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Presented by:

Sim Sui Theng

Hospital Miri
Microbial Etiology
Clinical Manifestations

 Sinusitis – An inflammation process
involving the mucous membranes of the
paranasal sinuses and/or underlying bone
 Normally involved the nasal mucosa 
 Can be classified based upon duration of
• Acute – sudden onset and lasts up to 4 weeks
• Subacute – lasts between 4 – 12 weeks
• Chronic – lasts at least 12 consecutive weeks

of the
nasal wall
and turbinates
of the frontal,
in relation
to the
and maxillary
and sphenoid
sinuses and Eustachian tube orifice
Allergy, viral
infections or air
pollutants induce
local inflammation in
sinonasal mucosa

Approximation of
mucosal surfaces in
the narrow channels
of OMC*

Swelling leads to
impairment of Sinus secretions pool Sinusiti
mucociliary & thicken, providing s
clearance & excellent culture
obstruction of the medium for m/o
sinus ostia
*OMC- Osteomeatal complex
Acute Sinusitis Chronic Sinusitis
-Well defined -Not well defined
- Virus (most common), Bacteria (2%) - Normally involve polymicrobial
- Examples of viruses: Rhinovirus, infections
parainfluenza, influenza virus, RSV, - Anaerobes
- Bacterial:
• Community-acquired:
 Streptococcus pneumoniae
 Haemophilus influenzae
 Moraxella catarrhalis
 Staphyloccus aureus
 Anaerobic bacteria
• Nosocomial:
 Staphylococcus aureus
 Streptococcal species
 Pseudomonas species
 Escherichia coli
 Klebsiella species
 Other Gram negative bacteria

 Nasal congestion
 Purulent nasal discharge
 Maxillary tooth discomfort
 Facial pain/pressure (worse when
bending forward)
 Headache
 Fever (Non-acute)
 Fatigue
 Cough
 Ear pain/ear fullness

(1) Acute sinusitis
 Viral rhinosinusitis
- Goal: Suppressing the full development of symptoms,
especially the nasal fluid production that leads to nose
At the 1st sign of May add an oral decongestant
cold… (pseudoephedrine) and/or
cough suppressant
1st generation (dextromethorphan) as
antihistamine (Eg. needed
Chlorpheniramine) + No improvement after 7-10
NSAID (Eg. days?
Antimicrobials may be required
Administer q12H until to treat secondary bacterial
cold symptoms clear sinusitis
 Community-acquired bacterial sinusitis
Recommended antibiotics
Centers for Disease Control and Sinus and Allergy Health Partnership
Prevention (CDC)
Amoxycillin (1.5 to 3.5g/day) Mild disease (No antibiotics in the last 4-6 weeks)
-Amoxycillin-clavulanate (625mg bd)
-Amoxycillin (1.5-3.5g/day)
-Cefuroxime axetil (500mg bd)
-Levofloxacin (500mg od)
-Moxifloxacin (400mg od)

Doxycycline (100mg bd) Mild disease (antibiotics in the last 4-6 weeks) OR
Moderate disease (no antibiotics in this time
-Amoxycillin (3-3.5g/day)
-Same as above (amoxycillin-clavulanate,
cefuroxime, levofloxacin, moxifloxacin)
Trimethoprim-Sulfamethoxazole Moderate disease (antibiotics in the last 4-6
(1 tablet bd) weeks):
-Amoxycillin-clavulanate, levofloxacin, 9
 Nosocomial bacterial sinusitis
- Antimicrobial coverage should be directed at S. aureus
and the Gram –ve bacteria based upon the sinus
aspirate C&S test
 Fungal sinusitis
- Mainly involve the immunocompromised patients
- Surgical intervention – diagnostic biopsy and for
debridement of the infection
- Empirical antifungal therapy: IV Amphotericin B
1mg/kg/day, duration depends on underlying host’s
immune status extent of surgical debridement &
response to therapy
- Chronic suppressive therapy following amphotericin B:
oral itraconazole or voriconazole

(2) Chronic sinusitis
 Antimicrobials: Amoxycillin-clavulanate (625mg
bd) OR cefuroxime (500mg bd) for 21 days OR
clarithromycin 500mg bd
 Decongestants: pseudoephedrine (short-term
use); do not use topical nasal decongestant
spray for chronic cases  rebound rhinitis after
72H use
 Nasal irrigation: irrigate twice a day with warm
saline solution using a bulb syringe
 Nasal steroids: 2 puffs of nasal spray/day
(decrease mucosal inflammation and swelling,
esp allergy)
 Adjunctive agents: Mucolytic agents (Eg.
Guaifenesin); Antihistamines
 Antihistamines
• MOA: Competes with histamines for H1-receptor sites on
effector cells in the gastrointestinal tract, blood vessels,
and respiratory tract
• Side effects: drowsiness & sedative, dry mouth,
constipation, urinary retention, nausea & vomiting and
epigastric pain
• Newer antihistamines: less sedative
• Some patients may respond better with older
• Counseling point:
 Drowsiness, blurred vision, lightheadedness – avoid driving,
handling machinery
Consipation – take more liquids, regular exercise, fiber-
containing diet
Dry mouth – frequent mouth care
Avoid alcohol, other antihistamines or mood stabilizers

