Sinusitis: What You Need to Know to Maximize Patient Outcomes

A respiratory tract infection is an infection that affects any part of the respiratory system. Sinusitis in an infection of the sinuses.

The parts of the respiratory system can be categorized as part of the upper respiratory tract or the lower respiratory tract.

The Sinuses

How Infection Occurs

Sinusitis can be caused by either bacteria or viruses. These organisms cause inflammation of the lining in the sinuses and narrow passages preventing mucus from draining out of the nose. When mucus accumulates in the sinuses, infection can occur. Mucus can accumulate in the sinuses in one of 3 ways.

1. The narrow passages become inflamed and blocked off leading to accumulation of mucus in the cavity
2. Mucus is excessively produced and cannot be cleared quickly enough leading to accumulation with drainage
3. Anatomical abnormalities that hinder drainage leading to accumulation

Risk Factors for Sinusitis

Signs & Symptoms

1. Runny nose – excessive mucus
2. Stuffy nose – accumulation of mucus
3. Facial pain or pressure – accumulation of mucus
4. Post nasal drip – where mucus drips down the throat (excessive production)
5. Sore throat – irritation from post nasal drip

Common Infecting Organisms

Appropriate Treatment

The recommendations in this study unit are based off of the following guidelines:

1. IDSA Clinical Practice Guidelines for the Management of Acute Bacterial Rhinosinusitis 2012
2. American Academy of Otolaryngology—Head and Neck Surgery Clinical Practice Guideline (Update):Adult Sinusitis 2015

There are 2 arms of treatment that must be considered: antimicrobial management and symptomatic management.

First and foremost, not every, in fact very few cases of sinusitis requires antibiotic treatment. Viral etiologies account for 90-98% of sinusitis cases. Antibiotics have no effect on viruses. Most viral cases will start to improve in 3-5 days and self resolve in 5-7 days. Approximately 70% of patients improve spontaneously in placebo-controlled randomized clinical trials.

When are Antibiotics Required

Since most viral cases will start to improve by day 3-5 we start to consider antibiotics if signs and symptoms are worsening after 3-4 days.

Since most viral cases will resolve completely in 7-9 days we will consider antibiotic therapy if symptoms persistent beyond 9 days.

If symptoms begin abruptly and severely we should consider it bacterial sinusitis. Severe symptoms include purulent discharge or facial pain, fever lasting more than 48 hours and headache.

If symptoms start to worsen 5-6 days after showing initial improvement. This is referred to as double sickening. When this happens, it is usually because the patient had a viral infection followed by a bacterial infection.

Choice of Antibiotics

There are 2 tiers to antimicrobial therapy in the treatment of sinusitis: first line and second line. The line chosen for initial therapy is determined by the absence or presence of risk factors for bacterial resistance.

Risk factors for antibiotic resistance are age: <2 or >65, exposure to daycare, prior antibiotics within the past month, hospitalization in the past 5 days and immunocompromised states.

First Line Therapy: Low dose amoxicillin-clavulanate (Augmentin)

875/125mg BID

Second Line Therapy: High dose amoxicillin-clavulanate (Augmentin)

2000/125mg BID

Antibiotics with Penicillin Allergy

Second line therapy is reserved for persons with risk factors for infection by bacteria with antibiotic resistance. The duration of treatment with second line therapy is 7-10 days compared to 5-7 days with first line therapy.

If a patient were to fail an initial round of low dose Augmentin i.e. not improving or worsening on days 3-5, we would increase to high dose Augmentin or switch to a different antimicrobial class like doxycycline. Treatment failure on high dose Augmentin would require switching to a different drug class (doxycycline or levofloxacin).

If a patient has failed 2 rounds of antibiotics, it becomes necessary to nail down specific bacteria for pathogen specific antibiotics or use diagnostic imaging to determine if the infection has extended beyond the sinuses. It is probably best to get the consultation of an infectious disease specialist at this point.

Inpatient Antibiotics

If a patient becomes ill enough that they require hospital admission the following antibiotics can be given intravenously for treatment of sinusitis.

• ceftriaxone 1-2g daily
• ampicillin-sulbactam 3g IV Q6H
• levofloxacin 750mg IV daily

Symptomatic Management

Adjunctive therapy for patients with bacterial sinusitis includes:

1. Intranasal saline irrigation with either physiologic or hypertonic saline
2. Intranasal corticosteroids
3. Hydration
4. Analgesics

The guidelines agree that antihistamines should only be used on patients who have a significant allergic component to their symptoms. They note that it can actually worsen congestion by drying the nasal mucosa. Studies do not provide clear evidence that topical decongestants have a clear benefit but if they are used the duration must not exceed 3 days as this can cause rebound congestion.

This study unit contains the core of what every practitioner needs to know with regards to the management of sinusitis. Keep the algorithms handy, refer to them often and soon it will become second nature.

Check out other units in the series: Respiratory Tract Infections

• Navigating Pneumonia: Where and How to Treat
• How to Manage Pneumonia in the Outpatient
• Community Acquired Pneumonia: When to Admit and How to Treat
• Community Acquired Pneumonia: When to Admit to ICU and How to Treat

If you’ve found this unit help I would love to hear from you! Leave a comment or question below.

The information on this website is intended to be used solely for educational and informational purposes. While the content may be about specific medical and health care issues, it is not a substitute for or replacement of personalized medical advice and is not intended to be used as the sole basis for making individualized medical or health-related decisions.