Medical Treatment for Acute Sinusitis Treatment & Management

Updated: Mar 29, 2018
  • Author: Ted L Tewfik, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Treatment

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.

In retrospective and prospective studies of pediatric patients with acute respiratory tract infection, including 4234 and 667 with acute sinusitis in the retrospective and prospective studies, respectively, Gerber et al found clinical outcomes with broad-spectrum antibiotics to be no better than those with narrow-spectrum antibiotics. In the retrospective patient cohort, for example, broad-spectrum antibiotics were associated with a 3.4% treatment failure rate, versus a 3.1% rate for the narrow-spectrum drugs. Moreover, in the prospective study, the risk of adverse events, as documented by clinicians, was higher for broad-spectrum antibiotics (3.7%) than for the narrow-spectrum treatments (2.7%). [8]

A retrospective cohort study by Pynnonen et al, conducted at a single academic institution, suggested that antibiotics are being overused in the treatment of patients with mild acute sinusitis of short duration. The investigators found that 66% of such patients were being given antibiotics, with antibiotic use varying according to the individual provider, the provider’s specialty (with emergency medicine providers tending to use more antibiotics), and whether a medical trainee was present. [9]

A study by Bergmark and Sedaghat indicated that in the United States, the antibiotic prescription rate for cases of acute rhinosinusitis is over 50% by primary care providers (PCPs) and emergency departments (EDs), reporting that PCPs prescribed antibiotics to 57.0% of adults presenting with acute rhinosinusitis and that EDs prescribed antibiotics to 59.1% of such patients. Among pediatric patients, the rates for PCPs and EDs were 52.9% and 51.4%, respectively. The investigators did find, however, that PCPs in the Northeast United States were more likely to prescribe antibiotics for acute rhinosinusitis than were those in other parts of the country. [10]

A study by Fleming-Dutra et al found that, based on the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, sinusitis was responsible for 56 ambulatory antibiotic prescriptions per 1000 population in the United States, the highest rate of such prescriptions for a single diagnosis. [11]

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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.

A study by Patel et al suggested that after complicated acute pediatric sinusitis resolves following initial medical or surgical intervention, few patients require subsequent surgical treatment. The investigators reviewed the records of 86 children and adolescents, aged 2 months to 18 years, with either orbital (80 patients) or intracranial (6 patients) complications of acute sinusitis; the children were treated either surgically (27 patients) or medically (59 patients) during the acute phase of the disease. The study determined that four of the patients treated surgically and five of those treated medically needed surgery following the initial resolution of their sinusitis; eight of the nine patients required it because medical therapy failed for persistent rhinosinusitis, and one needed it after a second complication developed. [12]

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Consultations

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

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