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Acute sinusitis and rhinosinusitis in adults
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Mar 2012. | This topic last updated: Feb 16, 2012.

INTRODUCTION — Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses lasting less than four weeks. The term "rhinosinusitis" is preferred to "sinusitis" since inflammation of the sinuses rarely occurs without concurrent inflammation of the nasal mucosa [1].

Classification of rhinosinusitis is based on symptom duration.

  • Acute rhinosinusitis — symptoms for less than four weeks
  • Subacute rhinosinusitis — symptoms for 4 to 12 weeks
  • Chronic rhinosinusitis — persists greater than 12 weeks (figure 1)
  • Recurrent acute rhinosinusitis — four or more episodes of ARS per year, with interim symptom resolution [2]

Acute rhinosinusitis is further specified as acute bacterial rhinosinusitis (ABRS) or acute viral rhinosinusitis (AVRS).

The most common etiology of ARS is a viral infection associated with the common cold. Viral rhinosinusitis is complicated by acute bacterial infection in only 0.5 to 2.0 percent of episodes [3]. Uncomplicated AVRS typically resolves in 7 to 10 days. ABRS also is most commonly a self-limited disease, with 75 percent of cases resolving without treatment in one month. Rarely, patients with untreated bacterial disease may develop serious complications. (See "Orbital cellulitis".)

Distinguishing AVRS of colds and influenza-like illnesses from bacterial infection is a frequent challenge to the primary care clinician. Antibiotics may be indicated for ABRS, but are ineffective and not recommended for AVRS. Despite the overwhelming prevalence of a viral etiology, however, 92 percent of patients in the United Kingdom [4] and 85 to 98 percent of patients in the United States (US) [5] are prescribed an antibiotic when seen for an upper respiratory or sinus infection.

This topic will address the diagnosis and treatment of acute rhinosinusitis. Chronic rhinosinusitis is discussed separately. (See "Clinical manifestations, pathophysiology, and diagnosis of chronic rhinosinusitis" and "Medical management of chronic rhinosinusitis".) Diagnosis and management of the common cold is also discussed separately. (See "The common cold in adults: Diagnosis and clinical features" and "The common cold in adults: Treatment and prevention".)

EPIDEMIOLOGY — Sinusitis affects more than 30 million adults in the United States annually [2].

Direct costs of sinusitis in the US, resulting from medications, outpatient and emergency room visits, and ancillary tests and procedures, are estimated at $3 billion per year [2,6]. The socioeconomic impact is further magnified by indirect costs from decreased productivity, days lost from work, and impaired quality of life.

PATHOPHYSIOLOGY — The vast majority of cases of acute rhinosinusitis (ARS) are due to viral infection. As noted above, acute bacterial infection occurs in only 0.5 to 2.0 percent of episodes. The most common viruses, determined by maxillary sinus puncture and aspiration, are rhinovirus, influenza virus, and parainfluenza virus [7].

Acute viral rhinosinusitis (AVRS) begins with viral inoculation via direct contact with conjunctiva or nasal mucosa. Viral replication in a nonimmune individual leads to detectable viral levels in nasal secretions within 8 to 10 hours. Symptoms, if they develop, usually present in the first day after inoculation.

Viral rhinitis spreads to the paranasal sinuses by systemic or direct routes. Nose blowing may be an important mechanism; positive intranasal pressures generated during nose blowing may propel contaminated fluid from the nasal cavity into the paranasal sinuses [8]. Inflammation follows, resulting in sinonasal hypersecretion and increased vascular permeability, followed by transudation of fluid into the nasal cavity and sinuses. Viruses also can exert a direct toxic effect on nasal cilia, impairing mucociliary clearance. A combination of mucosal edema, copious thickened secretions, and ciliary dyskinesia results in sinus obstruction and perpetuates the disease process [9].

Community-acquired acute bacterial rhinosinusitis (ABRS) occurs when bacteria secondarily infect the inflamed sinus cavity. Although usually occurring as a complication of viral infection, other predisposing conditions associated with acute bacterial sinusitis include allergy, mechanical obstruction of the nose, swimming, odontogenic infection, intranasal cocaine use, impaired mucociliary clearance (eg, cystic fibrosis, cilial dysfunction), immunodeficiency, and other factors that impair sinus drainage [10].

Normal respiratory flora in adults typically includes coagulase-negative Staphylococci, Corynebacterium, and Staphylococcus aureus. The most common bacteria associated with ABRS are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, with the first two comprising approximately 75 percent of cases of ABRS (table 1). When ABRS is due to extension of dental root infection into the sinus cavity, microaerophilic and anaerobic bacteria may be identified.

Community-acquired ABRS is typically caused by a single pathogen in high concentration (>100 colony-forming units [CFU]/mL), although two distinct pathogens in high concentrations are isolated in approximately 25 percent of patients [11].

CLINICAL MANIFESTATIONS — Symptoms of acute rhinosinusitis include nasal congestion and obstruction, purulent nasal discharge, maxillary tooth discomfort, and facial pain or pressure that is worse when bending forward [12-14]. Other signs and symptoms include fever, fatigue, cough, hyposmia or anosmia, ear pressure or fullness, headache, and halitosis.

Indications for urgent referral — Patients with high fever, acute facial pain, swelling, and erythema should be treated for acute bacterial rhinosinusitis, even if symptoms have not been present for seven days. Patients with high fevers and severe headache warrant immediate evaluation and probable imaging.

