific symptom that may be associated with viral or bacterial sinusitis.[2]
severe symptoms at onset (acute bacterial sinusitis) (uncommon)

• Symptoms that are severe at the onset of illness suggest bacterial infection.[1] [23] [4]
dental pain (uncommon)

• May be reported by patient or observed on physical examination with percussion of the maxillary teeth.
Suggests acute maxillary sinusitis.
Other diagnostic factors

cough (common)
• May present secondary to post-nasal drainage or exacerbation of asthma; particularly common in
children.
myalgia (common)
• Usually associated with acute viral sinusitis.
sore throat (common)

• Usually associated with acute viral sinusitis.
hyposmia (common)
• May be present in both acute viral and bacterial sinusitis.
oedematous turbinate (common)

• Associated with any inflammation of the nasal cavity lining, whether allergic, viral, or bacterial in
aetiology. Decongestion of the turbinate is essential prior to inspection of the middle meatus for
purulence.[18]
fever (uncommon)
• May occur in acute viral sinusitis but is more common in children than adults. Bacterial sinusitis is
less common than viral sinusitis, but abrupt onset of fever and worsening symptoms after an initial
improvement in acute rhinosinusitis suggests bacterial sinusitis.
Diagnostic tests
1st test to order
Test Result
clinical diagnosis diagnosis is based on
history and physical
• Laboratory tests and imaging studies are not indicated for evaluation
examination
of routine, uncomplicated acute sinusitis. Imaging may be warranted
in the case of recurrent episodes of sinusitis, suspected anatomical
abnormalities, or if an alternative diagnosis is suspected such as
migraine headache or malignancy.
DIAGNOSIS
Other tests to consider
Test Result
nasal endoscopy mucosal erythema,
purulent discharge
• Recommended in selected patients (e.g., patient refractory to
empirical antibiotic therapy, concern for antibiotic resistance, patient
immunocompromised) as it can provide excellent visualisation of the
nasal cavity and sinuses.
• There are 2 types of endoscope: rigid and flexible.
• Rigid: has superior resolution and only requires the use of one hand.
This easily allows cultures of the nasal cavity or sinus to be obtained
if necessary.
• Flexible: more comfortable for patients, but requires both hands to
use. It is preferred in children as it is better tolerated.
• Either type may be used in adults and children. Choice will depend
on the practitioner's familiarity with the procedure, and most will be
performed by an ENT specialist.
• [Fig-5]
11
Test Result
sinus culture positive for organism
• Not required for diagnosis but can be helpful for planning the
appropriate management plan for the patient, especially if the patient
is refractory to empirical antibiotic therapy, if there is a concern for
antibiotic resistance, or if the patient is immunocompromised.
• Endoscopic culture taken from the sinus drainage path is well
tolerated, and has a high correlation with the pathogenic bacteria,
especially when there is purulence in the middle meatus; it is
therefore the procedure of choice when cultures are required.[20]
• Cultures taken directly from the sinus (e.g., sinus puncture) are
accurate but can be very painful. Endoscopic cultures are preferred.
• Cultures taken from the nasal cavity or the nasopharynx, such as with
a swab, correlate poorly with the causative pathogen.
CT sinuses (non-contrast) identifies extent of
sinus disease, abnormal
• Ordered if complications are suspected, or if further investigation
anatomical structures
is required (e.g., with recurrent episodes, suspected anatomical
abnormalities) to rule out alternative diagnoses.
• Non-contrast CT scan is the imaging study of choice.[21] Sinus
opacification, air-fluid level, or marked or severe mucosal thickening
is consistent with, but not diagnostic of, acute rhinosinusitis. [2]A
completely normal scan excludes the diagnosis of sinusitis.
• CT cannot differentiate acute viral from acute bacterial sinusitis, so
clinical diagnosis is essential.
• [Fig-7]
• [Fig-8]
x-ray sinuses may show air-fluid level of

• Not usually appropriate for acute or subacute uncomplicated sinusitis, the involved sinuses
and should be supplanted by CT scan if imaging is required.[22]
• Plain x-rays of the sinus cavity in various views (anterior-posterior,
occipito-mental, lateral) have 76% sensitivity and 79% specificity
compared with sinus puncture.[2]
DIAGNOSIS
• Cannot differentiate acute viral from acute bacterial sinusitis, so

clinical diagnosis is essential.
MRI may show air-fluid level
or mucosal thickening of
• May be useful if extrasinus complications are suspected.[2]
the involved sinuses, or
extension of disease into
adjacent structures such
as the orbit or brain
lateral neck x-ray may show adenoid

hypertrophy in children
• Lateral neck x-rays can be helpful in children to evaluate the patient
for adenoid hypertrophy in patients with nasal obstruction. An
alternative is flexible nasal endoscopy, which can also confirm
adenoiditis.
Differential diagnosis
Condition Differentiating signs / Differentiating tests

symptoms
Allergic rhinitis • Ocular and/or nasal pruritus. • Allergen skin-prick testing:
• Sneezing. wheal and flare reaction
• Rhinorrhoea. after specific allergen is
• Headache, purulent introduced into the skin is
discharge, and facial pain/ 3 mm larger than negative
pressure are less common. (saline) control.
• In vitro-specific IgE
determination: specific
allergen response.[21]
Non-allergic rhinitis • Heterogeneous group • Diagnosis is clinical: there

of nasal diseases that are no differentiating tests.
has nasal obstruction or
rhinorrhoea as common
factors.
• History of pregnancy,
barometric changes, food-
associated symptoms, or
hypothyroidism.
Migraine • Patient reports a history of • Diagnosis is clinical,[25]

'recurrent sinus infection' there are no differentiating
in which moderate-severe tests. Radiological tests may
headache is the most exclude features of acute
prominent symptom. bacterial sinusitis.
• Sensitivity to light or noise.
• Aura.
• Nausea.
• Symptoms decrease if
sitting/lying in a quiet, dark
DIAGNOSIS
room.
• Absence of purulent nasal
discharge.
Adenoiditis • Difficult to differentiate in • Nasal flexible endoscopy

paediatric population as can be used to determine
both conditions have similar the source of infection, either
symptoms. from the adenoids or from
the sinuses.
13
Acute sinusitis Treatment
Step-by-step treatment approach

The goals of treatment are to relieve symptoms, eradicate infection, and prevent complications. Management
varies depending on whether the aetiology is viral or bacterial, and should involve shared decision-making
with the patient.[2] 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 steam inhalation may be useful, as well as use of over-the-counter
medications, depending on the specific symptoms. Treatments should be tried for 5 to 10 days before re-
assessing the patient. Antibiotics are not recommended in patients with suspected acute viral sinusitis.[2]
[3]
Analgesics/antipyretics
• Recommended for pain and/or fever.

