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This is a presentation of the
American Academy of Family Physicians
supported by an educational grant from
Aventis Pharmaceuticals

The AAFP gratefully acknowledges

Harold H. Hedges, III, M.D.
and
Susan M. Pollart, M.D.
for developing the content for the AAFP
and
Harold H. Hedges, III, M.D. for providing the
photo images included in this slide presentation.

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Harold H. Hedges, III, M.D.

Private Practice
Little Rock Family Practice Clinic
Little Rock, Arkansas

and

Susan P. Pollart, M.D.

Associate Professor of Family Medicine
University of Virginia Health System
Charlottesville, Virginia

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‡ Be knowledgeable of the causes of and risk factors associated

with sinusitis
‡ Differentiate acute from chronic sinusitis
‡ Evaluate patients by history, physical exam, appropriate
laboratory and imaging studies, and when indicated screen
patients for allergy
‡ Prescribe appropriate medication regimens for acute and
chronic sinusitis
‡ Know of the relationships between upper airway
(rhinosinusitis) and lower airway disease (asthma)

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‡ Allergic or nonallergic rhinitis nearly always precedes sinusitis

‡ Sinusitis without rhinitis is rare
‡ Nasal discharge and congestion are prominent symptoms of
sinusitis
‡ Nasal mucosa and sinus mucosa are similar and are contiguous

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‡ Affects 30-35 million persons/year

‡ 25 million office visits/year
‡ Direct annual cost $2.4 billion and increasing
‡ Added surgical costs: $1 billion
‡ Third most common diagnosis for which antibiotics are
prescribed

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‡ Sinus health depends on:

± Mucous secretion of normal viscosity, volume, and
composition,
± normal mucociliary flow to prevent mucous stasis and
subsequent infection;
± and open sinus ostia to allow adequate drainage and aeration.

‡ Senior BA, Kennedy DW. Management of sinusitis in the

asthmatic patient YYY
,1996;77:6-19.

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‡ Maxillary and ethmoid sinuses present at birth

‡ Frontal sinus developed by age 5 or 6
‡ Sphenoid sinus last to develop, 8-10

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‡ Provide mucus to upper airways

± Lubrication
± Vehicle for trapping viruses, bacteria, foreign material for
removal

‡ Give characteristics to voice

‡ Lessen skull weight
‡ Involved with olfaction

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Infectious or noninfectious inflammation of 1 or more sinuses

‡ 4 paranasal sinuses, each lined with pseudostratified
ciliated columnar epithelium and goblet cells
± Frontal
± Maxillary
± Ethmoid
± Sphenoid

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‡ Ostiomeatal complex is that area under the middle meatus

(airspace) into which the anterior ethmoid, frontal and
maxillary sinuses drain
‡ Posterior ethmoids drain into the upper meatus
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‡ Most upper respiratory infections are viral

‡ Short lived, last less than 10 days
‡ Sinus mucosa as well as nasal mucosa is involved
‡ Most will clear without antibiotics
‡ Treatment: decongestants, nasal lavage, rest, fluids

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‡ Acute bacterial sinusitis- infection lasting 4 weeks,

symptoms resolve completely (children 30 days)
‡ Subacute bacterial sinusitis- infection lasting between 4 to
12 weeks, yet resolves completely (children 30-90 days)
‡ Chronic sinusitis- symptoms lasting more than 12 weeks
(children >90 days)
‡ Some guidelines add treatment failure + a positive imaging
study

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‡ Episodes lasting fewer than 4 weeks and separated by

intervals of at least 10 days during which the patient is
totally asymptomatic
‡ 3 episodes in 6 months or 4/year

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‡ Patients with chronic, low grade symptoms experience

increase in mucous flow, change in viscosity or color, or
secretions
‡ Treated
‡ New symptoms resolve but chronic symptoms continue

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Nasal congestion Nasal congestion
Purulent rhinorrhea Rhinorrhea clear
Postnasal drip Runny nose
Headache Itching, red eyes
Facial pain Nasal crease
Anosmia Seasonal symptoms

Cough, fever

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‡ Obstruction of the various ostia

‡ Impairment in ciliary function
‡ Increased viscosity of secretions
‡ Impaired immunity
‡ Mucus accumulates
‡ Decrease in oxygenation in the sinuses
‡ Bacterial overgrowth

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‡ Viral upper respiratory infections

± Daycare centers
‡ Allergic and nonallergic stimuli
‡ Immunodeficiency disorders
± Immunoglobulin deficiency (IgA, IgG)
‡ Anatomic changes
± Deviated septum, concha bullosa, polyps

