Sinusitis, Acute, Medical Treatment Treatment & Management

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

Medical Care

The primary goals of management of acute sinusitis are to eradicate the infection, decrease the severity and duration of symptoms, and prevent complications. Most patients with acute sinusitis are treated in the primary care setting. Further evaluation by an otolaryngologist is recommended when (1) continued deterioration occurs with appropriate antibiotic therapy, (2) episodes of sinusitis recur, (3) symptoms persist after 2 courses of antibiotic therapy, or (4) comorbid immunodeficiency, nosocomial infection, or complications of sinusitis are present. The goals of management of acute sinusitis are the provision of adequate drainage and appropriate systemic treatment of the likely bacterial pathogens.

Drainage of the involved sinus can be achieved both medically and surgically (see the Medication and Surgical Care sections). Aggressively treat patients in intensive care who develop acute sinusitis in order to avoid septic complications. Consider removal of nasotracheal and nasogastric tubes and promote drainage either medically or surgically.

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Surgical Care

Sinus puncture and irrigation techniques allow for a surgical means of removal of thick purulent sinus secretions. The purpose of surgical drainage is to enhance mucociliary flow and provide material for culture and sensitivity. A surgical means of sinus drainage should be used when appropriate medical therapy has failed to control the infection and prolonged or slowly resolving symptoms result or when complications of sinusitis occur. Another indication for sinus puncture is to obtain culture material to guide antibiotic selection if empiric therapy has failed or antibiotic choice is limited. This is particularly important in patients who are immunocompromised or in intensive care. Sinusitis can be a prominent source of sepsis in these patients. In adults, sinus puncture can usually be achieved using local anesthesia; however, in children, a general anesthetic is usually necessary.

In today's era of minimally invasive surgical techniques, sinus endoscopy is commonly used to achieve sinus drainage. It offers the advantages of (1) being able to open multiple sinuses or to decompress the orbit in cases of complications and (2) allowing the surgeon to open the natural ostia of the involved sinuses.

The techniques and complications of open and endoscopic sinus surgical approaches are discussed in articles dealing with their individual surgical management.

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Consultations

Ophthalmological or neurosurgical consultation should be obtained when either orbital or intracranial complications develop.

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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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