• Examples include paracetamol, ibuprofen, or paracetamol/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 apnoea or severe lung disease as it may
increase the risk of breathing problems.[26] It 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.[27] [28]
Decongestants
• May restore sinus ostial patency and provide symptomatic relief of nasal congestion.[2] However,
evidence is lacking.[29]
• 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.
Intranasal corticosteroids
• Recommended in patients with congestion; considered beneficial and have a low incidence of
systemic adverse effects.[2] [30] [31] [32]
• May decrease allergic response in patients with allergic rhinitis, and therefore decrease swelling
associated with sinusitis.[2]
• At least 1 month of therapy is usually recommended; however, this will depend on disease course.
Topical anticholinergics (e.g., ipratropium)
TREATMENT
• Recommended in adults with rhinorrhoea.[33] [34]

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 (e.g., using a neti pot) 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 non-operated
sinuses.[35]
• The following instructions for a home-prepared saline irrigation may be helpful for patients:
[University of Michigan Health System: saline nasal sprays and irrigation]
• • Mix 1 tsp kosher salt (or other pure salt with coarse grains), 1 tsp sodium bicarbonate, and 1
litre of warm tap water
• Use 250-500 mL of solution in each nasal cavity 1-2 times daily, or as often as needed
• Lower the head over a sink and turn so that the left nostril is lower than the right
• Pour solution from the container into the right nostril
• Water will drain from the left nostril into the sink
• Gently blow the nose
• Repeat the same process for the other nostril.
Mucolytics
• Guaifenesin may be used to loosen sputum and bronchial secretions associated with upper
respiratory tract infections; however, there is currently insufficient evidence to support its use.[2] [3]
Acute bacterial sinusitis

Consensus on a universal treatment protocol for acute bacterial sinusitis is lacking. However, symptom-
based therapy, with or without antibiotic therapy, is generally considered an acceptable approach.[2] [3]
[4] [36] [32] [37]
A consensus statement from the Infectious Diseases Society of America (IDSA) emphasises that patients
with severe symptoms or worsening symptoms are more likely to have bacterial infection compared with
patients with mild symptoms, regardless of duration.[4] In this context, current guidelines recommend
more broad-spectrum first-line therapy for acute bacterial rhinosinusitis (ABRS).[2] [3] The IDSA
recommendations are not necessarily accepted by all physicians, and practices may vary.
Antibiotic therapy
• Guidelines generally have not recommended antibiotics for immunocompetent patients with non-
severe illness. Such cases are either viral sinusitis or mild bacterial sinusitis, both of which resolve
without treatment.[2] [3] [38] To this end, a randomised controlled trial compared a 10-day course
of amoxicillin with placebo for adults presenting to community practices with clinically diagnosed,
uncomplicated moderate to severe acute sinusitis. It found no difference in terms of improvement in
disease-specific quality of life after 3 to 4 days of treatment.[39]
• Guidelines generally recommend antibiotic therapy for immunocompromised patients or those with
severe illness. Indicators of severe illness include:[40] [2] [3] [4] [41]
TREATMENT
• Fever
• Moderate to severe facial or dental pain
• Unilateral sinus tenderness
15
• Periorbital oedema
• Worsening of symptoms after 3 to 5 days
• Lack of improvement after 7 to 10 days of observation.
• A risk-benefit analysis for use of antibiotics must consider the high rate of spontaneous resolution
without treatment, shortened duration of symptoms with treatment, as well as cost, adverse effects
of antibiotics, need for follow-up, and increased bacterial resistance.[8]
• Although guidelines may vary in their recommendations for empirical antibiotics,[4] studies have not
demonstrated a difference in clinical outcomes between various antibiotic regimens.[42]
• Amoxicillin with or without clavulanic acid has generally been recommended as a first-line agent
for non-severe disease in immunocompetent people, owing to its safety, efficacy, and low cost.[2]
A pharmacokinetically-enhanced extended-release formulation of amoxicillin/clavulanic acid can
be used for the treatment of acute bacterial sinusitis caused by penicillin-resistant Streptococcus
pneumoniae .[43] High-dose amoxicillin/clavulanic acid should be considered first-line therapy for
patients who have severe disease or are immunocompromised.[4]
• Guidance from the UK’s National Institute for Health and Care Excellence (NICE) recommends
phenoxymethylpenicillin as a first-line option in patients who have experienced symptoms for 10
days or more, but who are not systemically very unwell. If patients are systemically very unwell, and
have had sinusitis symptoms for 10 days or more, then the first-line recommendation from NICE is
amoxicillin/clavulanic acid.[44]
• Second- or third-generation cephalosporins can be used in combination with clindamycin as an
alternative to amoxicillin for penicillin-allergic patients. 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.
• Doxycycline is a suitable alternative in adults with allergies to beta-lactam antibiotics; however, its
use is not recommended in children.
• Quinolones, when used systemically, can cause disabling and potentially permanent adverse
effects in both children and adults. These adverse effects can involve the tendons, muscles, joints,
nerves, and central nervous system. Quinolones should therefore only be used in patients with
acute bacterial sinusitis who do not have other treatment options.[45] Quinolones may be tried
in adults if treatment with a penicillin or cephalosporin is not possible. They should be used with
caution in children.[46]
• Trimethoprim/sulfamethoxazole or a macrolide (e.g., azithromycin) have been used in patients with
an allergy to penicillins, but there are now relatively high rates of resistance to these drugs that limit
their usefulness.
• The recommended treatment course is unclear.[41] However, a 5-7 day course for adults and
10-14 day course for children is reasonable for most antibiotics for non-severe illness.[2] [3] NICE
recommends a 5 day course for adults and for children.[44] A 10-14 day course is reasonable for
immunocompromised patients or those with severe disease.[2] [3]
• If there is no symptom improvement after 3 to 5 days of treatment, an alternative antibiotic should
be considered.[3]
Antibiotic resistance
TREATMENT
• The prevalence of penicillin-resistant S pneumoniae , both intermediate- and high-level resistance,