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‡ Pollens
± Tree, grass, weeds

‡ House dust mite

‡ Animal danders
± Cat, dog, mice, gerbil, other animals with fur

‡ Molds
‡ Allergic foods and beverages

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‡ Tobacco smoke ‡ Cold air

‡ Perfumes ‡ Dry air
‡ Cleaning solutions ‡ Changes in barometric
pressure
‡ Potpourri
‡ Auto exhaust
‡ Burning candles
‡ Gas, diesel fuel
‡ Cosmetics
‡ Nonallergic foods
‡ Car exhaust, diesel fumes
‡ Nonallergic beverages
‡ Hair spray

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‡ Immotile cilia syndrome

‡ Prolonged exposure to cigarette smoke
‡ Common cold viruses causing URI
‡ Increased viscosity of mucus
‡ Medications
± First generation antihistamines (non sedating do not affect)
± Anticholinergics
± Aspirin
± Anesthetic agents
± Benzodiazepines

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‡ Allergic and nonallergic rhinitis

‡ Rhinosinusitis
‡ Aging rhinitis
‡ Cystic fibrosis
‡ Any disease causing obstruction, crusting of the mucosa

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‡ Deviated nasal septum

‡ Concha bullosa
‡ Foreign body
‡ Nasal polyps
‡ Congenital atresia
‡ Lymphoid hyperplasia
‡ Nasal structural changes found in Downs syndrome

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‡ Churg-Strauss vasculitis
‡ Systemic lupus erythematosis
‡ Sjogren¶s syndrome
‡ Sarcoidosis
‡ Wegener granulomatosis

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‡ Physical trauma
‡ Scuba diving
‡ Foreign body
‡ Cleft palate
‡ Dental disorders
‡ Any patient with chronic fatigue, fever, general
malaise/aching or headaches should be evaluated for
sinusitis

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‡ Usually begins with viral upper respiratory illness

‡ Symptoms initially improve, but then «
‡ Symptoms become persistent or severe
‡ Persistent« 10-14 days but fewer than 4 weeks
‡ Severe«temperature of 102°, purulent nasal discharge for
3-4 days, child appears ill
‡ Disease clears with appropriate medical treatment

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‡ Mucopurulent nasal discharge

± Highest positive predictive value

‡ Swelling of nasal mucosa

‡ Mild erythema
‡ Facial pain (unusual in children)
‡ Periorbital swelling

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‡ Decrease time of recovery

‡ Prevent chronic disease
‡ Decrease exacerbations of asthma or other secondary
diseases
‡ Do so in a cost-effective way!

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‡ Antihistamines recommended if allergy present

± Oral or topical
‡ Decongestants
± Oral or topical
‡ Antibiotic when indicated (bacteria)
‡ Nasal irrigation
‡ Guaifenesin 200-400 mg q4-6 hrs
‡ Hydration

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‡ Topical nasal sprays (limit use to 3-7 days)

± Phenylephrine
± Oxymetazoline
± Naphthazoline
± Tetrahydrozoline
± Zylometazoline
‡ Topical nasal spray (unlimited daily use)
± Ipatropium
‡ Oral
± Pseudoephedrine 30-60 mg
± Phenylephrine 2-4 times/day

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‡ Antibiotic may not be indicated

± Many are viral
± Benefit of antibiotics are only moderate
± Weigh factors of cost, side effects, antibiotic resistance,
and antibiotic reactions

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‡ Amoxicillin 500 mg tid for 10-14 days

± First line choice in most areas
± Local differences in antibiotic resistance occur

‡ Where beta-lactanase resistance is an issue

± Amoxicillin/clavulanate
± Cefuroxime
± Cefpodoxime
± Cefprozil

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‡ Amoxicillin should be considered because of its efficacy,

low cost, side-effect profile, and narrow spectrum (45-90
mg/kg/d in children; 500 mg tid or qid in adults for 10 to
14 days)
‡ If penicillin-allergic clarithromycin or azithromycin
‡ Erythromycin does not provide adequate coverage
‡ Trimethoprim/suflamethoxazole and erythro/sulfisoxazole
have significant pneumococcal resistance

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‡ Commercial buffered sprays

‡ Bulb syringe
± 1/4 tsp of salt to 7 ounces water

‡ Waterpik with lavage tip

± 1 tsp salt to reservoir

‡ Disposable enema bucket

± 2 tsp salt, 1 tsp soda per quart of water

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‡ Washes away irritants

‡ Moistens the dry nose
‡ Waterpik with nasal irrigator
‡ Ceramic irrigators
‡ Enema bucket with normal saline and soda
± ³Hose-in-the-nose´-- $2.50

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‡ With enema bucket/hose«.

