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WDIDN Sinusitis

Matthew DeLaney, MD and Doug Wallace, MD
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23:20

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Lots of folks will get sinusitis, most of these patients will have a virus. It can be hard to figure out who actually has bacterial sinusitis.

Pearls:

  • <2% infectious sinusitis cases in UC are bacterial in etiology. 

  • There are no historical or physical exam findings that significantly help to predict bacterial sinusitis. 

  • Imaging and laboratory testing play no role in the evaluation of sinusitis in UC. 

  • Azithromycin is NOT recommended for suspected bacterial sinusitis. 

  • Systemic steroids are generally not recommended to treat sinusitis. 

 

Bacterial vs. Viral

  • In non-specialty care (ie: primary care, UC) populations, >98% of infectious sinusitis is viral in etiology.

  • >75% of patients with bacterial sinusitis will improve without antibiotics within one week.

  • There are no reliable physical exam findings to rule in or rule out a bacterial cause of sinusitis. 

    • Examples of positive LHRs for findings predicting bacterial etiology include:

      • Purulent Rhinorrhea - 1.5

      • Unilateral Facial Pain - 1.8

      • Biphasic illness/”double sickening” - 2.1

      • No relief from nasal decongestant - 2.1

      • Tenderness over the maxillae - 0.75

      • Leukocytosis on CBC - 2.9

      • Elevated CRP or ESR - 1.8

    • N.B. A positive LHR <10 is NOT considered helpful for ruling in a diagnosis. 

  • Neither CT nor XR imaging is helpful in distinguishing bacterial from viral sinusitis. 

    • 87% of patients with viral URIs will have an abnormal CT of the sinuses. 

    • The Choosing Wisely Campaign specifically advises against using CT for diagnosing simple sinusitis. 

  • Amoxicillin/clavulanate is the recommended first line agent when treating for presumed bacterial sinusitis.

    • Doxycycline is a reasonable choice in penicillin allergic patients.

    • Azithromycin is NOT recommended for treating bacterial sinusitis due to high levels of resistance in S. pneumoniae and other common pathogenic bacteria. 

Symptomatic Treatments:

  • Asking patients to show the packaging of the OTC preparations they are using for symptomatic relief is often helpful because there are >200 individual products available for sinus symptoms in the U.S.

  • Pseudoephedrine is the most effective systemic decongestant, however, it is typically sold “behind the counter” rather than OTC. 

    • Pseudoephedrine should be avoided in patients with severe heart disease, benign prostatic hypertrophy (BPH) or who are taking MAOI medications.

  • Oxymetazoline (Afrin) is an effective topical decongestant option, however, rebound rhinorrhea can occur when using for more than 5 consecutive days.

  • Dextromethorphan is minimally effective for cough, but it is unfortunately the most effective OTC antitussive.   

  • Older/first generation antihistamines are more effective than newer/second generation antihistamines for congestion associated with sinusitis. 

  • Guaifenesin is the only FDA approved expectorant, however, a Cochrane Review failed to show any evidence to support its effectiveness.

  • Systemic steroids are generally not recommended as there is no evidence to suggest they are effective for treatment of sinus symptoms. 

  • Intranasal steroids are probably effective, but also supported by limited evidence. 

  • Sinus irrigation has limited evidence supporting its value.

    • Existing evidence for sinus irrigation supports the Neti Pot type –large volume, low pressure irrigation – strategy. 

    • When irrigating the sinuses, the safest practice is to use sterile, distilled water. Salt can be added as well to reduce stinging. 

      • Contaminated water (usually in the developing world) can cause amebic brain infection. 

 

 References:

  1. McCoul E. Assessment of Pharmacologic Ingredients in Common Over-the-Counter Sinonasal Medications [published online ahead of print, 2020 Jul 16]. JAMA Otolaryngol Head Neck Surg. 2020;e201836. PMID: 21642737

  2. Worrall G. Acute sinusitis. Can Fam Physician. 2011 May;57(5):565-7. PMID: 21642737; PMID: 21642737

  3. De Bock G, et al. Antimicrobial treatment in acute maxillary sinusitis: a meta-analysis. J Clin Epidemiol. 1997;50(8):881-890.PMID: 9291872

  4. Okuyemi K, et al. Radiologic imaging in the management of sinusitis. Am Fam Physician. PMID: 12469962

  5. Horak F, et al. A placebo-controlled study of the nasal decongestant effect of phenylephrine and pseudoephedrine in the Vienna Challenge Chamber. Ann Allergy Asthma Immunol. 2009;102(2):116-120. PMID: 19230461

  6. Akerlund A, et al. Nasal decongestant effect of oxymetazoline in the common cold: an objective dose-response study in 106 patients. J Laryngol Otol. 1989;103(8):743-746. PMID: 2671220

  7. Muether P, et al. Variant effect of first- and second-generation antihistamines as clues to their mechanism of action on the sneeze reflex in the common cold. Clin Infect Dis. 2001;33(9):1483-1488. PMID: 11588693

  8. Smith S, et al. Over-the-counter (OTC) medications for acute cough in children and adults in community settings. Cochrane Database Syst Rev. 2014;(11):CD001831.PMID: 25420096

  9. Zalmanovici Trestioreanu A, et al. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2013;2013(12):CD005149. Published 2013 Dec 2. PMID: 24293353

  10. King D, et al.. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst Rev. 2015;(4):CD006821. Published 2015 Apr 20.PMID: 25892369

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