has increased from 24% to 35% over a 10-year period.[16] Even so, high-dose amoxicillin remains
effective against intermediate-resistant pneumococci of variable susceptibilities.[47]
• The prevalence of macrolide-resistant S pneumoniae has increased 9% to 39% over a 10-year
period.[16]
• H influenzae and M catarrhalis develop penicillin resistance as a result of beta lactamase
production, with prevalence sometimes nearing 100%.[16]
• Antibiotic resistance depends on the geographic location. Therefore, an understanding of local
antibiotic protocols is important before prescribing a specific antibiotic. If the patient does not
respond to treatment after 3 to 5 days, an alternative antibiotic (such as high-dose amoxicillin/
clavulanic acid, a quinolone, or a cephalosporin), or an alternative, non-infectious aetiology, should
be considered.[3]
Symptomatic therapy
• Measures are the same as those used for acute viral sinusitis.
• Adequate rest and hydration, warm facial packs, and steam inhalation may be useful, as well as
use of over-the-counter medications including analgesics/antipyretics, decongestants, intranasal
corticosteroids,[32] intranasal saline sprays,[35] and mucolytics. There may be a modest clinical
benefit from use of intranasal corticosteroids.[2] [32] No studies conclusively support the use of the
other symptomatic therapies.[29]
Specialist referral
Referral to an ENT specialist may be indicated when:[2] [3]
• Patient is immunocompromised
• A complication of sinusitis is suspected (facial cellulitis, orbital cellulitis or abscess, intracranial
infection)
• Cranial nerve deficits are present, suggesting possible invasive fungal or orbital sinusitis
• Condition is refractory to usual antibiotic treatment
• Condition is recurrent (i.e., 4 or more episodes per year) or significantly affects quality of life
• There is a suspected allergic or immunological basis for the condition, or there are comorbidities
(e.g., asthma, nasal polyps) present that complicate management, or sinusitis is associated with
unusual opportunistic infections.
The specialist may be able to enhance care through confirmation of the diagnosis or provision of an
alternative diagnosis; by obtaining a sinus culture; by adjusting antibiotic therapy to cover less common
pathogens, such as anaerobes, Pseudomonas aeruginosa , or Staphylococcus aureus ; by obtaining
and interpreting imaging studies; or through consideration of surgery.[3]
Treatment details overview

Consult your local pharmaceutical database for comprehensive drug information including contraindications,
drug interactions, and alternative dosing. ( see Disclaimer )
Acute ( summary )
Patient group Tx line Treatment
TREATMENT
suspected acute viral sinusitis 1st supportive therapy
adjunct analgesic/antipyretic
17
Acute ( summary )
adjunct decongestant
adjunct intranasal corticosteroid
adjunct ipratropium
adjunct intranasal saline
adjunct mucolytic
immunocompromised or 1st antibiotic therapy

with severe illness
immunocompromised or plus ENT specialist referral

with severe illness
immunocompromised or plus supportive therapy

with severe illness
immunocompromised or adjunct analgesic/antipyretic

with severe illness
immunocompromised or adjunct decongestant

with severe illness
immunocompromised or adjunct intranasal corticosteroid

with severe illness
immunocompromised or adjunct intranasal saline

with severe illness
immunocompromised or adjunct mucolytic

with severe illness
immunocompetent non- 1st watchful waiting for up to 10 days, or

severe immediate commencement of antibiotics,
and supportive therapy
immunocompetent non- adjunct antibiotic therapy

severe
immunocompetent non- adjunct analgesic/antipyretic

severe
immunocompetent non- adjunct decongestant

severe
immunocompetent non- adjunct intranasal corticosteroid

severe
immunocompetent non- adjunct intranasal saline

severe
immunocompetent non- adjunct mucolytic

TREATMENT
severe
immunocompetent non- adjunct ENT specialist referral

severe
Ongoing ( summary )
recurrent episodes 1st ENT specialist referral
TREATMENT
19
Treatment options
Acute
suspected acute viral sinusitis 1st supportive therapy

» Viral sinusitis is suspected when symptoms are
stable and present for less than 10 days.
» Generally a self-limiting disease, and treatment

is primarily symptomatic.
» Adequate rest and hydration, warm facial

packs, and steam inhalation may be useful.
» Treatments should be tried for 5 to 10 days

before re-assessing the patient.
adjunct analgesic/antipyretic
» Recommended for pain and/or fever. 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 apnoea or severe lung disease as it may
increase the risk of breathing problems.[26] It 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.[27] [28]
Primary options
» paracetamol: children: 10-15 mg/kg orally

every 4-6 hours when required, maximum 75
mg/kg/day; adults: 500-1000 mg orally every
4-6 hours when required, maximum 4000 mg/
day
OR
Primary options
» ibuprofen: children: 5-10 mg/kg orally every

TREATMENT

kg/day; adults: 300-400 mg orally every 4-6
hours when required, maximum 2400 mg/day
OR
Acute
Secondary options
» paracetamol/codeine: children ≥12 years of

age: consult specialist for guidance on dose;
adults: 30-60 mg orally every 4-6 hours when
required
Dose refers to codeine component. Maximum
dose is based on paracetamol component of
4000 mg/day (adults)
adjunct decongestant
» May provide symptomatic relief of nasal
congestion.[2]
» 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.
Primary options
» oxymetazoline nasal: children 2-5 years

of age: (0.025%) 2-3 sprays/drops into each
nostril twice daily when required; children >5
years of age and adults: (0.05%) 1-2 sprays/
drops into each nostril twice daily when
required
OR
Secondary options
» pseudoephedrine: adults: 30-60 mg orally

every 4-6 hours when required, maximum
240 mg/day
adjunct intranasal corticosteroid
» Recommended in patients with congestion.
Considered beneficial and has a low incidence of
systemic adverse effects.[2] [30] [31] [32]
» At least 1 month of therapy is usually

recommended; however, this will depend on the
disease course.
Primary options
TREATMENT
» mometasone nasal: children 2-11 years of

age: 50 micrograms (1 spray) in each nostril
once daily; children ≥12 years of age and
adults: 100 micrograms (2 sprays) in each
nostril once daily
21
Acute
adjunct ipratropium
» Topical anticholinergics such as ipratropium
can be used in patients with rhinorrhoea.
Primary options
» ipratropium nasal: children ≥6 years of

age: (0.03%) 42 micrograms (2 sprays) in
each nostril two or three times daily; adults:
(0.06%) 84 micrograms (2 sprays) in each
nostril three times daily
adjunct intranasal saline
» Saline sprays may be useful for treating
congestion by reducing inflammation and
thinning mucus, and have the added advantage
of decreasing medication use.
» Saline nasal irrigations (e.g., using a neti pot)

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 non-operated sinuses.[35]
» A home-prepared saline irrigation may be

helpful for patients. [University of Michigan
Health System: saline nasal sprays and
irrigation]
Primary options
» saline nasal: children and adults: 1-2

sprays/drops into each nostril every 2-3 hours
or when required
adjunct mucolytic
» Guaifenesin may be used to loosen sputum
and bronchial secretions associated with upper
respiratory tract infections; however, there is
currently insufficient evidence to support its
use.[2] [3]
Primary options
» guaifenesin: children 6 months to 2 years

of age: 25-50 mg orally every 4 hours when
required, maximum 300 mg/day; children
TREATMENT
2-5 years of age: 50-100 mg orally every

