Sinusitis, Acute, Medical Treatment Follow-up

  • Author: Steven E Sobol, MD, FRCSC, MSc, FAAP; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Nov 19, 2009
 

Complications

  • Local complications
    • Mucoceles are chronic epithelial cysts that develop in sinuses in the presence of either an obstructed sinus ostium or minor salivary gland duct. They have the potential for progressive concentric expansion that can lead to bony erosion and extension beyond the sinus.
    • Maxillary sinus mucoceles are usually found incidentally on sinus radiographs and are of little significance in the absence of symptomatology or infection. Surgical treatment is not usually necessary, and these lesions often regress spontaneously over time.
    • Frontoethmoidal and sphenoethmoidal mucoceles, on the other hand, tend to be symptomatic and have a high potential for bony erosion. Frontoethmoidal mucoceles should be completely removed and the sinus obliterated. Sphenoethmoid mucoceles should be widely opened into the nasal cavity.
    • Osteomyelitis is a potential local complication most commonly occurring with frontal sinusitis. Osteomyelitis of the frontal bone is called a Pott puffy tumor and represents a subperiosteal abscess with local edema anterior to the frontal sinus. This can advance to form a fistula to the upper lid with sequestration of necrotic bone. This rare complication should be managed with a combination of systemic antibiotics, surgical drainage of affected sinuses, and debridement of necrotic bone.
  • Orbital complications
    • Orbital complications are the most common complications encountered with acute bacterial sinusitis. Infection can spread directly through the thin bone separating the ethmoid or frontal sinuses from the orbit or by thrombophlebitis of the ethmoid veins. Diagnosis should be based on an accurate physical examination including ophthalmological evaluation and appropriate radiological studies. CT scanning is the most sensitive means of diagnosing an orbital abscess, although ultrasound has been found to be 90% effective for diagnosing anterior abscesses.[6] The classification by Chandler, which is based on physical examination findings, provides a reasonable framework to guide management. This classification consists of 5 groups of orbital inflammation:[7]
      • Group 1 - Inflammatory edema (preseptal cellulitis) with normal visual acuity and extraocular movement
      • Group 2 - Orbital cellulitis with diffuse orbital edema but no discrete abscess
      • Group 3 - Subperiosteal abscess beneath the periosteum of the lamina papyracea resulting in downward and lateral globe displacement
      • Group 4 - Orbital abscess with chemosis, ophthalmoplegia, and decreased visual acuity
      • Group 5 - Cavernous sinus thrombosis with rapidly progressive bilateral chemosis, ophthalmoplegia, retinal engorgement, and loss of visual acuity; possible meningeal signs and high fever
    • Medical management, including sinus drainage and intravenous antibiotics, is advocated for any degree of orbital complication. The use of decongestant and antibiotic therapy is discussed in the Medical Care and Medication sections.
    • Among the classifications by Chandler, surgical drainage of both the infected sinuses and the orbit are advocated for groups 3-5 if inadequate improvement or progression of orbital cellulitis occurs despite medical therapy or if the patient has loss of visual acuity. Surgical procedures are discussed in Surgical Care.
  • Intracranial complications: Intracranial complications may occur as a result of direct extension through the posterior frontal sinus wall or through retrograde thrombophlebitis of the ophthalmic veins. Subdural abscess is the most common intracranial complication, although cerebral abscesses and infarction that result in seizures, focal neurological deficits, and coma may occur. Intracranial complications of sinusitis should be managed surgically with drainage of both the affected sinus and the cranial abscess.
  • Systemic complications: Sinusitis can result in sepsis and multisystem organ failure caused by seeding of the blood and various organ systems. Reports of bacteremia, thoracic empyema, and nosocomial pneumonia have been documented in the intensive-care population with acute sinusitis, and the mortality rate in this group can be as high as 11%.
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Patient Education

For excellent patient education resources, visit eMedicine's Headache Center. Also, see eMedicine's patient education article Sinus Infection.