The finding of any of the following should lead to urgent referral to a specialist for the possibility of complications of sinusitis, including intracranial and orbital extension [15]:

  • Abnormal vision (diplopia, blindness)
  • Change in mental status
  • Periorbital edema

DIAGNOSIS — Analysis of the predictive value of multiple signs and symptoms has identified the following as most highly predictive of acute sinusitis, whether viral or bacterial [2]:

  • Purulent rhinorrhea
  • Nasal congestion and facial pain/pressure

The diagnosis is further supported by the presence of secondary symptoms, including anosmia, ear fullness, cough, and headache.

Clinical presentation is unfortunately of limited accuracy in distinguishing pure viral rhinosinusitis from secondary bacterial infection [16]. Several clinical criteria have been suggested to distinguish bacterial and viral infection, based on studies with methodological flaws, including lack of gold standards for establishing diagnosis and response and heterogeneous patient selection criteria [5,12,17,18]. The criteria suggested by Berg and Carenfelt for bacterial sinus infection are based on symptom correlation with bacterial cultures from antral puncture [19]; these criteria, however, may not be applicable to a primary care population.

Symptom duration and progression — The diagnosis of viral rhinosinusitis is based primarily upon history of the quality, duration, and progression of symptoms. Partial or complete resolution of symptoms within 7 to 10 days following the onset of an upper respiratory tract infection is indicative of acute viral rhinosinusitis (AVRS) [2,19-23]. In comparison, the probability of identifying a bacterial infection by sinus aspiration is about 60 percent for patients with symptoms persisting beyond 10 days [24].

A panel organized by the Centers for Disease Control, including representatives of the American Academy of Family Physicians, American College of Physicians, American Society of Internal Medicine, and the Infectious Diseases Society of America, identified the following symptoms as suggestive of acute bacterial rhinosinusitis (ABRS) [5,25,26]:

Rhinosinusitis symptoms lasting seven or more days and any of the following:

  • Purulent nasal discharge, or
  • Maxillary tooth or facial pain, especially unilateral, or
  • Unilateral maxillary sinus tenderness, or
  • Worsening symptoms after initial improvement

Worsening of rhinosinusitis symptoms after an initial improvement (double worsening) is particularly suggestive of ABRS [2,23].

Physical examination — Physical examination should encompass the usual evaluation for respiratory infections, including assessment of vital signs, eyes, ears, pharynx, teeth or sinus tenderness, lymph nodes, and chest. While direct visualization of the sinuses is not possible, a handheld otoscope or nasal speculum can be used to perform anterior rhinoscopy.

Notable exam findings may include diffuse mucosal edema, narrowing of the middle meatus, inferior turbinate hypertrophy, and copious rhinorrhea or purulent discharge. Polyps or septal deviation may be noted incidentally and may indicate pre-existing anatomic risk factors for the development of ABRS. Pain localized to the sinuses when the patient is asked to bend forward may be more reliable than pain provoked by direct percussion in the diagnosis of rhinosinusitis [27].

Transillumination of the sinuses has limited value as a diagnostic technique [28]. It is of potential use only for examining the maxillary and frontal sinuses and does not distinguish viral from bacterial acute rhinosinusitis.

Microbiologic culture — Viral culture of nasal secretions is impractical and unnecessary, given the self-limited nature of AVRS.

Bacterial culture of material from blind swabs of the nasal cavity or from purulent nasal secretions is not recommended, as results are not reliable. Therefore, patients who require antibiotic therapy will generally be treated empirically in the primary care setting, with antibiotic choice based on likely pathogen and susceptibility. (See 'Treatment' below.)

Endoscopic cultures can be performed with minimal morbidity in the otolaryngologist's office (figure 2) and are better tolerated than classic antral puncture with a large bore trocar or needle passed through the canine fossa or inferior meatus [29-31]. Endoscopically-guided middle meatal cultures correlated with cultures performed during maxillary antrostomy in 86 percent of patients in one study [32] and with maxillary punctures in 90 percent in a small prospective series [33].

Endoscopic or sinus aspirate culture, while not indicated in routine medical practice, should be considered if there is a suspicion of intracranial extension of the infection or other serious complications. Culture may also be helpful in patients where atypical pathogens may be suspected, including patients with nosocomial sinusitis, immunocompromise, cystic fibrosis, or recent hospitalization. Cultures are also indicated in patients with documented sinusitis who are not responding to empiric antibiotic therapy.

Radiologic tests — Radiography is generally not indicated in the initial evaluation of acute rhinosinusitis (ARS). Plain sinus films and sinus CT may show sinus fluid levels in patients with both AVRS and ABRS and cannot distinguish between viral and bacterial etiologies. Common findings of sinusitis on CT include air-fluid levels, mucosal edema, and air bubbles within the sinuses (figure 3).

Some form of mucosal abnormality on CT scan may be observed in as many as 42 percent of asymptomatic healthy individuals [34,35]. In one study of 31 patients with self-diagnosed "colds" confirmed by viral culture, mucosal thickening, or air-fluid levels of the maxillary sinuses were found on CT scan within two to three days of symptom onset in 87 percent [36]. CT abnormalities were also documented in ethmoid, frontal, and sphenoid sinuses (65, 32, and 39 percent, respectively). Resolution of radiographic abnormalities occurred by two weeks, and no subject received antibiotic therapy.