4 hours when required, maximum 600 mg/
day; children 6-11 years of age: 100-200 mg
orally every 4 hours when required, maximum
1200 mg/day; children >11 years of age and
Acute
adults: 200-400 mg orally every 4 hours when
required, maximum 2400 mg/day
immunocompromised or 1st antibiotic therapy

with severe illness
» Guidelines generally recommend antibiotic
therapy for immunocompromised patients or
those with severe illness.[2] [3] [41]
» Although guidelines may vary in their

recommendations for empirical antibiotics,[4]
studies have not demonstrated a difference in
clinical outcomes between various antibiotic
regimens.[42]
» High-dose amoxicillin/clavulanate is now

recommended by the Infectious Diseases
Society of America (IDSA) as a first-line agent
for people who have severe disease or are
immunocompromised, owing to the increased
endemic rates of beta-lactamase-producing
S pneumoniae .[4] High-dose amoxicillin/
clavulanate is effective against pneumococci of
variable susceptibilities.[47]
» For penicillin-allergic patients, a reasonable

alternative is therapy with clindamycin plus a
third-generation cephalosporin (e.g., cefixime,
cefpodoxime). 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.
» Doxycycline is a suitable alternative in adults

with allergies to beta-lactam antibiotics; however,
its use is not recommended in children.
» Quinolones (e.g., moxifloxacin, levofloxacin),

when used systemically, can cause disabling
and potentially permanent adverse effects
in both children and adults. These adverse
effects can involve the tendons, muscles, joints,
nerves, and central nervous system. Quinolones
should therefore only be used in patients with
acute bacterial sinusitis who do not have other
treatment options.[45] Quinolones may be
tried in adults if treatment with a penicillin or
cephalosporin is not possible. They should be
used with caution in children.[46]
TREATMENT
» The recommended treatment course

is unclear.[41] However, 10 to 14 days is
reasonable, particularly for immunocompromised
patients or those with severe disease.[2] [3]
23
Acute
» If there is no improvement in symptoms after
3 to 5 days of treatment, an alternative antibiotic
should be considered.[3] Another consideration
should be an ENT specialist consultation.
» Intravenous antibiotics may be required in

patients with severe infection that requires
hospitalisation.
Primary options
» amoxicillin/clavulanate: children: 90 mg/kg/

day orally given in 2 divided doses; adults:
2000 mg orally (extended-release) twice daily
Dose refers to amoxicillin component.
OR
Secondary options
» clindamycin: children: 30-40 mg/kg/day

orally given in 3 divided doses; adults:
150-450 mg orally three times daily
--AND--
» cefixime: children: 8 mg/kg/day orally given
in 1-2 divided doses; adults: 400 mg orally
once daily
-or-
» cefpodoxime: children: 10 mg/kg/day orally
given in 2 divided doses; adults: 200 mg
orally twice daily
OR
Secondary options
» doxycycline: adults: 100 mg orally twice

daily, or 200 mg orally once daily
OR
Secondary options
» moxifloxacin: children: consult specialist

for guidance on dose; adults: 400 mg orally/
intravenously once daily
OR
Secondary options
TREATMENT
» levofloxacin: children: consult specialist

OR
Secondary options
Acute
» ceftriaxone: children: 50 mg/kg/day
intravenously given in divided doses every 12
hours; adults: 1-2 g intravenously every 12-24
hours
OR
Secondary options
» cefotaxime: children: 100-200 mg/kg/day

intravenously given in divided doses every
6 hours; adults: 2 g intravenously every 4-6
hours
immunocompromised or plus ENT specialist referral
with severe illness
» The specialist may adjust antibiotic therapy to
cover less common causative microorganisms
(e.g., add metronidazole or clindamycin to
cover anaerobes), re-evaluate the patient
for underlying conditions or anatomical
abnormalities, or consider surgery.[3]
immunocompromised or plus supportive therapy

with severe illness
» Adequate rest and hydration, warm facial
packs, and steam inhalation may be useful, as
well as use of over-the-counter medications.
Selection of therapy will depend on the specific
symptoms.
immunocompromised or adjunct analgesic/antipyretic

with severe illness

Primary options
TREATMENT

day
25
Acute
OR
Primary options

OR
Secondary options

required
4000 mg/day (adults).
immunocompromised or adjunct decongestant
with severe illness
congestion.[2]


congestion.
Primary options

required
OR
Secondary options

240 mg/day
immunocompromised or adjunct intranasal corticosteroid
TREATMENT
with severe illness

» Considered beneficial and has a low incidence

of systemic adverse effects.[2] [30] [32]
Acute
disease course.
Primary options

nostril once daily
immunocompromised or adjunct intranasal saline
with severe illness


irrigation]
Primary options

or when required
immunocompromised or adjunct mucolytic
with severe illness
» Guaifenesin may be used to loosen phlegm
use.[2] [3]
Primary options

TREATMENT

27
Acute
immunocompetent non- 1st watchful waiting for up to 10 days, or
severe immediate commencement of antibiotics,
and supportive therapy
» Some guidelines recommend watchful
waiting for up to 10 days with symptomatic
therapy before instituting subsequent antibiotic
therapy,[2] as the majority of non-severe
cases will resolve without them.[38] 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.[2] [41] The 2012
Infectious Diseases Society of America (IDSA)
guideline advises initiation of antibiotics for all
adults and children with clinically diagnosed
acute bacterial sinusitis [4]
immunocompetent non- adjunct antibiotic therapy

severe
» Antibiotics are not usually recommended
immediately in patients who are
immunocompetent and who have non-severe
illness (i.e., absence of fever, mild facial or
dental pain), as the majority of cases will resolve
without them.[38]
» 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.[2] [41]
» The 2012 Infectious Diseases Society of

