GraffitientfernungSee related handout on acute sinusitiswritten by the authors of non steroid alternative to flonase article. Acute rhinosinusitis is one of the most common conditions alternatibe physicians treat in ambulatory care. Most cases of acute rhinosinusitis are caused by viral upper respiratory infections. A meta-analysis based on individual patient data found that bodybuilding fruhstuck clinical signs alternatiev symptoms were not effective for identifying patients with rhinosinusitis who would benefit from antibiotics. C-reactive protein and erythrocyte sedimentation rate are somewhat useful tests for confirming acute bacterial maxillary sinusitis.
Current Concepts in Adult Acute Rhinosinusitis
See related handout on acute sinusitis , written by the authors of this article. Acute rhinosinusitis is one of the most common conditions that physicians treat in ambulatory care. Most cases of acute rhinosinusitis are caused by viral upper respiratory infections. A meta-analysis based on individual patient data found that common clinical signs and symptoms were not effective for identifying patients with rhinosinusitis who would benefit from antibiotics.
C-reactive protein and erythrocyte sedimentation rate are somewhat useful tests for confirming acute bacterial maxillary sinusitis. Four signs and symptoms that significantly increase the likelihood of a bacterial cause when present are double sickening, purulent rhinorrhea, erythrocyte sedimentation rate greater than 10 mm per hour, and purulent secretion in the nasal cavity. Although cutoffs vary depending on the guideline, antibiotic therapy should be considered when rhinosinusitis symptoms fail to improve within seven to 10 days or if they worsen at any time.
First-line antibiotics include amoxicillin with or without clavulanate. Current guidelines support watchful waiting within the first seven to 10 days after upper respiratory symptoms first appear. Evidence on the use of analgesics, intranasal corticosteroids, and saline nasal irrigation for the treatment of acute rhinosinusitis is poor.
Nonetheless, these therapies may be used to treat symptoms within the first 10 days of upper respiratory infection. Radiography is not recommended in the evaluation of uncomplicated acute rhinosinusitis. For patients who do not respond to treatment, computed tomography of the sinuses without contrast media is helpful to evaluate for possible complications or anatomic abnormalities.
Referral to an otolaryngologist is indicated when symptoms persist after maximal medical therapy and if any rare complications are suspected. Symptoms of acute rhinosinusitis manifest when the mucosal lining in the paranasal sinuses and nasal cavity becomes inflamed.
Because the nasal mucosa is contiguous with mucosa of the paranasal sinuses, inflammation of the sinuses rarely occurs without inflammation of the nasal mucosa. Although this process is commonly called sinusitis, rhinosinusitis is the more accurate term. Each year in the United States, rhinosinusitis affects one in seven adults, resulting in more than 30 million annual diagnoses. Avoid prescribing antibiotics in the emergency department for uncomplicated sinusitis. Do not routinely obtain radiographic imaging for patients who meet diagnostic criteria for uncomplicated acute rhinosinusitis.
Do not routinely prescribe antibiotics for acute, mild to moderate sinusitis unless symptoms which must include purulent nasal secretions and maxillary pain or facial and dental tenderness to percussion last at least seven days or symptoms worsen after initial clinical improvement. American Academy of Family Physicians. For more information on the Choosing Wisely Campaign, see http: For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see https: For patients with acute rhinosinusitis, diagnostic imaging is not recommended unless a complication or alternative diagnosis is suspected.
In uncomplicated acute bacterial rhinosinusitis, watchful waiting without antibiotics is an appropriate initial management strategy when there is assurance of follow-up. In patients with rhinosinusitis, antibiotic therapy is recommended if symptoms persist seven days or more with no clinical improvement or if symptoms worsen at any time. Amoxicillin with or without clavulanate is the first-line antibiotic for most patients with acute bacterial rhinosinusitis.
Doxycycline or a respiratory fluoroquinolone levofloxacin [Levaquin] or moxifloxacin [Avelox] may be used as an alternative to amoxicillin for treating bacterial rhinosinusitis in patients who are allergic to penicillin. Mild rhinosinusitis symptoms lasting fewer than 10 days can be managed with supportive care, including analgesics, intranasal corticosteroids, and saline nasal irrigation.
For information about the SORT evidence rating system, go to https: Acute rhinosinusitis refers to symptoms lasting less than four weeks; subacute, four to 12 weeks 3 ; and chronic, more than 12 weeks. Acute bacterial rhinosinusitis is caused by various factors Table 1.
As a result, secretions stagnate, providing a favorable environment for bacterial growth. The most common viruses in acute viral rhinosinusitis are rhinovirus, adenovirus, influenza virus, and parainfluenza virus. Information from references 5 and 6. In the first three to four days of illness, viral rhinosinusitis cannot be differentiated from early acute bacterial rhinosinusitis.
Clinical practice guideline update: Otolaryngol Head Neck Surg. During the past decade, expert panels have created evidence-based guidelines for the diagnosis Table 2 and management of acute rhinosinusitis in adults.
Clinical Practice Guideline update: Purulent nasal discharge with nasal obstruction, facial pain, or facial pressure. Symptoms last less than seven days and do not worsen. Presumed acute bacterial rhinosinusitis: Severe symptoms in first three to four days of illness; symptoms persist seven days or longer after initial presentation; symptoms worsen within seven days of initial presentation.
