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Medical Treatment for Acute Sinusitis Follow-up

  • Author: Ted L Tewfik, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: May 04, 2016
 

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.[12] 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[13] :

  • 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.

Subdural empyema is a life-threatening infection that may complicate acute sinusitis. Boto et al (2011) reported the case of a previously healthy 10-year-old girl who developed subdural empyema due to Gemella morbillorum infection after an untreated maxillary, ethmoidal, and sphenoidal sinusitis.[14] Despite immediate drainage of the empyema and treatment with broad-spectrum antibiotics, she developed frontal cerebritis and refractory intracranial hypertension, needing urgent decompressive craniectomy. She recovered gradually with slight right-sided hemiparesis and aphasia.

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%. Fukushima et al (2012) reported on a case of a 39-year-old man admitted for the onset of acute purulent meningitis.[15] A cerebrospinal fluid culture grew Streptococcus sanguis. Sinusitis was found to be the cause of the meningitis. Treatment with intravenous antibiotics was successful.

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Patient Education

For excellent patient education resources, see eMedicineHealth's patient education article Sinus Infection.

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Contributor Information and Disclosures
Author

Ted L Tewfik, MD Professor of Otolaryngology-Head and Neck Surgery, Professor of Pediatric Surgery, McGill University Faculty of Medicine; Senior Staff, Montreal Children's Hospital, Montreal General Hospital, and Royal Victoria Hospital

Ted L Tewfik, MD is a member of the following medical societies: American Society of Pediatric Otolaryngology, Canadian Society of Otolaryngology-Head & Neck Surgery

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Association for Physician Leadership, American Medical Association, Colorado Medical Society

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

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 Sleep Medicine, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, The Triological Society, American Society for Laser Medicine and Surgery, Association of Military Surgeons of the US

Disclosure: Received honoraria from Accarent, Inc. for speaking and teaching.

Acknowledgements

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

Disclosure: Nothing to disclose.

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.

References
  1. Bishai WR. Issues in the management of bacterial sinusitis. Otolaryngol Head Neck Surg. 2002 Dec. 127(6 Suppl):S3-9. [Medline].

  2. Ray NF, Baraniuk JN, Thamer M, Rinehart CS, Gergen PJ, Kaliner M. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol. 1999 Mar. 103(3 Pt 1):408-14. [Medline].

  3. [Guideline] Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2007 Sep. 137(3 Suppl):S1-31. [Medline].

  4. Khalid AN, Ladha KS, Luong AU, Quraishi SA. Association of Vitamin D Status and Acute Rhinosinusitis: Results From the United States National Health and Nutrition Examination Survey 2001-2006. Medicine (Baltimore). 2015 Oct. 94 (40):e1447. [Medline]. [Full Text].

  5. Savolainen S, Jousimies-Somer H, Karjalainen J. Do simple laboratory tests help in etiologic diagnosis in acute maxillary sinusitis?. Acta Otolaryngol Suppl. 1997. 529:144-7. [Medline].

  6. Georgy MS, Peters AT. Chapter 8: Rhinosinusitis. Allergy Asthma Proc. 2012 May-Jun. 33 Suppl 1:S24-7. [Medline].

  7. Pynnonen MA, Lynn S, Kern HE, et al. Diagnosis and treatment of acute sinusitis in the primary care setting: A retrospective cohort. Laryngoscope. 2015 May 22. [Medline].

  8. Fleming-Dutra KE, Hersh AL, Shapiro DJ, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among US Ambulatory Care Visits, 2010-2011. JAMA. 2016 May 3. 315 (17):1864-1873. [Medline].

  9. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015 Apr. 152 (2 Suppl):S1-S39. [Medline].

  10. Patel RG, Daramola OO, Linn D, et al. Do you need to operate following recovery from complications of pediatric acute sinusitis?. Int J Pediatr Otorhinolaryngol. 2014 Jun. 78(6):923-5. [Medline].