America (IDSA) guideline advises initiation
of antibiotics for all adults and children with
clinically diagnosed acute bacterial sinusitis [4]
» Despite IDSA's exclusion of amoxicillin as a

treatment option for these patients, evidence still
supports the use of this drug as a reasonable
first-line choice for immunocompetent patients
with less severe disease.[2] Amoxicillin/
clavulanate may be used as a second-line
option, although some guidelines recommend
TREATMENT
this as a first-line option.[2] [4]
» Guidance from the UK’s National Institute

for Health and Care Excellence (NICE)
recommends phenoxymethylpenicillin as a first-
line option in patients who have experienced
Acute
symptoms for 10 days or more, but who are
not systemically very unwell. If patients are
systemically very unwell, and have had sinusitis
symptoms for 10 days or more, then the first-
line recommendation from NICE is amoxicillin/
clavulanate.[44]
» 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.
» Doxycycline is a suitable alternative in adults

with allergies to beta-lactam antibiotics; however,
its use is not recommended in children.
» Quinolones (e.g., moxifloxacin, levofloxacin),

when used systemically, can cause disabling
and potentially permanent adverse effects
in both children and adults. These adverse
effects can involve the tendons, muscles, joints,
nerves, and central nervous system. Quinolones
should therefore only be used in patients with
acute bacterial sinusitis who do not have other
treatment options.[45] Quinolones may be
tried in adults if treatment with a penicillin or
cephalosporin is not possible. They should be
used with caution in children.[46]
» The recommended treatment course is

unclear.[41] However, a 5-7 day course for
adults and 10-14 day course for children is
reasonable.[2] [3] NICE recommends a 5 day
course for adults and for children.[44]
» If there is no improvement in symptoms after

3 to 5 days of treatment, an alternative antibiotic
should be considered.[3] Another consideration
should be an ENT specialist consultation.
Primary options
» amoxicillin: children: 45-90 mg/kg/day orally

given in 2 divided doses; adults: 500-1000
mg orally three times daily, or 875 mg orally
twice daily
TREATMENT
OR
Primary options
29
Acute
» amoxicillin/clavulanate: children: 45-90 mg/
kg/day orally given in 2 divided doses; adults:
500-875 mg orally twice daily, or 2000 mg
orally (extended-release) twice daily
Dose refers to amoxicillin component.
OR
Primary options
» phenoxymethylpenicillin: children 1-11

months of age: 62.5 mg orally four times
daily; children 1-5 years of age: 125 mg orally
four times daily; children 6-11 years of age:
250 mg orally four times daily; children 12-17
years of age and adults: 500 mg orally four
times daily
OR
Secondary options
» clindamycin: children: 30-40 mg/kg/day

orally given in 3 divided doses; adults:
150-450 mg orally three times daily
--AND--
» cefuroxime: children: 30 mg/kg/day orally
given in 2 divided doses; adults: 250-500 mg
orally twice daily
-or-
» cefpodoxime: children: 10 mg/kg/day orally
given in 2 divided doses; adults: 200 mg
orally twice daily
-or-
» cefprozil: children: 30 mg/kg/day orally
given in 2 divided doses; adults: 250-500 mg
orally twice daily
OR
Secondary options
» doxycycline: adults: 100 mg orally twice

daily, or 200 mg orally once daily
OR
Secondary options
» moxifloxacin: children: consult specialist

TREATMENT
OR
Secondary options
Acute
» levofloxacin: children: consult specialist for
guidance on dose; adults: 500 mg orally once
daily
immunocompetent non- adjunct analgesic/antipyretic
severe

Primary options

day
OR
Primary options

OR
Secondary options

required
4000 mg/day (adults).
TREATMENT
immunocompetent non- adjunct decongestant

severe
congestion.[2]

31
Acute

congestion.
Primary options

required
OR
Secondary options

240 mg/day
immunocompetent non- adjunct intranasal corticosteroid
severe
» Considered beneficial and has a low incidence

of systemic adverse effects.[2] [30] [32]

disease course.
Primary options

nostril once daily
immunocompetent non- adjunct intranasal saline
severe

TREATMENT

Acute
irrigation]
Primary options

or when required
immunocompetent non- adjunct mucolytic
severe
» Guaifenesin may be used to loosen phlegm
use.[2] [3]
Primary options

immunocompetent non- adjunct ENT specialist referral
severe
» Patients should be referred to an ENT
specialist when condition is refractory to usual
antibiotic treatment.[2] [3]

cover less common causative microorganisms
Ongoing
TREATMENT
recurrent episodes 1st ENT specialist referral

» Patients should be referred to an ENT
specialist when condition is recurrent (i.e., 4 or
33
Ongoing
more episodes per year) or significantly affects
quality of life.[2] [3]

cover less common causative micro-organisms
TREATMENT
Acute sinusitis Follow up
Recommendations
Monitoring
FOLLOW UP
No specific monitoring is required. However, patients with conditions that predispose them to developing
acute sinusitis, such as allergic rhinitis or asthma, may require further monitoring, including skin/blood
testing and pulmonary function tests.
Patient instructions
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. 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. Steam inhalation and warm facial packs may be
useful. Adequate sleep and hydration should be encouraged.
Complications
Complications Timeframe Likelihood

chronic sinusitis variable low
Defined as sinusitis symptoms persisting 12 weeks or longer.[2]
The microbial pathogens responsible for acute sinusitis and chronic sinusitis are different, so the empirical
antibiotics of choice should reflect the likely causative bacteria.
bacterial meningitis variable low
Although the true rate of bacterial meningitis from acute sinusitis is unknown, it is considered to be
uncommon. It occurs due to direct extension of the sinus infection.
A common organism associated with infection is Streptococcus milleri , which is often difficult to isolate
from routine culture.[48]
Appropriate intravenous antibiotics and surgical intervention are the mainstays of management.
subdural abscess variable low
Occurs due to direct extension of the sinus infection.
Commonly caused by S milleri .[48]
Appropriate intravenous antibiotics and surgical intervention are the mainstays of management.
peri-orbital or orbital cellulitis variable low
35
Complications Timeframe Likelihood

Peri-orbital (pre-septal) cellulitis occurs more commonly in children under 3 years of age, and does not
FOLLOW UP
affect vision.
Orbital (post-septal) cellulitis occurs more commonly in children over 3 years of age, and may cause vision
impairment.
Peri-orbital cellulitis may develop into orbital cellulitis, which is a more serious condition that warrants
hospital admission, and has a higher morbidity compared with peri-orbital cellulitis.
Mainstay of treatment is broad-spectrum antibiotics. Treatment is always empirical initially, with therapy
targeted according to cultures, once known.
sub-periosteal abscess or orbital abscess variable low
Although the incidence is unknown, these are common enough that physicians who manage patients with
acute sinusitis should be familiar with these complications.
Diagnosis is made based on physical examination that demonstrates exophthalmos and peri-orbital
erythema. CT scan confirms the diagnosis.
Appropriate empirical intravenous antibiotics and intravenous corticosteroids (in some cases) are the
mainstays of management. However, patients with an abscess >2 cm and age >9 years are more likely to
require surgical intervention.
cavernous sinus thrombosis variable low
Extremely rare, but should be considered as a possible complication.
Culture-directed intravenous antibiotic therapy, anticoagulation, and appropriate surgical intervention are
important for optimal outcome.
Prognosis
In general, acute sinusitis is a self-limiting disease and generally resolves within 1 month. However, the use
of antibiotics in appropriately selected patients may limit the length and severity of symptoms.
Recurrence
Patients with structural anatomical variants (e.g., concha bullosa, deviated septum, infra-orbital ethmoid
cell) are more prone to develop recurrent acute sinusitis and even persistent sinusitis. Recurrence is also
dependent on exposure to an exacerbating condition such as a viral upper respiratory tract infection.
Complications
Complications are more commonly seen in the paediatric population, and occur due to direct extension of
the infection into neighbouring structures. Orbital spread of infection with orbital cellulitis or orbital abscess
represent the most common complications. Intracranial spread of infection resulting in meningitis or abscess
is much less common.
FOLLOW UP
37
Acute sinusitis Guidelines
Diagnostic guidelines
Europe
BSACI guidelines for the management of rhinosinusitis and nasal polyposis