Inflammation of the nasal cavity and paranasal sinus, characterized by either nasal congestion or obstruction or nasal discharge with or without facial pain or pressure with or without decreased sense of smell. Symptoms last less than 10 days and do not worsen. Symptoms persist more than 10 days after start of URI; symptoms worsen after five days. Two major symptoms or one major and more than two minor symptoms.
Purulent nasal discharge, nasal congestion or obstruction, facial congestion or fullness, facial pain or pressure, decreased sense of smell, fever.
For mild symptoms, watchful waiting for first three days of illness. Headache; ear pain, pressure, fullness; halitosis; dental pain; cough; fever; fatigue. Severe symptoms in first three to four days of illness; symptoms persist more than 10 days after start of URI; symptoms worsen after three to four days.
Joint Task Force on Practice Parameters Nasal congestion, purulent rhinorrhea, facial-dental pain, postnasal drainage, headache, cough, tenderness over sinuses, dark circles under eyes. Symptoms persist more than 10 to 14 days.
Rhinosinusitis Initiative Two or more major symptoms or one major and two or more minor symptoms see IDSA symptom lists above. Severe symptoms in first three to four days of illness; symptoms persist more than 10 days after start of URI; symptoms worsen within 10 days of initial improvement. Information from references 1 through 3 , 7 , 16 , and Erythrocyte sedimentation rate and C-reactive protein CRP are somewhat useful tests for diagnosing acute bacterial maxillary sinusitis. Radiography is not recommended in the evaluation of acute uncomplicated rhinosinusitis.
Positive results are not helpful because they cannot differentiate between viral and bacterial sinusitis. For patients with recurrent acute or chronic rhinosinusitis, computed tomography CT of the sinuses without contrast media is the imaging method of choice. CT is primarily used to define the anatomy of the sinuses before surgery, as well as to assess the extent, pattern, and a probable mechanical cause of the recurrent or chronic rhinosinusitis. A thickened mucosa of 5 mm or greater on CT is a significant sign of sinus infection.
Because viral rhinosinusitis is a self-limited disease, management is primarily directed toward symptom relief and avoidance of unnecessary antibiotics.
Physicians continue to overprescribe antibiotics for acute rhinosinusitis. Watchful waiting is appropriate in place of antibiotics for seven to 10 days after upper respiratory symptoms appear when there is assurance of follow-up. Physicians may also provide these patients with a safety net antibiotic prescription also called a delayed prescription , with instructions describing when to fill the prescription. As a result of this research, the AAO-HNS guideline recommends offering watchful waiting to patients regardless of illness severity.
Antibiotics for the treatment of acute bacterial rhinosinusitis are outlined in Table 3. First line for coverage of beta lactamase—producing Haemophilus influenzae and Moraxella Branhamella catarrhalis. For possible Streptococcus pneumoniae resistance e. For moderate to severe disease, high risk of resistance, recent antibiotic use, or treatment failure. For patients with penicillin allergy or as second-line antibiotic.
Non—type I penicillin allergy or second-line antibiotic. Information from references 1 and Respiratory fluoroquinolones are not recommended as first-line antibiotics because they conferred no benefit over beta-lactam antibiotics and are associated with a variety of adverse effects.
Food and Drug Administration safety alert, fluoroquinolones should be reserved for patients who do not have other treatment options. The recommended duration of therapy for uncomplicated acute bacterial rhinosinusitis is five to 10 days for most adults. Treatment failure occurs when a patient's symptoms do not improve by seven days after diagnosis or when they worsen at any time, with or without antibiotic therapy.
Current guidelines consider analgesics, intranasal corticosteroids, and saline nasal irrigation to be options for the management of rhinosinusitis symptoms. Selection of interventions should be based on shared decision making. Decongestants, antihistamines, and guaifenesin are not recommended for patients with acute bacterial rhinosinusitis because of their unproven effectiveness, potential adverse effects, and cost.
Two systematic reviews of randomized controlled trials showed minimal benefit and symptom relief occurred late at 15 to 21 days 32 , One small randomized controlled trial found hypertonic saline decreased nasal symptoms Available in a low-pressure method using a spray or squeeze bottle or a gravity-flow method using a vessel with a nasal spout.
Another study found no significant difference between groups receiving no treatment vs. Significant adverse effects; phenylephrine is similar in effectiveness to placebo for nasal congestion due to seasonal allergic rhinitis One comparative trial found no significant difference in improvement among groups receiving no treatment vs.
Information from references 31 through An over-the-counter analgesic, such as acetaminophen or a nonsteroidal anti-inflammatory drug, is often sufficient to relieve pain or fever in acute rhinosinusitis.
Narcotics are not recommended because of potential adverse effects. Intranasal corticosteroids may be helpful in reducing mucosal swelling of inflamed tissue and facilitating sinus drainage because of an anti-inflammatory effect.
Even though their benefits are only marginal, 3 intranasal corticosteroids are often used as an adjunct to antibiotic therapy in the symptomatic treatment of acute bacterial sinusitis. They are likely most beneficial in patients with concurrent allergic rhinitis.
Intranasal irrigations with either physiologic or hypertonic saline have been shown to improve mucociliary clearance and may be beneficial for the treatment of acute rhinosinusitis. It is important to inform patients to prepare irrigations using distilled, boiled, or filtered water because there have been reports of amebic encephalitis due to contaminated tap water rinses.
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