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]

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]

Consultations

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

Guidelines

Battisti AS, Pangia J. Sinusitis. 2018 Jan. [QxMD MEDLINE Link]. [Full Text].
Sharma GK, Taliaferro HG. Sinusitis, Recurrent. 2018 Jan. [QxMD MEDLINE Link]. [Full Text].
DeBoer DL, Kwon E. Acute Sinusitis. StatPearls. 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Santee CA, Nagalingam NA, Faruqi AA, et al. Nasopharyngeal microbiota composition of children is related to the frequency of upper respiratory infection and acute sinusitis. Microbiome. 2016 Jul 1. 4 (1):34. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): Adult Sinusitis Executive Summary. Otolaryngol Head Neck Surg. 2015 Apr. 152 (4):598-609. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link]. [Full Text].
Gerber JS, Ross RK, Bryan M, et al. Association of Broad- vs Narrow-Spectrum Antibiotics With Treatment Failure, Adverse Events, and Quality of Life in Children With Acute Respiratory Tract Infections. JAMA. 2017 Dec 19. 318 (23):2325-36. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Bergmark RW, Sedaghat AR. Antibiotic prescription for acute rhinosinusitis: emergency departments versus primary care providers. Laryngoscope. 2016 Nov. 126 (11):2439-44. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
[Guideline] Peters AT, Spector S, Hsu J, et al,. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol. 2014 Oct. 113 (4):347-85. [QxMD MEDLINE Link]. [Full Text].
[Guideline] 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. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012 Apr. 54 (8):e72-e112. [QxMD MEDLINE Link]. [Full Text].
University of Michigan Health System. Acute rhinosinusitis in adults. August 2011. Available at http://www.med.umich.edu/1info/FHP/practiceguides/Rhino/rhino.pdf.
[Guideline] US Food and Drug Administration. Fluoroquinolone Antibacterial Drugs: Drug Safety Communication - FDA Advises Restricting Use for Certain Uncomplicated Infections. FDA. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm500665.htm. May 25, 2016; Accessed: Oct 5, 2016.
[Guideline] Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013 Jul. 132 (1):e262-80. [QxMD MEDLINE Link]. [Full Text].
[Guideline] Yoon YK, Park CS, Kim JW, et al. Guidelines for the Antibiotic Use in Adults with Acute Upper Respiratory Tract Infections. Infect Chemother. 2017 Dec. 49 (4):326-52. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Rovelsky SA, Remington RE, Nevers M, et al. Comparative effectiveness of amoxicillin versus amoxicillin-clavulanate among adults with acute sinusitis in emergency department and urgent care settings. J Am Coll Emerg Physicians Open. 2021 Jun. 2 (3):e12465. [QxMD MEDLINE Link]. [Full Text].
Sobol SE, Marchand J, Tewfik TL, Manoukian JJ, Schloss MD. Orbital complications of sinusitis in children. J Otolaryngol. 2002 Jun. 31(3):131-6. [QxMD MEDLINE Link].
Chandler JR, Langenbrunner DJ, Stevens ER. The pathogenesis of orbital complications in acute sinusitis. Laryngoscope. 1970 Sep. 80(9):1414-28. [QxMD MEDLINE Link].
Cushen R, Francis NA. Antibiotic use and serious complications following acute otitis media and acute sinusitis: a retrospective cohort study. Br J Gen Pract. 2020 Apr. 70 (693):e255-63. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Bishai WR. Issues in the management of bacterial sinusitis. Otolaryngol Head Neck Surg. 2002 Dec. 127(6 Suppl):S3-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].

Media Gallery

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

of 1

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	+++	-	-	-	++

Back to List

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 Emeritus 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; 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 advisor.

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.