While not helpful in differentiating between viral and bacterial etiology, CT imaging is useful in refuting sinusitis as a diagnosis. Diagnoses such as allergy or non-allergic rhinitis, or atypical facial pain, might be considered in the absence of radiologic evidence of sinonasal mucosal edema or an air-fluid level. It is reasonable to consider CT imaging in patients with persistent symptoms in whom rhinosinusitis is not clearly suspected and one hopes to avoid a trial of empiric antibiotics.

Imaging studies are indicated in patients with clinical signs or symptoms of complicated ABRS including diminished visual acuity, diplopia, periorbital edema, severe headache, or altered mental status. Imaging may also be helpful in recurrent or treatment-resistant sinusitis to help delineate anatomic blockage of the osteomeatal complex [37].

Noncontrast CT scan is generally acknowledged to be the imaging procedure of choice for the sinus. CT is preferable to plain films for its ability to discern bony and soft tissue detail. Additionally, the sensitivity and specificity of plain sinus radiography is poor for detecting mucosal thickening of the paranasal sinuses (76 and 79 percent, respectively) [38,39]. The high false-negative rate is attributable to poor visualization of the ethmoid sinuses in plain films and the high false-positive rate to artifact and the inability to distinguish polyps and nasal masses from fluid or mucosal edema.

MRI is not indicated for routine evaluation of ABRS. It provides complementary soft tissue detail and is used in conjunction with CT for the evaluation of complications of acute rhinosinusitis, when extra sinus involvement is suspected.

Ultrasonography is of limited use in the diagnosis of ABRS, due to its high operator variability and inferior accuracy relative to other modalities [40,41].

TREATMENT — Treatment of viral rhinosinusitis aims to relieve symptoms of nasal obstruction and rhinorrhea; treatment does not shorten the clinical course of the disease. Treatment of acute bacterial rhinosinusitis (ABRS) may include antibiotics to eliminate the infection and prevent complications, although 40 to 60 percent of patients with ABRS will clear their infection spontaneously [42].

It is generally not possible to distinguish acute viral rhinosinusitis (AVRS) from ABRS in the first 10 days of illness based on history, examination, or radiologic study. Since AVRS is expected to resolve within 10 days, and ABRS may also resolve spontaneously within the first 10 days, patients who present with fewer than 10 days of symptoms in general should be managed with supportive care [43]. Exceptions would be patients who experience clinical worsening after initial improvement ("double sickening"), patients with severe symptoms and clearly worsening clinical course, and immunocompromised patients.

Acute viral rhinosinusitis (AVRS) — AVRS is a self-limited process. Treatment is supportive, aimed at symptom relief.

  • Analgesics such as nonsteroidal anti-inflammatories and acetaminophen are recommended for pain relief.
  • Mechanical irrigation with buffered, hypertonic saline may reduce the need for pain medication and improve overall patient comfort, particularly in patients with frequent sinus infections (table 2) [2,44]. In another study, however, hypertonic saline spray administered three times daily was not superior to normal saline spray or no spray in improving the nasal symptom scores or day of resolution in patients with acute rhinosinusitis [45].
  • Topical glucocorticoids (corticosteroids) have been shown to be beneficial as monotherapy for AVRS [46]. A randomized trial of mometasone furoate 200 mcg twice daily was superior to placebo and equivalent to amoxicillin in 981 subjects without acute bacterial rhinosinusitis (ABRS), with symptom relief reported following two to three days of use.
  • Topical decongestants, such as oxymetazoline, have been shown to significantly reduce edema but should be used sparingly (no more than three consecutive days) to avoid rebound congestion [47]. When compared to systemic decongestants, topical therapy appears to be as effective, if not more effective, and has the advantage of fewer side effects [2,48].
  • Oral decongestants are frequently used to reduce edema and facilitate aeration and drainage. Consistent reports on their efficacy are lacking, however. Some [49,50], but not all [51], studies have demonstrated improved patency of the nasal airway and sinus ostia. One randomized trial compared several decongestants (ephedrine sulfate 25 mg, pseudoephedrine HCL 60 mg, phenylephrine HCL 10 mg, and phenylpropanolamine HCL 25 mg) with placebo; only ephedrine was superior to placebo in this trial [52]. When eustachian tube dysfunction is a significant confounding factor, a short course (3 to 5 days) of oral decongestants may be warranted. Oral decongestants should be used with caution in patients with cardiovascular disease, hypertension, or benign prostate hypertrophy due to systemic adverse effects with oral alpha adrenergic preparations [53].
  • Rhinorrhea associated with the common cold and allergic rhinitis results from parasympathetic stimulation of the submucous gland of the paranasal mucosa. Topical ipratropium bromide 0.06 percent has been shown to significantly diminish such rhinorrhea [54].
  • Antihistamines are frequently prescribed for symptom relief due to their drying effects; however, there are no studies investigating their efficacy for this indication [2]. Additionally, over-drying of the mucosa may lead to further discomfort. Use in non-atopic patients should thus be limited to avoid potential side effects at the expense of little potential therapeutic benefit.
  • Mucolytics such as guaifenesin serve to thin secretions and may promote ease of mucus drainage and clearance. However, no published trials exist to definitively support their use [2].
  • Zinc preparations including lozenges, nasal sprays, and nasal gels have been used to hasten recovery in the common cold [55,56]. However, these preparations may cause anosmia, and their use is not recommended. The US Food and Drug Administration issued a public health advisory in June 2009 advising that three over-the-counter cold remedy products containing zinc (Zicam) should not be used because of multiple reports of permanent anosmia [57]. (See "The common cold in adults: Treatment and prevention", section on 'Zinc'.)