Published by: British Society for Allergy and Clinical Immunology Last published: 2008
European position paper on rhinosinusitis and nasal polyps 2007

Published by: European Academy of Allergology and Clinical Last published: 2007
Immunology
North America
Clinical practice guideline: adult sinusitis

Published by: American Academy of Otolaryngology-Head and Neck Last published: 2015
GUIDELINES
Surgery Foundation
Management of acute bacterial sinusitis in children aged 1 to 18 years

Published by: American Academy of Pediatrics Last published: 2013
Clinical practice guideline for acute bacterial rhinosinusitis in children and

adults
Published by: Infectious Diseases Society of America Last published: 2012
Canadian clinical practice guidelines for acute and chronic rhinosinusitis

Published by: Association of Medical Microbiology and Infectious Last published: 2011
Disease Canada; Canadian Society of Allergy and Clinical Immunology;
Canadian Society of Otolaryngology - Head and Neck Surgery; Canadian
Association of Emergency Physicians; Family Physicians Airways Group
of Canada
Treatment guidelines
Europe
Sinusitis (acute): antimicrobial prescribing

Published by: National Institute for Health and Care Excellence Last published: 2017
BSACI guidelines for the management of rhinosinusitis and nasal polyposis

Published by: British Society for Allergy and Clinical Immunology Last published: 2008
European position paper on rhinosinusitis and nasal polyps 2007

Published by: European Academy of Allergology and Clinical Last published: 2007
Immunology
Acute sinusitis Guidelines
North America
Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults:

Advice for High-Value Care From the American College of Physicians and the
Centers for Disease Control and Prevention
Published by: American College of Physicians and the Centers for Last published: 2016
Disease Control and Prevention
Clinical practice guideline: adult sinusitis

Published by: American Academy of Otolaryngology-Head and Neck Last published: 2015
Surgery Foundation
Management of acute bacterial sinusitis in children aged 1 to 18 years

Published by: American Academy of Pediatrics Last published: 2013
Clinical practice guideline for acute bacterial rhinosinusitis in children and
GUIDELINES
adults
Published by: Infectious Diseases Society of America Last published: 2012
Canadian clinical practice guidelines for acute and chronic rhinosinusitis