  11. Slack CL, Dahn KA, Abzug MJ, Chan KH. Antibiotic-resistant bacteria in pediatric chronic sinusitis. Pediatr Infect Dis J. 2001 Mar. 20(3):247-50. [Medline].

  12. Sobol SE, Marchand J, Tewfik TL, Manoukian JJ, Schloss MD. Orbital complications of sinusitis in children. J Otolaryngol. 2002 Jun. 31(3):131-6. [Medline].

  13. Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope. 1970 Sep. 80(9):1414-28. [Medline].

  14. Boto LR, Calado C, Vieira M, Camilo C, Abecasis F, Campos AR, et al. [Subdural empyema due to gemella morbillorum as a complication of acute sinusitis]. Acta Med Port. 2011 May-Jun. 24(3):475-80. [Medline].

  15. Fukushima K, Noda M, Saito Y, Ikeda T. Streptococcus sanguis meningitis: report of a case and review of the literature. Intern Med. 2012. 51(21):3073-6. [Medline].

  16. [Guideline] Slavin RG, Spector SL, Bernstein IL, Kaliner MA, Kennedy DW, Virant FS, et al. The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol. 2005 Dec. 116(6 Suppl):S13-47. [Medline].

  17. Taylor JA, Weber W, Standish L, et al. Efficacy and safety of echinacea in treating upper respiratory tract infections in children: a randomized controlled trial. JAMA. 2003 Dec 3. 290(21):2824-30. [Medline].

 
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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 pneumoniae Haemophilus influenzae Moraxella catarrhalis Anaerobic bacteria
Sensitive Intermediate Resistant
Amoxicillin 500 mg PO tid +++ ++ + ++ + +
Clarithromycin 250-500 mg PO bid ++ ++ + ++ +++ +
Azithromycin 500 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 pneumoniae Haemophilus influenzae Moraxella catarrhalis Anaerobic bacteria
Sensitive Intermediate Resistant
Amoxicillin/clavulanate 500 mg PO tid +++ ++ + +++ +++ +++
Cefuroxime 250-500 mg PO bid +++ ++ + +++ ++ ++
Cefpodoxime



+



cefixime



200 mg PO bid



400 mg/d PO



-



++



+++



-



++



-



+



+++



+++



+++



+++



-



Ciprofloxacin 500-750 mg PO bid ++ + + ++ +++ +
Levofloxacin 500 mg/d PO +++ +++ +++ +++ +++ +++
Trovafloxacin 200 mg/d PO +++ +++ +++ +++ +++ +++
Clindamycin 300 mg PO tid +++ +++ +++ - - +++
Metronidazole 500 mg PO tid - - - - - +++
Table 3. Dosage, Route, and Spectrum of Activity of Commonly Used Intravenous Antibiotics*
Antibiotic Dosage Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Gram-negative Anaerobic bacteria
Piperacillin 3-4 g IV q4-6h +++ + - +++ +++
Piperacillin/tazobactam 3.375 g IV q6h +++ +++ +++ +++ ++
Ticarcillin 3 g IV q4h +++ - - +++ ++
Ticarcillin/clavulanate 3.1 g IV q4h +++ +++ - +++ ++
Imipenem 500 mg IV q6h +++ +++ +++ +++ +++
Meropenem 1 g IV q8h +++ +++ +++ +++ ++
Cefuroxime 1 g IV q8h +++ +++ +++ ++ ++
Ceftriaxone 2 g IV bid +++ +++ +++ +++ ++
Cefotaxime 2 g IV q4-6h +++ +++ +++ +++ ++
Ceftazidime 2 g IV q8h +++ +++ +++ +++ ++
Gentamicin 1.7 mg/kg IV q8h - +++ +++ ++ -
Tobramycin 1.7 mg/kg IV q8h - +++ +++ ++ -
Vancomycin 1 g IV q6-12h +++ - - - ++
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