Community-acquired acute bacterial rhinosinusitis — For patients who present with 10 or more days of symptoms (purulent rhinorrhea, nasal congestion, and facial pressure), the likelihood of a diagnosis of ABRS increases. There are two acceptable treatment options for patients with mild symptoms for 10 or more days: observation or empiric antibiotic therapy.

Observation — Observation is considered a viable option due to a high rate of spontaneous resolution in community-acquired, uncomplicated rhinosinusitis, as evidenced by randomized, controlled studies of antimicrobials versus placebo [58,59].

Watchful waiting with assurance of follow-up has been recommended in 2007 guidelines from a multidisciplinary expert panel for selected patients with symptoms suggestive of mild ABRS [2]:

  • Mild pain
  • Temperature <38.3°C or 101°F

Patients under observation should be treated supportively for relief of symptoms for seven days after the time of diagnosis. If there is no improvement over this interval, or if there is worsening at any time, antimicrobial therapy is then initiated.

Factors such as age, general state of health, and comorbidities should be considered when choosing this option. Patients with moderately severe symptoms who meet clinical criteria for ABRS and patients with severe symptoms regardless of duration of illness should be treated with an antibiotic. (See 'Antimicrobials' below.)

Antimicrobials — Several studies and meta-analyses have addressed the efficacy of systemic antibiotics in the treatment of acute rhinosinusitis (ARS). Given the difficulty in distinguishing viral from bacterial infection, these studies are complicated by heterogeneity in patient symptoms, underlying etiology, and outcomes of treatment.

  • A randomized trial of adult patients (n = 166) presenting to primary care offices who met clinical criteria for acute bacterial rhinosinusitis evaluated whether a 10-day course of amoxicillin, compared to placebo, improved disease-related quality of life as measured by a symptom score [60]. There was no difference between groups at day 3, the primary specified outcome, or at day 10, although there was greater symptom improvement reported by the amoxicillin group at day 7. All patients were also offered symptomatic treatment for relief of pain, fever, cough, and nasal congestion.
  • A 2008 meta-analysis based on individual patient data (n = 2547) from nine randomized trials found that 15 patients with rhinosinusitis would need to be treated with antibiotics before one additional patient would be cured [16]. Clinical signs and symptoms did not define a patient subgroup that was more likely to benefit from treatment or distinguish viral from bacterial infection.
  • Another 2008 meta-analysis pooled results from 17 randomized trials in which acute sinusitis was variably diagnosed (the majority by clinical criteria, but also imaging, microbiology, and inflammatory markers) [61]. There was variability in choice of antibiotic, use of ancillary therapy, and inclusion of children (three studies). Compared to placebo, antibiotics were associated with a higher rate of cure or symptom improvement at 7 to 15 days (OR 1.64, 95% CI 1.35-2.0), but the magnitude of effect was moderate (cure or improvement in 77 percent with antibiotics versus 68 percent with placebo). The 9 percent difference in cure/improvement rate with antibiotic therapy was at the expense of an 8 percent increase in adverse effects, mostly gastrointestinal (30 percent versus 22 percent for placebo-treated patients).
  • A meta-analysis that analyzed data from five trials comparing antibiotics to placebo, defining failure as lack of cure or improvement at 7 to 15 days follow-up, found an increased response rate for antibiotics (RR 0.66, 95% CI 0.44-0.98) [62]. 80 percent of the participants not treated with antibiotics, and 90 percent of the antibiotic group, improved within two weeks. No one antibiotic was superior to another in the review of 51 studies comparing antibiotics.

When antibiotics are administered, treatment is most often initiated empirically. An antimicrobial with the narrowest spectrum against the most probable pathogen(s) is advised to minimize the risk of promoting drug resistance. Although culture-guided therapy is optimal, obtaining suitable cultures requires endoscopy or antral puncture and is generally reserved for patients with complications. (See 'Microbiologic culture' above.)

Four meta-analyses have concluded that newer and broader spectrum antibiotics are not significantly more effective than narrow spectrum antibiotics in patients with acute bacterial sinusitis [62-65]. A retrospective cohort study of 29,102 adults found nearly identical results with amoxicillin, trimethoprim-sulfamethoxazole, or erythromycin compared with broader spectrum antibiotics [66]. We prefer a 10 to 14 day course of amoxicillin (500 mg three times a day) for its narrow spectrum, relatively low cost, and low side-effect profile.

Trimethoprim-sulfamethoxazole, doxycycline, and macrolides are cost-effective acceptable alternative first-line therapies in penicillin allergic patients [2]. Macrolides possess anti-inflammatory properties that may add additional therapeutic benefit. Local and regional histograms of bacterial resistance should be referenced to understand resistance trends in the local community.

Increasing rates of penicillin resistance among S. pneumoniae, mediated by an altered penicillin binding protein, have led to higher dosing regimens of amoxicillin or a change in class of antimicrobial. Resistance rates vary regionally and range from 15 to 30 percent for intermediate- or highly-resistant pneumococci in the US [6,67]. Higher-dose amoxicillin (1 gram four times daily) could be used to treat intermediate-resistant S. pneumoniae. However, beta-lactamase producing M. catarrhalis and H. influenzae cannot be overcome by higher dosing [2] and may require combination therapy with amoxicillin-clavulanate. Cefpodoxime, cefdinir, cefuroxime, or levofloxacin are also acceptable choices for alternative coverage [68].