Published by: Association of Medical Microbiology and Infectious Last published: 2011
Disease Canada; Canadian Society of Allergy and Clinical Immunology;
Canadian Society of Otolaryngology - Head and Neck Surgery; Canadian
Association of Emergency Physicians; Family Physicians Airways Group
of Canada
39
Acute sinusitis Online resources
Online resources
1. University of Michigan Health System: saline nasal sprays and irrigation (external link)
ONLINE RESOURCES
Acute sinusitis References
Key articles
• Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg. 1997;117:S1-S7.
REFERENCES
Abstract
• Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult
sinusitis. Otolaryngol Head Neck Surg. 2015;152(suppl 2):S1-S39. Full text Abstract
• Slavin RG, Spector SL, Bernstein IL, et al. The diagnosis and management of sinusitis: a practice
parameter update. J Allergy Clin Immunol. 2005;116(suppl 6):S13-S47. Abstract
• Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial
rhinosinusitis in children and adults. Clin Infect Dis. 2012;54:e72-e112. Full text Abstract
• Gwaltney JM Jr, Scheld WM, Sande MA, et al. The microbial etiology and antimicrobial therapy of
adults with acute community-acquired sinusitis: a 15-year experience at the University of Virginia and
review of other selected studies. J Allergy Clin Immunol. 1992;90:457-461. Abstract
References
1. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg. 1997;117:S1-S7.
Abstract
2. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult
sinusitis. Otolaryngol Head Neck Surg. 2015;152(suppl 2):S1-S39. Full text Abstract
3. Slavin RG, Spector SL, Bernstein IL, et al. The diagnosis and management of sinusitis: a practice
parameter update. J Allergy Clin Immunol. 2005;116(suppl 6):S13-S47. Abstract
4. Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial
rhinosinusitis in children and adults. Clin Infect Dis. 2012;54:e72-e112. Full text Abstract
5. Gwaltney JM Jr, Hendley JO, Simon G, et al. Rhinovirus infections in an industrial population. II.
Characteristics of illness and antibody response. JAMA. 1967;202:494-500. Abstract
6. Anand VK. Epidemiology and economic impact of rhinosinusitis. Ann Otol Rhinol Laryngol Suppl.
2004;193:3-5. Abstract
7. Osguthorpe JD. Adult rhinosinusitis: diagnosis and management. Am Fam Physician. 2001;63:69-77.
Full text Abstract
8. Piccirillo JF. Clinical practice. Acute bacterial sinusitis. N Engl J Med. 2004;351:902-910. Abstract
9. Gwaltney JM Jr. Acute community-acquired sinusitis. Clin Infect Dis. 1996;23:1209-1225. Full text
Abstract
41
10. Berg O, Carenfelt C, Rystedt G, et al. Occurrence of asymptomatic sinusitis in common cold and other
acute ENT infections. Rhinology. 1986;24:223-225. Abstract
REFERENCES
11. Chen Y, Dales R, Lin M. The epidemiology of chronic rhinosinusitis in Canadians. Laryngoscope.
2003;113:1199-1205. Abstract
12. Taylor A. Sinusitis. Pediatr Rev. 2006;27:395-397. Abstract
13. Fireman P. Diagnosis of sinusitis in children: emphasis on the history and physical examination. J
Allergy Clin Immunol. 1992;90:433-436. Abstract
14. Gwaltney JM Jr, Scheld WM, Sande MA, et al. The microbial etiology and antimicrobial therapy of
adults with acute community-acquired sinusitis: a 15-year experience at the University of Virginia and
review of other selected studies. J Allergy Clin Immunol. 1992;90:457-461. Abstract
15. Low DE, Desrosiers M, McSherry J, et al. A practical guide for the diagnosis and treatment of acute
sinusitis. CMAJ 1997;156(suppl 6):S1-S14. Abstract
16. Jenkins SG, Farrell DJ, Patel M, et al. Trends in anti-bacterial resistance among Streptococcus
pneumoniae isolated in the USA, 2000-2003: PROTEKT US years 1-3. J Infect. 2005;51:355-363.
Abstract
17. Eloy P, Poirrier AL, De Dorlodot C, et al. Actual concepts in rhinosinusitis: a review of clinical
presentations, inflammatory pathways, cytokine profiles, remodeling, and management. Curr Allergy
Asthma Rep. 2011;11:146-162. Abstract
18. Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis: definitions, diagnosis,
epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003;129(suppl 3):S1-S32. Abstract
19. Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute
rhinosinusitis: a meta-analysis of individual patient data. Lancet. 2008;371:908-914. Abstract
20. Dubin MG, Ebert CS, Coffey CS, et al. Concordance of middle meatal swab and maxillary sinus
aspirate in acute and chronic sinusitis: a meta-analysis. Am J Rhinol. 2005;19:462-470. Abstract
21. Gendo K. Evidence-based diagnostic strategies for evaluating suspected allergic rhinitis. Ann Intern
Med. 2004;140:278-289. Abstract
22. Cornelius RS, Martin J, Wippold FJ, et al. ACR appropriateness criteria sinonasal disease. J Am Coll
Radiol. 2013;10:241-246. Abstract
23. Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: developing guidance for clinical trials.
Otolaryngol Head Neck Surg. 2006;135(suppl 5):S31-S80. Abstract
24. Thomas M, Yawn BP, Price D, et al. EPOS primary care guidelines: European position paper on the
primary care diagnosis and management of rhinosinusitis and nasal polyps: a summary. Prim Care
Respir J. 2008;17:79-89. Full text Abstract
25. Silberstein SD, Holland S, Freitag F, et al. Evidence-based guideline update: pharmacologic
treatment for episodic migraine prevention in adults. Report of the Quality Standards Subcommittee
of the American Academy of Neurology and the American Headache Society. Neurology.
2012;78:1337-1345. Full text Abstract
REFERENCES
26. US Food and Drug Administration. FDA drug safety communication: FDA restricts use of prescription
codeine pain and cough medicines and tramadol pain medicines in children; recommends against use
in breastfeeding women. April 2017. https://www.fda.gov/ (last accessed 21 April 2017). Full text
27. Medicines and Healthcare Products Regulatory Agency. Codeine: restricted use as analgesic in
children and adolescents after European safety review. Drug Safety Update. 2013;6:S1. Full text
28. European Medicines Agency. Restrictions on use of codeine for pain relief in children - CMDh
endorses PRAC recommendation. June 2013. http://www.ema.europa.eu (last accessed 24 January
2016). Full text
29. Shaikh N, Wald ER. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children.
Cochrane Database Syst Rev. 2014;(10):CD007909. Full text Abstract
30. Meltzer EO, Bachert C, Staudinger H. Treating acute rhinosinusitis: comparing efficacy and
safety of mometasone furoate nasal spray, amoxicillin, and placebo. J Allergy Clin Immunol.
2005;116:1289-1295. Full text Abstract
31. Hayward G, Heneghan C, Perera R, et al. Intranasal corticosteroids in management of acute sinusitis:
a systematic review and meta-analysis. Ann Fam Med. 2012;10:241-249. Full text Abstract
32. Zalmanovici Trestioreanu A, Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst
Rev. 2013;(12):CD005149. Full text Abstract
33. Hayden FG, Diamond L, Wood PB. Effectiveness and safety of intranasal ipratropium bromide in
common colds: a randomized, double-blind, placebo-controlled trial. Ann Intern Med. 1996;125:89-97.
Abstract
34. AlBalawi ZH, Othman SS, Alfaleh K. Intranasal ipratropium bromide for the common cold. Cochrane
Database Syst Rev. 2013;(6):CD008231. Full text Abstract
35. King D, Mitchell B, Williams CP, et al. Saline nasal irrigation for acute upper respiratory tract infections.
Cochrane Database Syst Rev. 2015;(4):CD006821. Full text Abstract
36. Lemiengre MB, van Driel ML, Merenstein D, et al. Antibiotics for clinically diagnosed acute
rhinosinusitis in adults. Cochrane Database Syst Rev. 2012;(10):CD006089. Full text Abstract
37. Smith MJ. Evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children: a
systematic review. Pediatrics. 2013;132:e284-e296. Full text Abstract
38. Guarch Ibáñez B, Buñuel Álvarez JC, López Bermejo A, et al. The role of antibiotics in acute sinusitis:
a systematic review and meta-analysis. [In Spanish.] An Pediatr (Barc). 2011;74:154-160. Abstract
39. Garbutt JM, Banister C, Spitznagel E, et al. Amoxicillin for acute rhinosinusitis: a randomized
controlled trial. JAMA. 2012;307:685-692. Abstract
43
40. Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians
and for the Centers for Disease Control and Prevention. Appropriate Antibiotic Use for Acute
Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College
REFERENCES
of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016 Mar
15;164(6):425-34. Full text Abstract
41. Falagas ME, Giannopoulou KP, Vardakas KZ, et al. Comparison of antibiotics with placebo for
treatment of acute sinusitis: a meta-analysis of randomized controlled trials. Lancet Infect Dis.
2008;8:543-552. Abstract
42. Rosenfeld RM. CLINICAL PRACTICE. Acute Sinusitis in Adults. N Engl J Med. 2016 Sep
8;375(10):962-70. Abstract
43. Anon JB, Ferguson B, Twynholm M, et al. Pharmacokinetically enhanced amoxicillin/clavulanate