Table 1: Relative Adverse Effect Profile of Antihistamines
Medication Relative Relative
Sedative Effect Anticholinergic Effect
Alkylamine Class

Brompheniramine maleate Low Moderate

Chlorpheniramine maleate Low Moderate
Dexchlorpheniramine maleate Low Moderate
Ethanolamine Class

Carbinoxamine maleate High High

Clemastine fumarate Moderate High
Diphenhydramine HCl High High
Ethylenediamine Class

Pyrilamine maleate Low Low to none

Tripelennamine HCl Moderate Low to none
Phenothiazine Class

Promethazine HCl High High

“Non-sedating” Peripherally Selective

Cetirizine Low to moderate Low to none
Fexofenadine Low to none Low to none
Loratadine Low to none Low to none
 Decongestant
• MOA: Sympathomimetic agent which acts on
adrenergic receptors & produces vasoconstriction.
It shrinks swollen mucosa & improve ventilation.
• Topical decongestant: drops/spray
• Problem: prolonged use can cause rebound
vasodilation (rhinitis medicamentosa) ~ if use more
than 3-5 days
• Side effects: burning, stinging, sneezing & dryness
of nasal mucosa
• Counseling point: To use as small dose as
infrequently as possible & only when absolutely
necessary (Eg during bedtime to aid falling asleep);
duration: limited to 3-5 days

Table 2: Duration of Action of Topical Decongestants
Medication Duration (hr)
Short Acting
Phenylephrine HCl Up to 4
Intermediate Acting
Naphazoline HCl 4–6
Tetrahydrozoline HCl
Long Acting
Oxymetazoline HCl Up to 12
Xylometazoline HCl

Table 3: Oral Dosages of Commonly Prescribed Antihistamines and Decongestan
Dosage and Interval
Adults Children

Chlorpheniramine maleate, 4mg q6H 6-12 yr: 2mg q6H
plain 2-6 yr: 1mg q6H
Chlorpheniramine maleate, 8 – 12mg daily at bedtime 6-12 yr: 8mg at bedtime
sustained release or 8 – 12mg q8H <6 yr: Not recommended
Diphenhydramine HCl 25 – 50mg q8H 5mg/kg/day q8H
(up to 25mg per dose)
Clemastine fumarate 1.34mg bd to 2.68mg tds Not recommended
Loratadine 10mg od 10mg od
Fexofenadine 60mg bd 6-11 yr: 30mg bd
Cetirizine 5 – 10mg od >6 yr: 5mg od
Pseudoephedrine 60mg q4-6H 6-12 yr: 30mg q4-6H
120mg q12H for SR tablet 2-5 yr: 15mg q4-6H
Ephedrine sulfate 25 – 50mg q4H 2-3 mg/kg/day divided q4H (up
to 25mg q4H) 16
 Nasal Steroid
• MOA: Reduce inflammatory by blocking mediator release,
suppress neutrophil chemotaxis, reduce intracellular
edema & cause mild vasoconstriction
• Eg: Budesonide nasal spray, beclomethasone
• Side effects: sneezing, stinging, headache, epistaxis
• Should NOT be used in pts with nasal septum ulcers or
recent nasal surgery or trauma
• Counseling point:
 Blocked nose should be cleared with decongestant before
administration to ensure adequate penetration
Avoid sneezing/blowing their nose at least 10 mins after

Table 4: Dosage of Nasal Steroids
Medication Dosage and Interval
Beclomethasone dipropionate  >12 yr: 1 inhalation (42µg) per nostril 2-4X/day
(max: 336µg/day)
 6-12 yr: 1 inhalation per nostril 3X/day
Beclomethasone  >12 yr: 1-2 inhalations once daily
dipropionate, monohydrate  6-12 yr: 1 inhalation per nostril bd
Budesonide  >6 yr: 2 sprays (64µg) per nostril a.m. & p.m., or 4
sprays per nostril a.m. (max: 256µg)
Fluticasone Adults: 2 sprays (100µg) per nostril once daily; after
a few days decrease to 1 spray per nostril
Children >4 yr and adolescents: 1 spray per nostril
od (max: 200µg/day)
Mometasone furoate  >12 yr: 2 sprays (100µg) per nostril od

1) Metson, R & Sindwani, R., 2007. Chronic sinusitis. UpToDate
2) Snow, V,et al. Ann Intern Med 2001; 134:495. Position paper
endorsed by the American Academy of Family Physicians, the
American College of Physicians-American Society of Internal
Medicine, and the Infectious Diseases Society of America.
3) Antimicrobial treatment guidelines for acute bacterial
rhinosinusitis. Otolaryngol Head Neck Surg 2000; 123:S1
4) Gwaltney, JM, 2007. Acute sinusitis and rhinosinusitis in
adults. UpToDate (15.1)
5) Katzung, BG: Basic & Clinical Pharmacology
6) Lexi-Comp-Drug Information Handbook International, 14th