Topical glucocorticoids — Topical glucocorticoid (corticosteroid) therapy reduces inflammation and edema in the nasal mucosa and may be beneficial in the setting of acute inflammation and bacterial infection.

Published reports investigating topical glucocorticoids should be interpreted with caution, as they often contain both heterogeneous patient populations (acute, chronic and/or viral rhinosinusitis) and treatment regimens (concomitant decongestant, saline irrigation, antibiotic). A meta-analysis of three studies, involving patients with ABRS diagnosed by symptoms and confirmed by radiological or endoscopic studies, found that use of intranasal steroids, alone or as adjuvant therapy to antibiotics, increased the rate of symptom response compared to placebo (RR 1.11, 95% CI 1.04-1.18) [69]. One randomized study of patients with ABRS did not demonstrate benefit for intranasal glucocorticoids [70]. Subgroup analysis of this study, however, found that patients with less-severe symptoms did benefit, possibly because thicker nasal secretions and closed ostia in patients with more severe illness limit penetrance of the topical steroids [70].

Systemic glucocorticoids — A systematic review and meta-analysis of four randomized trials in adults with acute sinusitis (n = 1008) found that systemic glucocorticoids plus antibiotic, compared with antibiotic plus placebo or, in one trial, a nonsteroidal anti-inflammatory, resulted in improved symptom control at days three to seven (risk ratio, RR 1.4, 95% CI 1.1-1.8) [71]. Radiologic findings consistent with acute sinusitis were part of the diagnostic criteria in three studies. These results data are limited by the potential for attrition bias and the lack of long-term follow-up on the effects of steroids.

Unlike topical glucocorticoids, systemic glucocorticoids possess a significant side effect profile, including hyperglycemia, hypertension, increased appetite, mood changes, and insomnia, as well as effects on bone metabolism and cataract formation with more chronic exposure. We suggest not using systemic glucocorticoids in the outpatient treatment of acute rhinosinusitis, pending the availability of additional data from higher-quality trials.

Adjunctive therapy — Symptomatic relief measures, including analgesics, nasal saline irrigation, and topical and systemic decongestants, are appropriate for patients with ABRS and are discussed in the section on acute viral rhinosinusitis. (See 'Acute viral rhinosinusitis (AVRS)' above.)

Treatment failure — Treatment failure is defined as progression of symptoms at any time during treatment or failure to improve after seven days of therapy. Patients who fail first-line therapy require alternative antibiotic selection. Ideally, an endoscopically-guided culture could be performed to redirect antibiotic therapy. If no material is available on endoscopy for culture, a broader antibiotic choice can be empirically started and monitored for improvement. Levofloxacin (500 mg every 24 hours) or high-dose amoxicillin-clavulanate (two 1000 mg XR tablets twice daily, dose based on amoxicillin component) for 10 to 14 days has been recommended [6].

A CT scan of the sinuses may be performed if symptoms worsen or fail to improve, to verify that symptoms are in fact due to acute sinusitis, and not to concomitant allergy or other noninfectious etiologies.

Relapse after treatment — Recurrence of symptoms within two weeks of response to initial treatment usually represents inadequate eradication of infection. Patients who had a good response to initial therapy and who have mild symptoms of relapse can be treated with a longer course of the same antibiotic.

Patients who had only minimal symptom response with the initial antibiotic or whose relapse is moderate to severe, however, are more likely to have organisms resistant to the initial empiric antibiotic and would require a change in the drug selected. (See 'Treatment failure' above.)

Surgery — There is no indication for surgery in patients with uncomplicated ABRS. However, surgery may be emergently indicated in patients experiencing extra-sinus complications of ABRS including periorbital and orbital abscess, epidural abscess, meningitis, and brain abscess.

Nosocomial bacterial rhinosinusitis — Patients with extended stays in the intensive care unit (ICU), burn victims, and those with prolonged intubation, particularly nasotracheal, are at increased risk of developing ABRS [72]. Acute sinusitis affects 1 to 8 percent of patients in the ICU and usually presents as fever of unknown origin.

Gram-negative organisms including Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterobacter species, Proteus mirabilis, Serratia marcescens and some gram-positive cocci, in particular S. aureus, predominate in nosocomial infections [1,73].

Most patients will respond to conservative therapy with removal of nasal foreign bodies and treatment with nasal decongestants and culture-directed antibiotic therapy. If these measures fail, surgery may be indicated [73].

Acute invasive fungal rhinosinusitis — Acute, fulminant invasive fungal rhinosinusitis (IFRS) is a disease of immunosuppressed patients or patients with poorly controlled diabetes. The rapidly progressive and life-threatening nature of such an infection makes early diagnosis of paramount importance. If a diagnosis of IFRS is entertained, immediate consultation of an otolaryngologist is mandated.

Diagnosis is made by endoscopic examination and biopsy. Rhinoscopy may show either pale, ischemic mucosa or dusky, purplish mucosa with crusting. Histopathology demonstrates intravascular tissue invasion by fungal organisms. The most common species are Mucor, Rhizopus, Aspergillus, Absidia, and Basidiobolus [74]. Radiographic studies are ancillary and should not be relied on for treatment decision making.

Treatment is primarily emergency surgical debridement and, if possible, correction of the underlying immunologic derangement. Secondary treatment includes systemic anti-fungal therapy. Despite timely surgical debridement, and appropriate adjuvant medical treatment, mortality rates remain upwards of 50 percent. (See "Fungal rhinosinusitis".)

