1

Acute sinusitis

2

What is sinusitis? Hirschmann JV. Arch Intern Med 2002;162:256–64

• 90% of patients with colds have X-ray evidence of sinus disease which usually resolves spontaneously in 2–3 weeks.

• Clinical picture is a cold or influenza-like illness plus:

nasal congestion

maxillary toothache

sinus discomfort or tenderness

purulent nasal discharge

fever

headache or facial pain often made worse by bending forward

3

Does this patient have sinusitis?Diagnosing acute sinusitis by history and physical examination

Williams JW Jr and Simel DL. JAMA 1993;270:1242–46

• Maxillary toothache

• Purulent nasal secretion

• Poor response to decongestants

• Abnormal transillumination

• History of coloured nasal discharge

4 or more LR+ 6.4

3 LR+ 2.6

2 LR+ 1.1

1 LR+ 0.5

0 LR+ 0.1

4

Treatment options for sinusitis?Piccirillo JF. NEJM 2004;351:902–10

Antibiotic use limited

• Both in suspected sinusitis and X ray ‘confirmed’ sinusitis, RCTs on the use of antibiotics give conflicting results. The benefit of antibiotic is therefore uncertain

• Where they have shown benefit, there is no evidence for the use of newer agents over older agents

• Two-thirds of patients recover without antibiotic treatment

• A 7–10 day period of watchful waiting would be reasonable before antibiotics are prescribed

5

Management optionsPiccirillo JF. NEJM 2004;351:902–10.

• Agency for Health Care Policy and Research

– X-ray on suspicion, antibiotics for abnormal X-ray

– Use clinical decision rules to guide prescribing

– Symptomatic treatment only initially

– Routine empirical use of antibiotics

• Two-thirds of patients recover without antibiotics

• Initial symptomatic treatment or clinical decision rules are a cost-effective approach for uncomplicated cases