(2000/125 mg) in acute bacterial rhinosinusitis caused by Streptococcus pneumoniae, including
penicillin-resistant strains. Ear Nose Throat J. 2006;85:500,502,504. Abstract
44. The National Institute for Health and Care Excellence. Sinusitis (acute): antimicrobial prescribing.
October 2017 [internet publication] Full text
45. US Food & Drug Administration. FDA Drug Safety Communication: FDA updates warnings for oral and
injectable fluoroquinolone antibiotics due to disabling side effects. July 2016 [internet publication] Full
text
46. Adefurin A, Sammons H, Jacqz-Aigrain E, et al. Ciprofloxacin safety in paediatrics: a systematic

review. Arch Dis Child. 2011;96:874-880. Full text Abstract
47. Harrison CJ, Woods C, Stout G, et al. Susceptibilities of Haemophilus influenzae, Streptococcus
pneumoniae, including serotype 19A, and Moraxella catarrhalis paediatric isolates from 2005 to 2007
to commonly used antibiotics. J Antimicrob Chemother. 2009;63:511-519. Full text Abstract
48. Han JK, Kerschner JE. Streptococcus milleri: an organism for head and neck infections and abscess.
Arch Otolaryngol Head Neck Surg. 2001;127:650-654. Full text Abstract
Acute sinusitis Images
Images
IMAGES
Figure 1: Right inferior turbinate and septum are visible prior to decongestant spray
From the collection of Melissa Pynnonen, MD
45
Figure 2: Right middle turbinate and middle meatus are visible after decongestant spray
IMAGES
Figure 3: Left middle meatus with severe oedema and purulent secretions
IMAGES
Figure 4: Left middle meatus with healthy mucosa and non-purulent secretions
47
IMAGES Acute sinusitis Images
Figure 5: Nasal endoscopy of the left nasal cavity showing a small polyp and pus in the middle meatus
From the collection of Joseph K. Han
IMAGES
Figure 6: CT scan with right ethmoid sinus opacification and adjacent orbital abscess
49
IMAGES Acute sinusitis Images
Figure 7: Non-contrast CT scan of the sinuses showing non-specific maxillary sinus air-fluid levels
IMAGES
Figure 8: Normal non-contrast CT scan of the sinuses
51
Acute sinusitis Disclaimer
Disclaimer
This content is meant for medical professionals situated outside of the United States and Canada. The BMJ
Publishing Group Ltd ("BMJ Group") tries to ensure that the information provided is accurate and up-to-
date, but we do not warrant that it is nor do our licensors who supply certain content linked to or otherwise
accessible from our content. The BMJ Group does not advocate or endorse the use of any drug or therapy
contained within nor does it diagnose patients. Medical professionals should use their own professional
judgement in using this information and caring for their patients and the information herein should not be
considered a substitute for that.
This information is not intended to cover all possible diagnosis methods, treatments, follow up, drugs and
any contraindications or side effects. In addition such standards and practices in medicine change as new
data become available, and you should consult a variety of sources. We strongly recommend that users
independently verify specified diagnosis, treatments and follow up and ensure it is appropriate for your
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DISCLAIMER
Contributors:
// Authors:
Melissa A. Pynnonen, MD, MSc

Associate Professor
Director, Health Services Research, Department of Otolaryngology-Head and Neck Surgery, University of
Michigan, Ann Arbor, MI
DISCLOSURES: MAP declares that she has no competing interests.
Gordon H. Sun, MD, MSc

Chief
Division of Otolaryngology and Ophthalmology, Rancho Los Amigos National Rehabilitation Center,
Downey, CA
DISCLOSURES: GHS is a contractor with Medscape from WebMD and a consultant for Partnership for
Health Analytic Research, LLC.
// Acknowledgements:
Dr Melissa A. Pynnonen and Dr Gordon H. Sun would like to gratefully acknowledge Dr Joseph K. Han, a
previous contributor to this monograph. JKH declares that he has no competing interests.
// Peer Reviewers:
Benjamin S. Bleier, MD
Instructor of Otology and Laryngology
Harvard Medical School, Massachusetts Eye and Ear Infirmary, Department of Otolaryngology - Head and
Neck Surgery, Boston, MA
DISCLOSURES: BSB is a co-founder and equity shareholder in Luxxeal, Inc.
Christos Georgalas, MD, PhD, DLO, FRCS (ORL-HNS)

Assistant Professor/Consultant
Academic Medical Center, Amsterdam, The Netherlands
DISCLOSURES: CG declares that he has no competing interests.

Acute Sinusitis: The Right Clinical Information, Right Where It's Needed

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Acute sinusitis

The right clinical information, right where it's needed

Last updated: Feb 02, 2018

◊ Majority of cases in adults and children are of viral aetiology.

◊ Duration of symptoms more than 10 days often indicates bacterial cause.

◊ Imaging is not required for diagnosis unless complications are suspected.

◊ Condition is usually self-limiting; however, symptomatic therapy is recommended.

less. It can be caused by either a viral or a bacterial infection.[1]

• Acute: 4 weeks or less

• Non-contrast CT scan is the imaging study of choice.[21]

• May be useful if extrasinus complications are suspected.[2]

History & examination factors

symptoms that worsen after an initial improvement (acute bacterial sinusitis)

purulent nasal discharge (common)

nasal obstruction (common)

facial pain/pressure (common)

severe symptoms at onset (acute bacterial sinusitis) (uncommon)

dental pain (uncommon)

Other diagnostic factors

sore throat (common)

oedematous turbinate (common)

x-ray sinuses may show air-fluid level of

• Cannot differentiate acute viral from acute bacterial sinusitis, so

lateral neck x-ray may show adenoid

Condition Differentiating signs / Differentiating tests

Non-allergic rhinitis • Heterogeneous group • Diagnosis is clinical: there

Migraine • Patient reports a history of • Diagnosis is clinical,[25]

Adenoiditis • Difficult to differentiate in • Nasal flexible endoscopy

Step-by-step treatment approach

Acute viral sinusitis

• Recommended for pain and/or fever.

• Recommended in adults with rhinorrhoea.[33] [34]

Acute bacterial sinusitis

• The prevalence of penicillin-resistant S pneumoniae , both intermediate- and high-level resistance,

Treatment details overview

suspected acute viral sinusitis 1st supportive therapy

adjunct intranasal corticosteroid

adjunct intranasal saline

immunocompromised or 1st antibiotic therapy

immunocompromised or plus ENT specialist referral

immunocompromised or plus supportive therapy

immunocompromised or adjunct analgesic/antipyretic

immunocompromised or adjunct decongestant

immunocompromised or adjunct intranasal corticosteroid

immunocompromised or adjunct intranasal saline

immunocompromised or adjunct mucolytic

immunocompetent non- 1st watchful waiting for up to 10 days, or

immunocompetent non- adjunct antibiotic therapy

immunocompetent non- adjunct analgesic/antipyretic

immunocompetent non- adjunct decongestant

immunocompetent non- adjunct intranasal corticosteroid

immunocompetent non- adjunct intranasal saline

immunocompetent non- adjunct mucolytic

immunocompetent non- adjunct ENT specialist referral

recurrent episodes 1st ENT specialist referral

suspected acute viral sinusitis 1st supportive therapy

» Generally a self-limiting disease, and treatment

» Adequate rest and hydration, warm facial

» Treatments should be tried for 5 to 10 days

» Codeine is contraindicated in children younger

» paracetamol: children: 10-15 mg/kg orally

» ibuprofen: children: 5-10 mg/kg orally every

6-8 hours when required, maximum 40 mg/