COMPLICATIONS — Complications of acute viral rhinosinusitis (AVRS), aside from acute bacterial rhinosinusitis (ABRS), are uncommon. While transient hyposmia is frequent, permanent anosmia occurs rarely. Viral-induced anosmia is more common in women and may be associated with a more severe antecedent viral infection [75,76].

Complications of ABRS, which now rarely occur, are related to local extension into the central nervous system (meningitis), orbit of the eye (orbital cellulitis), and periorbital tissues (osteitis of the sinus bones). (See "Orbital cellulitis".) Acute sinus infection may also be a precursor of chronic sinus disease, although this relationship is not well studied. (See "Clinical manifestations, pathophysiology, and diagnosis of chronic rhinosinusitis".)

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SUMMARY AND RECOMMENDATIONS

  • Acute rhinosinusitis (ARS), inflammation of the nasal cavity and paranasal sinuses lasting less than four weeks, is subdivided into acute viral rhinosinusitis (AVRS) and acute bacterial rhinosinusitis (ABRS). ABRS occurs in 0.5 to 2.0 percent of episodes. (See 'Introduction' above and 'Pathophysiology' above.)
  • The diagnosis of ARS is based on the presence of (1) purulent rhinorrhea and (2) nasal congestion and facial pain. Symptoms do not accurately distinguish viral from bacterial infection. ABRS is suggested by the presence of symptoms for seven or more days, especially if symptoms initially improve and then worsen. Cultures from nasal swabs or secretions are inaccurate. Radiography is generally not indicated in the initial evaluation of ARS. (See 'Diagnosis' above.)
  • AVRS is expected to resolve within 10 days; ABRS may also resolve spontaneously within the first 10 days. Patients who present with fewer than 10 days of symptoms, in the absence of high fever or symptoms suggesting complicated illness, should be managed with supportive care. We suggest mild analgesics, systemic or limited-duration topical decongestants, and fluid (Grade 2C). We suggest treatment with intranasal glucocorticoids (Grade 2B). We suggest not treating symptoms with antihistamines or zinc (Grade 2B). (See 'Indications for urgent referral' above and 'Acute viral rhinosinusitis (AVRS)' above.)
  • We suggest that patients with mild symptoms lasting more than 10 days be treated with observation and supportive therapy (as above) for an additional seven days (Grade 2C). (See 'Observation' above.)
  • We suggest treatment with an antibiotic for patients with moderate to severe symptoms of ABRS (T >101, severe pain) or for patients whose symptoms worsen during observation (Grade 2B). We recommend a narrow spectrum antibiotic for empiric therapy (Grade 1A). Our preference is for amoxicillin 500 mg three times a day for 10 to 14 days; trimethoprim-sulfamethoxazole, doxycycline, and macrolides are alternatives. We suggest topical glucocorticoids as adjunctive therapy (Grade 2B). (See 'Antimicrobials' above and 'Topical glucocorticoids' above.)
  • Nosocomial ABRS is relatively common in patients with prolonged nasotracheal intubation and often involves gram negative organisms. Nasal foreign bodies should be removed and patients treated with culture-directed antibiotic therapy. Immunosuppressed patients are at risk for acute fulminant invasive fungal rhinosinusitis; treatment involves endoscopic biopsy, emergency surgical debridement, and systemic antifungal therapy. (See 'Nosocomial bacterial rhinosinusitis' above and 'Acute invasive fungal rhinosinusitis' above.)
  • Complications of ABRS occur rarely and include orbital cellulitis, osteitis, and meningitis. (See 'Complications' above.)

