Management of acute bacterial rhinosinusitis
Correspondence to: T Daniller (firstname.lastname@example.org)
Rhinosinusitis is one of the most common conditions presenting to clinicians worldwide, and can potentially have an enormous and a devastating socioeconomic impact.1 The majority of infections are viral in origin, and acute bacterial infection occurs in only 0.5 - 2% of cases.1 The dilemma and diagnostic challenge are therefore to distinguish acute viral rhinosinusitis (AVRS) from acute bacterial rhinosinusitis (ABRS).
Acute rhinosinusitis (ARS) is defined as symptomatic inflammation of the nasal cavity and paranasal sinuses of less than four weeks’ duration. Inflammation of the paranasal sinuses rarely occurs without associated inflammation of the nasal mucosa, and the preferred term is rhinosinusitis.1 As the focus of this review is ABRS, please see the reference list – an excellent source for definitions of subacute, chronic and recurrent ARS and any related inquiry.
Whatever the insult, the underlying problem is sinus ostial obstruction. This is usually due to a preceding viral infection. However, a number of host and environmental factors may predispose an individual to the development of ABRS (Table 1).
AVRS occurs via direct contact with the nasal mucosa or conjunctiva, with symptom onset within approximately 24 hours. Most commonly, rhinovirus, influenza and parainfluenza viruses are implicated. Thereafter, infection spreads contiguously or systemically to the paranasal sinuses. Positive intranasal pressures, as generated during nose blowing, are believed to play a role.
Inflammation ensues that results in nasal hypersecretion, mucosal oedema, increased vascular permeability and impaired mucociliary clearance with transudation of fluid into the sinuses and nasal cavity. This in turn leads to impaired drainage and ventilation of the paranasal sinuses due to obstruction of the sinus ostia. The ostiomeatal complex – the common drainage pathway for the frontal, anterior ethmoidal and maxillary sinuses – is particularly sensitive to this and affected most commonly. Retained, thickened secretions in concert with ciliary dyskinesia, obstructed ostia as well as the antigravitational placement of the ostia, especially of the maxillary antrum, perpetuate the disease process. This leads to the establishment of a favourable milieu for secondary bacterial colonisation and infection.
The normal nasal flora include: coagulase-negative staphylococci, corynebacteria and Staphylococcus aureus. The organisms (aerobic bacteria) most commonly associated with acute sinusitis are: Streptococcus pneumonia, Haemophilus influenzae and Moraxella catarrhalis. In odontogenic infections, or more chronic cases, microaerophilic organisms and anaerobes may be encountered.
Clinical manifestations and diagnosis1
Purulent rhinorrhoea, nasal congestion and facial pain or pressure are highly predictive of acute sinusitis, but the distinction between AVRS and ABRS is often difficult. Secondary symptoms such as anosmia, ear fullness, headache and cough may support the diagnosis. The diagnosis of ABRS is made when symptoms or signs of ABRS are present 10 days or more after the onset of upper respiratory symptoms, or with a worsening of symptoms and signs within 10 days (usually after 5 days) after initial improvement (double worsening). ARS is defined by EPOS3 , 4 as symptoms lasting less than 12 weeks with complete resolution, and the BSACI4 guidelines incorporate a clinical, endoscopic and radiological diagnosis. The RI guidelines4 use major and minor criteria for a diagnosis of ARS, at least two major symptoms or one major symptom with two or more minor symptoms. (See Table 2, cardinal symptoms in bold.)
Physical examination may reveal diffuse mucosal oedema with narrowing of the middle meatus, inferior turbinate hypertrophy and copious rhinorrhoea or purulent discharge. Pain localised to the sinuses on bending forward is more reliable than pain provoked by percussion of the sinuses.
Blind nasal swabs are not recommended. Endoscopically guided middle meatal cultures correlate well with maxillary punctures, but are not indicated routinely. Culture may be helpful in treating complicated cases, cases not responding to empiric treatment, or where atypical pathogens are suspected.
Radiological examination is usually not indicated in the initial evaluation. In cases not responding to treatment, in recurrent infections or in complicated ABRS, a high-resolution CT scan is the preferred modality. Plain films have a low sensitivity and specificity. MRI is not indicated for routine evaluation and ultrasonography is of limited use. (Excellent summary of guidelines in Table 2.4 )
Treatment1 , 8 , 9
Supportive treatment is indicated in AVRS; however, it does not shorten the clinical course. ABRS may also be treated with antibiotics to eliminate infection and prevent complications, although in a large proportion of patients (40 - 60%) the condition will resolve spontaneously (Table 3).
