History

Acute sinusitis is a clinical diagnosis; thus, an understanding of its presentation is of paramount importance in differentiating this entity from allergic or vasomotor rhinitis and common URTIs. No specific clinical symptom or sign is sensitive or specific for acute sinusitis, so the overall clinical impression should be used to guide management. A history of purulent secretions and facial or dental pain are specific symptoms that may point to a bacterial etiology. In a patient in intensive care, acute sinusitis should be suspected in the presence of sepsis of unknown origin.

Physical

Anterior rhinoscopic examination, with or without a topical decongestant, is important to assess the status of the nasal mucosa and the presence and color of nasal discharge. Predisposing anatomical variations can also be noted during anterior rhinoscopy. Sinus transillumination and palpation are of little predictive value. A basic evaluation of ocular and neurological function is also necessary in order to rule out potential complications.

Endoscopic examination may reveal the origin of the purulent discharge from the middle meatus and may provide information about the nature of ostiomeatal obstruction. The use of endoscopy may also aid in the etiologic diagnosis of acute sinusitis by allowing the careful attainment of purulent secretions from the sinus ostia for culture.

Causes

The bacteria most commonly involved in acute sinusitis are part of the normal nasal flora. These bacteria can become sinus pathogens when they are deposited into the sinuses by sneezing, coughing, or direct invasion under conditions that optimize their growth. The most common bacterial pathogens in acute sinusitis are Streptococcus pneumoniae (30-40%), Haemophilus influenzae (20-30%), and Moraxella catarrhalis (12-20%). Staphylococcus aureus and Streptococcus pyogenes are isolated in rare cases. Sixty-six percent of patients with acute sinusitis grow at least 1 pathogenic bacterial species on sinus aspirates, while 26-30% percent of patients have multiple predominant bacterial species.

Anaerobic organisms have been found in fewer than 10% of patients with acute bacterial sinusitis, despite the ample environment available for their growth. The exceptions are in sinusitis resulting from a dental source and in patients with chronic sinus disease, in whom anaerobic organisms are usually isolated.

Gram-negative organisms, including Pseudomonas aeruginosa (15.9%), Escherichia coli (7.6%), Proteus mirabilis (7.2%), Klebsiella pneumoniae, and Enterobacter species, predominate in nosocomial sinusitis, accounting for 60% of cases. Polymicrobial invasion is seen in 25-100% of cultures. The other pathogenic organisms found in nosocomial patients are gram-positive organisms (31%) and fungi (8.5%). Viruses are the most common trigger of acute sinusitis. Rhinovirus, influenza, and parainfluenza viruses are the primary pathogens in 3-15% of patients with acute sinusitis.

Fungal causes of sinusitis are discussed in Allergic Fungal Sinusitis and Sinusitis, Fungal.

A study by Khalid et al indicated that the likelihood of developing acute rhinosinusitis is 33% greater in individuals with a 25-hydroxyvitamin D level below 20 ng/mL. Information was derived from the National Health and Nutrition Examination Survey 2001-2006.^[7]

Differential Diagnoses

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Media Gallery

Air-fluid level (arrow) in the maxillary sinus suggests sinusitis.

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Table 1. Dosage, Route, and Spectrum of Activity of Commonly Used First-Line Antibiotics*

Antibiotic	Dosage	Streptococcus pneumoniae			Haemophilus influenzae	Moraxella catarrhalis	Anaerobic bacteria
Antibiotic	Dosage	Sensitive	Intermediate	Resistant	Haemophilus influenzae	Moraxella catarrhalis	Anaerobic bacteria
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
Antibiotic	Dosage	Sensitive	Intermediate	Resistant	Haemophilus influenzae	Moraxella catarrhalis	Anaerobic bacteria
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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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; Ryte; Neosoma; MI10<br/>Received income in an amount equal to or greater than $250 from: Neosoma; Cyberionix (CYBX)<br/>Received ownership interest from Cerescan for consulting for: Neosoma, MI10.

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, The Society of Federal Health Professionals (AMSUS)

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.