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Contributor Information and Disclosures
Author

Steven E Sobol, MD, FRCSC, MSc, FAAP  Assistant Professor, Director of Pediatric Otolaryngology, Department of Otolaryngology Head and Neck Surgery, Emory University School of Medicine; Otolaryngologist-In-Chief, Children's Healthcare of Atlanta at Egleston

Steven E Sobol, MD, FRCSC, MSc, FAAP is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery

Disclosure: Nothing to disclose.

Coauthor(s)

Melvin D Schloss, MD, FRCSC  Director of Pediatric Otolaryngology, Professor, Department of Otolaryngology, McGill University, Canada

Melvin D Schloss, MD, FRCSC is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Pediatrics, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Ted L Tewfik, MD, FRCS(C)  Professor, Department of Otolaryngology, Director of Continuing Medical Education of Otolaryngology, McGill University Medical School; Director, Director of Professional Affairs of Otolaryngology, Department of Otolaryngology, Montreal Children's Hospital; Senior Staff, Montreal General Hospital and Royal Victoria Hospital

Ted L Tewfik, MD, FRCS(C) is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Society of Pediatric Otolaryngology, Canadian Medical Association, Canadian Society of Otolaryngology-Head & Neck Surgery, Quebec Medical Association, and Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Specialty Editor Board

Jack A Coleman, MD  Consulting Staff, Franklin Surgical Associates

Jack A Coleman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Academy of Sleep Medicine, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Rhinological and Otological Society, American Society for Laser Medicine and Surgery, and Association of Military Surgeons of the US

Disclosure: accarent, inc Honoraria Speaking and teaching

Francisco Talavera, PharmD, PhD  Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

Stephen G Batuello, MD  Consulting Staff, Colorado ENT Specialists

Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society

Disclosure: Nothing to disclose.

Christopher L Slack, MD  Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position

References

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Air-fluid level (arrow) in the maxillary sinus suggests sinusitis.
Table 1. Dosage, Route, and Spectrum of Activity of Commonly Used First-Line Antibiotics*
Antibiotic Dosage Streptococcus pneumoniaeHaemophilus influenzaeMoraxella catarrhalisAnaerobic bacteria
SensitiveIntermediateResistant
Amoxicillin500 mg PO tid++++++++++
Clarithromycin250-500 mg PO bid+++++++++++
Azithromycin500 mg PO first day, then



250 mg/d PO for 4 days



+++++++++++
Table 2. Dosage, Route, and Spectrum of Activity of Commonly Used Second-Line Antibiotics*
Antibiotic Dosage Streptococcus pneumoniaeHaemophilus influenzaeMoraxella catarrhalisAnaerobic bacteria
SensitiveIntermediateResistant
Amoxicillin/clavulanate500 mg PO tid+++++++++++++++
Cefuroxime250-500 mg PO bid+++++++++++++
Cefpodoxime



+



cefixime



200 mg PO bid



400 mg/d PO



-



++



+++



-



++



-



+



+++



+++



+++



+++



-



Ciprofloxacin500-750 mg PO bid++++++++++
Levofloxacin500 mg/d PO++++++++++++++++++
Trovafloxacin200 mg/d PO++++++++++++++++++
Clindamycin300 mg PO tid+++++++++--+++
Metronidazole500 mg PO tid-----+++
Table 3. Dosage, Route, and Spectrum of Activity of Commonly Used Intravenous Antibiotics*
Antibiotic Dosage Streptococcus pneumoniaeHaemophilus influenzaeMoraxella catarrhalisGram-negative Anaerobic bacteria
Piperacillin3-4 g IV q4-6h++++-++++++
Piperacillin/tazobactam3.375 g IV q6h++++++++++++++
Ticarcillin3 g IV q4h+++--+++++
Ticarcillin/clavulanate3.1 g IV q4h++++++-+++++
Imipenem500 mg IV q6h+++++++++++++++
Meropenem1 g IV q8h++++++++++++++
Cefuroxime1 g IV q8h+++++++++++++
Ceftriaxone2 g IV bid++++++++++++++
Cefotaxime2 g IV q4-6h++++++++++++++
Ceftazidime2 g IV q8h++++++++++++++
Gentamicin1.7 mg/kg IV q8h-++++++++-
Tobramycin1.7 mg/kg IV q8h-++++++++-
Vancomycin1 g IV q6-12h+++---++
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