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REFERENCES

  1. Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: Establishing definitions for clinical research and patient care. Otolaryngol Head Neck Surg 2004; 131:S1.
  2. Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007; 137:S1.
  3. Fokkens W, Lund V, Mullol J, European Position Paper on Rhinosinusitis and Nasal Polyps Group. EP3OS 2007: European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology 2007; 45:97.
  4. Ashworth M, Charlton J, Ballard K, et al. Variations in antibiotic prescribing and consultation rates for acute respiratory infection in UK general practices 1995-2000. Br J Gen Pract 2005; 55:603.
  5. Hickner JM, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Ann Intern Med 2001; 134:498.
  6. Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004; 130:1.
  7. Gwaltney JM Jr. Acute community-acquired sinusitis. Clin Infect Dis 1996; 23:1209.
  8. Gwaltney JM Jr, Hendley JO, Phillips CD, et al. Nose blowing propels nasal fluid into the paranasal sinuses. Clin Infect Dis 2000; 30:387.
  9. Mogensen C, Tos M. Quantitative histology of the maxillary sinus. Rhinology 1977; 15:129.
  10. Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part I. Evaluation. Am Fam Physician 2004; 70:1685.
  11. Evans FO Jr, Sydnor JB, Moore WE, et al. Sinusitis of the maxillary antrum. N Engl J Med 1975; 293:735.
  12. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997; 117:S1.
  13. Piccirillo JF. Clinical practice. Acute bacterial sinusitis. N Engl J Med 2004; 351:902.
  14. Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines. Mayo Clin Proc 2011; 86:427.
  15. Ah-See KW, Evans AS. Sinusitis and its management. BMJ 2007; 334:358.
  16. Young J, De Sutter A, Merenstein D, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet 2008; 371:908.
  17. Williams JW Jr, Simel DL. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA 1993; 270:1242.
  18. Hansen JG, Schmidt H, Rosborg J, Lund E. Predicting acute maxillary sinusitis in a general practice population. BMJ 1995; 311:233.
  19. Berg O, Carenfelt C. Analysis of symptoms and clinical signs in the maxillary sinus empyema. Acta Otolaryngol 1988; 105:343.
  20. Axelsson A, Runze U. Symptoms and signs of acute maxillary sinusitis. ORL J Otorhinolaryngol Relat Spec 1976; 38:298.
  21. Axelsson A, Runze U. Comparison of subjective and radiological findings during the course of acute maxillary sinusitis. Ann Otol Rhinol Laryngol 1983; 92:75.
  22. Williams JW Jr, Simel DL, Roberts L, Samsa GP. Clinical evaluation for sinusitis. Making the diagnosis by history and physical examination. Ann Intern Med 1992; 117:705.
  23. Fokkens W, Lund V, Bachert C, et al. EAACI position paper on rhinosinusitis and nasal polyps executive summary. Allergy 2005; 60:583.
  24. Gwaltney JM Jr, Scheld WM, Sande MA, Sydnor A. The microbial etiology and antimicrobial therapy of adults with acute community-acquired sinusitis: a fifteen-year experience at the University of Virginia and review of other selected studies. J Allergy Clin Immunol 1992; 90:457.
  25. Gonzales R, Bartlett JG, Besser RE, et al. Principles of appropriate antibiotic use for treatment of acute respiratory tract infections in adults: background, specific aims, and methods. Ann Intern Med 2001; 134:479.
  26. Snow V, Mottur-Pilson C, Hickner JM, et al. Principles of appropriate antibiotic use for acute sinusitis in adults. Ann Intern Med 2001; 134:495.
  27. Wilson JF. In the clinic. Acute sinusitis. Ann Intern Med 2010; 153:ITC31.
  28. Low DE, Desrosiers M, McSherry J, et al. A practical guide for the diagnosis and treatment of acute sinusitis. CMAJ 1997; 156 Suppl 6:S1.
  29. Benninger MS, Appelbaum PC, Denneny JC, et al. Maxillary sinus puncture and culture in the diagnosis of acute rhinosinusitis: the case for pursuing alternative culture methods. Otolaryngol Head Neck Surg 2002; 127:7.
  30. Benninger MS, Payne SC, Ferguson BJ, et al. Endoscopically directed middle meatal cultures versus maxillary sinus taps in acute bacterial maxillary rhinosinusitis: a meta-analysis. Otolaryngol Head Neck Surg 2006; 134:3.
  31. Talbot GH, Kennedy DW, Scheld WM, et al. Rigid nasal endoscopy versus sinus puncture and aspiration for microbiologic documentation of acute bacterial maxillary sinusitis. Clin Infect Dis 2001; 33:1668.
  32. Gold SM, Tami TA. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis. Laryngoscope 1997; 107:1586.
  33. Vogan JC, Bolger WE, Keyes AS. Endoscopically guided sinonasal cultures: a direct comparison with maxillary sinus aspirate cultures. Otolaryngol Head Neck Surg 2000; 122:370.
  34. Havas TE, Motbey JA, Gullane PJ. Prevalence of incidental abnormalities on computed tomographic scans of the paranasal sinuses. Arch Otolaryngol Head Neck Surg 1988; 114:856.
  35. Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991; 101:56.
  36. Gwaltney JM Jr, Phillips CD, Miller RD, Riker DK. Computed tomographic study of the common cold. N Engl J Med 1994; 330:25.
  37. Osguthorpe JD, Hadley JA. Rhinosinusitis. Current concepts in evaluation and management. Med Clin North Am 1999; 83:27.
  38. Berger G, Steinberg DM, Popovtzer A, Ophir D. Endoscopy versus radiography for the diagnosis of acute bacterial rhinosinusitis. Eur Arch Otorhinolaryngol 2005; 262:416.
  39. Lau J, Zucker D, Engels EA, et al. Diagnosis and treatment of acute bacterial rhinosinusitis. Evid Rep Technol Assess (Summ) 1999; :1.
  40. Engels EA, Terrin N, Barza M, Lau J. Meta-analysis of diagnostic tests for acute sinusitis. J Clin Epidemiol 2000; 53:852.