± Add 2 teaspoons of salt and 1 tsp of baking soda to a quart of
warm water
± Over tub, sink, or in shower lean over, head tilted slightly
downward and to side place hose in upper nostril (fluid may
return from either nostril or through mouth) run in 1/2
solution. Turn head to opposite side and repeat process.
± Use once, twice daily or as often as needed

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‡ Assess for chronic causes

± Identify allergic and nonallergic triggers
‡ Allergy testing, nasal smears for eosinophilia
± Consider other medical conditions associated with sinusitis
± Rhinolaryngoscopy
± Imaging studies
Sinus x-rays
CT scanning (limited, coronal views)

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‡ Helpful in older children and adults

‡ Normal transillumination decreases chance of pus in the
sinus
‡ No light reflex suggests mucopurulent material or
thickening of nasal mucosa
‡ Inexpensive screening tool

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‡ Have patient sit at your eye level in darkened room (the

darker the better)
‡ Let eyes get accustomed to dark
‡ Place bright light (transilluminator) over inferior orbital
ridge to look at maxillary sinuses, under superior orbital
rim for frontal sinuses
‡ Look at palate for presence/absence of transilluminated
light

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‡ Nasal polyps
‡ Septal deviation
‡ Concha bullosa
‡ Eustachian tube dysfunction
‡ Causes of hoarseness
‡ Adenoid hyperplasia
‡ Tumors

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‡ Not used for imaging suspected acute sinusitis

‡ Suspected fungal sinusitis
‡ Suspected tumors

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‡ Streptococcus pneumoniae 30%

‡ Haemophilus influenza 20%
‡ Moraxella catarrhalis 20%
‡ Sterile 30%

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‡ In the absence of risk factors, i.e. attendance in daycare

center, recent antibiotics, age younger than 2«
‡ 80% of patients will respond to amoxicillin
‡ Give Rx for 5 days with a refill -- if responding treat for 10
to 14 days, if not, switch to another

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‡ No response to amoxicillin within 3-5 days

‡ Recent treatment with amoxicillin for other causes
‡ Symptoms present for more than 30 days
‡ Recurrent sinus infections

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‡ Cefdinir (Omnicef)
‡ Cefuroxime (Ceftin)
‡ Cephpodoxime (Vantin)
‡ Azithromycin
‡ Clarithromycin

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Give antibiotic until patient free of symptoms then add 7 days

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‡ Symptoms present longer than 8 weeks or 4/year in adults

or 12 weeks or 6 episodes/year in children
‡ Eosinophilic inflammation or chronic infection
‡ Associated with positive CT scans
‡ Poor (if any) response to antibiotics

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‡ Fatigue ‡ Missing school/work

‡ Concentration
‡ Nuisance
‡ Sleep disturbance
‡ Emotional well being
‡ Social interactions
‡ Halitosis
‡ Decreased production
‡ Impaired studying
‡ Sniffing/snorting
‡ Blowing nose

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‡ Nasal discharge
‡ Nasal congestion
‡ Headache
‡ Facial pain or pressure
‡ Olfactory disturbance
‡ Fever and halitosis
‡ Cough (worse when lying down)

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‡ Allergic and nonallergic rhinitis

‡ Uncorrected anatomic conditions
‡ Ciliary dyskinesia
‡ Cystic fibrosis
‡ Tumors
‡ Immunodeficiency disorders
± IgA, IgM

‡ Granulomatous diseases

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‡ CT or MRI scanning
± Anatomic defects, tumors, fungi

‡ Allergy testing
± Inhalants, fungi, foods

‡ Sinus aspiration for cultures

± Bacterial
± Fungal

‡ Immunoglobulins

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‡ Nasal steroid spray

‡ Guafenesin
‡ Decongestants
‡ Steam inhalation
‡ Nasal irrigation
‡ Antibiotics with exacerbations

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‡ Streptococcus pneumoniae
‡ Haemophilus influenza
‡ Moraxella catarrhalis
‡ Staph aureus
‡ Coagulase negative staphylococcus
‡ Anerobic bacteria

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‡ In one study, while initial aspirates showed strep

pneumoniae, H. influenzae, and M catarrhalis, subsequent
cultures showed Porphyromonas, Peptostreptococcus, and
aerobic organisms found to be increasingly resistant to
antibiotics
± Brook I, et al. Bacteriology and beta-lactamase activity in
acute and chronic maxillary sinusitis. Y 
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 1996;122;418-23.

