Laboratory Studies

Some authors have reported on the use of laboratory tests including sedimentation rate, white blood cell counts, and C-reactive protein levels to help diagnose acute sinusitis.^[4]These tests appear to add little to the predictive value of clinical findings in the diagnosis.

Cultures are not routinely obtained in the evaluation of acute sinusitis but should be obtained in a patient in intensive care or with immunocompromise, in children not responding to appropriate medical management, and in patients with complications of sinusitis. Because the nose is colonized with multiple nonpathogenic species of bacteria, care must be taken when evaluating culture results. A specific organism is considered pathogenic when more than 104 colony-forming units of the species are grown on culture or when polymorph counts are greater than 5000 cells/mL.

Imaging Studies

Imaging studies are not necessary when the probability of sinusitis is either high or low but may be useful when the diagnosis is in doubt, based upon a thorough history and physical examination. Plain sinus radiographs may demonstrate mucosal thickening, air-fluid levels, and sinus opacification. Limitations of plain films include interobserver variability, inability to distinguish infection from a polyp or tumor disease, and poor depiction of the ethmoid and sphenoid sinuses.

CT scanning has poor specificity for the diagnosis of acute sinusitis, demonstrating sinus air-fluid levels in 87% of individuals with simple URTIs and 40% of asymptomatic individuals. CT scanning is the modality of choice, however, in specific circumstances such as in the evaluation of a patient in intensive care, when complications are suspected, or in the preoperative evaluation of surgical candidates. CT scanning can give valuable information regarding the anatomical and mechanical contributions in the development of acute sinusitis. Coronal views with bone windows are the preferred sinus study for evaluating each of the sinuses as well as the ostiomeatal complex.

Magnetic resonance imaging (MRI) is excellent for evaluating soft tissue disease within the sinuses, but it is of little value in the diagnostic workup for acute sinusitis.

Treatment & Management

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.

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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 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.