Treatment failure is defined as progression of symptoms at any time during treatment or failure to improve after 7 days of therapy. Relapse after treatment occurs due to recurrence of symptoms within 2 weeks as a result of inadequate eradication of infection. Unusual pathogens are often the culprit in patients with nosocomial infections and in those who are immune compromised. These patients may benefit from culture-directed therapy. In the acute setting, surgery is indicated only for complicated cases of ABRS.
Transient hyposmia commonly occurs, but permanent viral-induced anosmia is rare. Complicated ABRS arises due to local extension and spread to the CNS (meningitis, intracerebral/epidural abscesses), orbit (orbital cellulitis) and periorbita (periorbital abscess, osteitis).
ABRS may persist and become a chronic rhinosinusitis.
When to refer
Refer patients with:
• high fever, acute facial pain
• swelling and erythema
• abnormal vision (diplopia, blindness)
• altered mental status or meningism
• periorbital oedema and proptosis.
Table 1. Factors that may predispose to the development of ABRS
Host: Immotile cilia syndrome/ciliary dyskinesia
Anatomical abnormalities, e.g. severe septal deviation/spurs, nasal polyps, neoplasms, concha bullosa, paradoxically bent turbinates
Environmental: Infectious agents (viral/bacterial/fungal)
Irritants: tobacco smoke, noxious chemicals
Iatrogenic/traumatic: Nasal packing
Table 2. Rhinosinusitis initiative (RI) guidelines
Purulent nasal discharge (anterior or posterior)
Fever (acute only)
Table 3. Treatment of AVRS and ABRS
• Analgesia (paracetamol/NSAIDs)
• Mechanical irrigation with buffered hypertonic saline/normal saline
• Topical nasal steroid sprays (mometasone furoate 200 mg bd, superior to placebo and amoxicillin)
• Topical decongestants (oyxmetazoline) – not longer than 3 days
• Oral decongestants (beware: cardiovascular disease/hypertension/benign prostatic hypertrophy)
• Ipratropium bromide (0.06%)
• Mucolytics (guaifenesin)
• Zinc preparations not recommended (anosmia)
Community acquired, uncomplicated (mild pain and temperature <38.3°C) – treat supportively for 7 days after diagnosis; if no improvement or if worsening, initiate antibiotics (age, general state of health and co-morbidities important)
2. Antimicrobials (moderately severe and severe symptoms)
1st-line: amoxicillin 1 g tds for 10 days
Alternatives: amoxicillin-clavulanate 1g bd plus additional 500 mg amoxicillin bd or 2 g bd SR for 10 days
Cefpodoxime proxetil 200 - 400 mg bd for 10 days
Cefuroxime axetil 500 mg - 1g bd for 10 days
Amoxicillin 90 mg/kg/d in 3 divided doses for 10 days
Alternatives: amoxicillin-clavulanate 90 mg/kg/d total amoxicillin in 2 or 3 divided doses for 10 days
Cefpodoxime proxetil 8 - 16 mg/kg/d bd for 10 days
Cefuroxime axetil 15 - 30 mg/kg bd for 10 days
(Please see reference 9 for β-lactam allergy and failed initial therapy)
3. Adjunctive treatment
Intranasal steroid sprays (topical)
Systemic steroids not recommended as outpatient treatment
Analgesics, nasal saline irrigation, decongestants
1. Hwang PH, Getz A. Acute sinusitis and rhinosinusitis in adults. Available at www.uptodate.com (accessed 5 January 2012).
2. Rosenfield RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137(3 Suppl):S1-S3.
3. Thomas M, Yawn B, Price D, Lund V, Mullol J, Fokkens W. European Position Paper on Rhinosinusitis and Nasal Polyps Group. EPOS primary care guidelines: European position paper on the primary care diagnosis and management of rhinosinusitis and nasal polyps 2007 – a summary. Prim Care Respir J 2008;17(2):79-89.
4. Meltzer EO, Hamilos DL. Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines. Mayo Clin Proc 2011;86(5):427-443. Epub 2011; April 13.
5. Du Plessis DJ. Current approach to sinusitis. CME 2004;22(5):240-245.
6. Sinusitis Update Workgroup. The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol 2005;116:S13-47.
7. Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part I. Evaluation. American Family Physician 2004;70(9):1685-1692.
8. Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part II. Treatment. American Family Physician 2004;70(9):1697-1704.
9. Working Group of the Infectious Diseases Society of southern Africa. Updated guideline for the management of upper respiratory tract infections in South Africa: 2008. SA Fam Pract 2009;51(2):105-114.
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