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‡ Correlation of routine nasal culture and sinus culture are

poor
‡ Endoscopically guided aspiration of cultures from medial
meatus do correlate with sinus culture
± Gold SM, Tami TA. Role of middle meatus aspiration
culture in the diagnosis of chronic sinusitis. D 

1997;107: 1586.

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‡ Has not been evaluated as has its use in otitis media

‡ Increasing evidence of antibiotic resistance is an issue
‡ May be tried in chronic or recurrent disease

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‡ Orbital
± Diplopia, proptosis
± Periorbital erythema, swelling

‡ Bone
± Periosteal abscesses

‡ Brain
± Intracranial abscesses causing neurologic symptoms

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‡ Mechanism is not understood

‡ Evidence is compelling
‡ Failure to control upper airway inflammation leads to suboptimal
asthma control
‡ Correcting the rhinosinusitis results in better asthma control

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‡ Allergy testing, possible immunotherapy

‡ Sinus aspiration for bacterial culture
‡ Surgical intervention
± Correct obstructive process
± Drain sinus abscesses
± Consideration to remove nasal polyps

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‡ Acutely ill child or adult with high fever, severe head pain
‡ Suspected sphenoid sinusitis
‡ Anytime complications of eye, bone or intracranial
structures are present

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The recommendations cited are those proposed by a task

force of the American Academy of Pediatrics in
consultation with other groups regarding the evaluation,
diagnosis, and treatment of patients aged 1-21 years with
sinus disease«expert opinion was used when insufficient
data could be found.

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The diagnosis of acute bacterial sinusitis is based on clinical

criteria with patients presenting with URI symptoms that are
either persistent or severe.

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‡ Imaging studies are not necessary to confirm a diagnosis of

clinical sinusitis in children younger than 6 years (older
than age 6 years is controversial)
‡ Children with persistent symptoms (>10 days, < 30 days)
predicted abnormal radiographs 80% of the time
‡ Children < 6 symptoms predicted 88% of the time
‡ Normal x-ray suggests ABS is not present

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‡ CT scans of the paranasal sinuses should be reserved for:

± Patients in whom surgery is being considered as a
management strategy
± Patients who do not respond to medical regimes which
include adequate antibiotic use
± Assisting in diagnosis of anatomical changes interfering
with airflow or drainage

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‡ Patients presenting with complications of sinusitis

± Neurologic symptoms, diplopia, periorbital or facial swelling
with or without erythema

‡ Patients with sinus symptoms accompanied by severe,

boring, mid-head pain
± Rule out sphenoid sinusitis

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‡ Antibiotics are recommended for the management of acute

bacterial sinusitis to achieve a more rapid clinical cure
‡ Patients must meet requirements of persistent or severe
disease
‡ Response improved with doses >Minimal Inhibition
Concentration

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‡ Nasal saline irrigation

‡ Oral decongestants
‡ Oral or nasal antihistamines
‡ Topical decongestants
‡ Mucolytic agents
‡ Topical steroids

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‡ Acute and chronic sinusitis is one of the most common

diseases treated in family practice
‡ It is important to treat sinusitis aggressively to prevent
chronic symptoms or development of serious
complications
‡ The underlying causes of chronic sinus disease should be
sought out and corrected

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‡ Dykewicz M. Rhinitis and Sinusitis. 
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, 2003;

111:S520-9.
‡ Hamilos DL. J Y
u
 2000;106:213-27.
‡ Kaliner MA. Current Review of Rhinitis. Current
Medicine, Inc., 2002.
‡ Kaliner MA. Current Review of Allergic Diseases. Current
Medicine, Inc., 2000.
‡ Agency for Healthcare Research and Quality
‡ American Academy of Pediatrics
‡ New England Medical Center Evidence-based Practice Center

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‡Practice Recommendation: Reduce unnecessary use of antibiotics. Providers

should be consistent with the recommended criteria for prescribing antibiotics in
acute sinusitis endorsed by the CDC, American Academy of Family Physicians,
the American College of Physicians-American Society of Internal Medicine,
and the Infectious Diseases Society of America.
‡Practice Recommendation: Use first line antibiotics, which are amoxicillin or
trimethoprim-sulphamethoxazole (TMP/SMX).
‡Practice Recommendation: Use an antibiotic that covers resistant bacteria
(amoxicillin-clavulanate [Augmentin] or another second line agent) to treat
patients if failed on 10-14 days of amoxicillin.

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This has been a presentation of the

American Academy of Family Physicians

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