Acute Sinusitis Management

1. See Also
   1. Acute Sinusitis
2. Management: General Measures
   1. Symptomatic relief
      1. Warm, moist compresses over sinuses
      2. Tylenol
   2. Nasal Saline spray (2% buffered saline) or Neti Pot
      1. Effective Decongestant
      2. Also use as pretreatment prior to Intranasal Steroid
      3. Effective in recurrent Sinusitis when used daily
         1. Rabago (2002) J Fam Pract 51:1049-55
         2. Papsin (2003) Can Fam Physician 49:168-73
   3. Mucolytic
      1. Guaifenesin (e.g. Mucinex) 600 to 1200 mg PO bid
   4. Combination Mucolytic with Decongestant
      1. Entex PSE bid
   5. Topical Decongestants (Maximum of 3 days of use)
      1. Oxymetazoline (Afrin)
      2. Phenylephrine (Neo-Synephrine)
   6. Systemic Decongestants (e.g Pseudoephedrine)
      1. Not recommended due to systemic adverse effects and adds little to symptomatic relief over other options
      2. Diversion to Methamphetamine production only reinforces a policy to discourage pseudophedrine availability and use
      3. Consider 3 days of Afrin nasal spray for facial pain relief
   7. Intranasal Steroids (treat for 3-6 weeks minimum if indicated)
      1. Chronic Sinusitis
      2. Nasal Polyps
      3. Dolor (2001) JAMA 286:3097-105
   8. Avoid Antihistamines
      1. Dry secretions
      2. Impede osteomeatal complex drainage
3. Management: Antibiotics
   1. Indicated only in acute bacterial Sinusitis
      1. See Acute Sinusitis for Diagnosis
      2. See Sinusitis Prediction Rules
      3. Persistent Sinusitis symptoms >7-10 days
      4. Moderate to severe facial pain
      5. Fever over 101 F
   2. Protocol
      1. Antibiotic course
         1. Minimum course: 10 days
         2. Consider longer course for persistent or recurrent symptoms suggestive of bacterial Sinusitis: 14-28 days
      2. Change antibiotic if no improvement in 7 days
         1. Beta-lactamase resistance in acute cases: <30%
         2. Beta-lactamase resistance in chronic cases: 40-50%
   3. First-Line
      1. Indications to start on first-line agents
         1. Mild to moderate symptoms
         2. No daycare exposure or recent antibiotic use
            1. Consider starting with high dose Amoxicillin if higher risk for Antibiotic Resistance
      2. Amoxicillin
         1. Adult: 1000 mg orally twice daily
         2. Child: 90 mg/kg/day divided bid to tid (high dose)
         3. Disadvantages: Misses Beta-lactamase producers
            1. HaemophilusInfluenzae
            2. Moraxella catarrhalis
            3. Penicillin Resistant Pneumococcus (increasing)
      3. Trimethoprim Sulfamethoxazole (Bactrim, Septra)
         1. No longer recommended as first-line agent
            1. Higher resistance rate than other agents
         2. Dosing
            1. Adult: 160 TMP and 800 SMZ bid
            2. Child: 8 mg/kg/day TMP,40 mg/kg/day SMZ div. bid
         3. Disadvantages
            1. Misses Staphylococcus
            2. Risk of Toxic Epidermal Necrolysis
            3. Risk of Steven's Johnson Syndrome
   4. Second-Line
      1. Indications to start on second-line agents
         1. Severe symptoms
         2. Consider for daycare exposure or recent antibiotic use (or use high dose Amoxicillin instead)
      2. Amoxicillin-Clavulanate (Augmentin)
         1. Adult: 875 mg PO bid or 500 mg PO tid
         2. Child
            1. TID: 40 mg/kg/day divided q8 hours
            2. BID: 45 mg/kg/day divided q12 hours
      3. Cefuroxime (Zinacef, Ceftin)
         1. Adult: 250 to 500 mg PO bid
         2. Child: 30 mg/kg/day divided bid
      4. Cefpodoxime (Vantin)
         1. Adult: 200 mg PO bid
         2. Child: 10 mg/kg/day once daily
      5. Cefdinir (Omnicef)
         1. Adult: 300 mg PO bid or 600 mg PO qd
         2. Child: 14 mg/kg/day divided qd-bid
      6. Avoid Cefixime
         1. Poor Gram Positive Bacteria coverage
   5. Third Line
      1. Consider adding Flagyl to second-line agents
      2. Consider second-line agent for longer course (4 week)
      3. Fluoroquinolones (avoid under age 16 years)
         1. Levofloxacin (Levaquin) 500 mg daily
         2. Moxifloxacin (Avelox) 400 mg daily
4. Management: Penicillin or Cephalosporin Allergy
   1. Macrolide antibiotics (High bacterial resistance rate)
      1. Erythromycin
      2. Azithromycin (Zithromax)
      3. Clarithromycin (Biaxin)
   2. Trimethoprim-Sulfamethoxazole (Bactrim, Septra)
      1. Increasing bacterial resistance
      2. Other agents are preferred for Sinusitis
   3. Clindamycin (Cleocin)
      1. Consider in combination with Rifampin if severe
      2. Poor efficacy against Gram Negative Bacteria
   4. Fluoroquinolones (avoid under age 16 years)
      1. See Third line agents above
5. Management: Referral Indications to ENT
   1. See Also Sinus Surgery
   2. Sinusitis refractory to maximal medical management
      1. Recurrent Acute Sinusitis
      2. Persistent Chronic Sinusitis Symptoms
   3. Complicated Sinusitis
      1. Immunocompromised patient
      2. Toxic appearance
      3. Suspected contiguous orbital or cerebral involvement
         1. See red flag symptoms in Acute Sinusitis
         2. Sphenoid and Frontal Sinusitis are higher risk
6. References
   1. (2000) Otolaryngol Head Neck Surg 123:S1-S31
   2. (2001) Pediatrics 108:A24
   3. Aring (2011) Am Fam Physician 83(9): 1057-63
   4. Brook (2000) Laryngol 109:2-20
   5. Dowell (1998) Am Fam Physician 58:1113-23
   6. Osguthorpe (2001) Am Fam Physician 63:69-76
   7. Poole (1999) Am J Med 106(5A):38S-47S
   8. Snow (2001) Ann Intern Med 134:495-7