  41. Varonen H, Mäkelä M, Savolainen S, et al. Comparison of ultrasound, radiography, and clinical examination in the diagnosis of acute maxillary sinusitis: a systematic review. J Clin Epidemiol 2000; 53:940.
  42. Hwang PH. A 51-year-old woman with acute onset of facial pressure, rhinorrhea, and tooth pain: review of acute rhinosinusitis. JAMA 2009; 301:1798.
  43. Tan T, Little P, Stokes T, Guideline Development Group. Antibiotic prescribing for self limiting respiratory tract infections in primary care: summary of NICE guidance. BMJ 2008; 337:a437.
  44. Rabago D, Zgierska A, Mundt M, et al. Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. J Fam Pract 2002; 51:1049.
  45. Adam P, Stiffman M, Blake RL Jr. A clinical trial of hypertonic saline nasal spray in subjects with the common cold or rhinosinusitis. Arch Fam Med 1998; 7:39.
  46. Meltzer EO, Bachert C, Staudinger H. Treating acute rhinosinusitis: comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo. J Allergy Clin Immunol 2005; 116:1289.
  47. Spector SL, Bernstein IL, Li JT, et al. Parameters for the diagnosis and management of sinusitis. J Allergy Clin Immunol 1998; 102:S107.
  48. Caenen M, Hamels K, Deron P, Clement P. Comparison of decongestive capacity of xylometazoline and pseudoephedrine with rhinomanometry and MRI. Rhinology 2005; 43:205.
  49. Roth RP, Cantekin EI, Bluestone CD, et al. Nasal decongestant activity of pseudoephedrine. Ann Otol Rhinol Laryngol 1977; 86:235.
  50. Melén I, Friberg B, Andréasson L, et al. Effects of phenylpropanolamine on ostial and nasal patency in patients treated for chronic maxillary sinusitis. Acta Otolaryngol 1986; 101:494.
  51. Aust R, Drettner B, Falck B. Studies of the effect of peroral fenylpropanolamin on the functional size of the human maxillary ostium. Acta Otolaryngol 1979; 88:455.
  52. MCLAURIN JW, SHIPMAN WF, ROSEDALE R Jr. Oral decongestants. A double blind comparison study of the effectiveness of four sympathomimetic drugs: objective and subjective. Laryngoscope 1961; 71:54.
  53. Ziment I. Management of respiratory problems in the aged. J Am Geriatr Soc 1982; 30:S36.
  54. Druce HM, Spector SL, Fireman P, et al. Double-blind study of intranasal ipratropium bromide in nonallergic perennial rhinitis. Ann Allergy 1992; 69:53.
  55. Caruso TJ, Prober CG, Gwaltney JM Jr. Treatment of naturally acquired common colds with zinc: a structured review. Clin Infect Dis 2007; 45:569.
  56. Mossad SB. Effect of zincum gluconicum nasal gel on the duration and symptom severity of the common cold in otherwise healthy adults. QJM 2003; 96:35.
  57. www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm166996.htm (Accessed on June 16, 2009).
  58. Merenstein D, Whittaker C, Chadwell T, et al. Are antibiotics beneficial for patients with sinusitis complaints? A randomized double-blind clinical trial. J Fam Pract 2005; 54:144.
  59. Bucher HC, Tschudi P, Young J, et al. Effect of amoxicillin-clavulanate in clinically diagnosed acute rhinosinusitis: a placebo-controlled, double-blind, randomized trial in general practice. Arch Intern Med 2003; 163:1793.
  60. Garbutt JM, Banister C, Spitznagel E, Piccirillo JF. Amoxicillin for acute rhinosinusitis: a randomized controlled trial. JAMA 2012; 307:685.
  61. Falagas ME, Giannopoulou KP, Vardakas KZ, et al. Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis of randomised controlled trials. Lancet Infect Dis 2008; 8:543.
  62. Ahovuo-Saloranta A, Borisenko OV, Kovanen N, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2008; :CD000243.
  63. de Ferranti SD, Ioannidis JP, Lau J, et al. Are amoxycillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis. BMJ 1998; 317:632.
  64. de Bock GH, Dekker FW, Stolk J, et al. Antimicrobial treatment in acute maxillary sinusitis: a meta-analysis. J Clin Epidemiol 1997; 50:881.
  65. Karageorgopoulos DE, Giannopoulou KP, Grammatikos AP, et al. Fluoroquinolones compared with beta-lactam antibiotics for the treatment of acute bacterial sinusitis: a meta-analysis of randomized controlled trials. CMAJ 2008; 178:845.
  66. Piccirillo JF, Mager DE, Frisse ME, et al. Impact of first-line vs second-line antibiotics for the treatment of acute uncomplicated sinusitis. JAMA 2001; 286:1849.
  67. Small CB, Bachert C, Lund VJ, et al. Judicious antibiotic use and intranasal corticosteroids in acute rhinosinusitis. Am J Med 2007; 120:289.
  68. Henry DC, Kapral D, Busman TA, Paris MM. Cefdinir versus levofloxacin in patients with acute rhinosinusitis of presumed bacterial etiology: a multicenter, randomized, double-blind study. Clin Ther 2004; 26:2026.
  69. Zalmanovici A, Yaphe J. Steroids for acute sinusitis. Cochrane Database Syst Rev 2007; :CD005149.
  70. Williamson IG, Rumsby K, Benge S, et al. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial. JAMA 2007; 298:2487.
  71. Venekamp RP, Thompson MJ, Hayward G, et al. Systemic corticosteroids for acute sinusitis. Cochrane Database Syst Rev 2011; :CD008115.
  72. Bach A, Boehrer H, Schmidt H, Geiss HK. Nosocomial sinusitis in ventilated patients. Nasotracheal versus orotracheal intubation. Anaesthesia 1992; 47:335.
  73. Casiano RR, Cohn S, Villasuso E 3rd, et al. Comparison of antral tap with endoscopically directed nasal culture. Laryngoscope 2001; 111:1333.
  74. Schell WA. Unusual fungal pathogens in fungal rhinosinusitis. Otolaryngol Clin North Am 2000; 33:367.
  75. Sugiura M, Aiba T, Mori J, Nakai Y. An epidemiological study of postviral olfactory disorder. Acta Otolaryngol Suppl 1998; 538:191.
  76. Harris R, Davidson TM, Murphy C, et al. Clinical evaluation and symptoms of chemosensory impairment: one thousand consecutive cases from the Nasal Dysfunction Clinic in San Diego. Am J Rhinol 2006; 20:101.
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