Sinusitis is usually defined as an acute bacterial infection involving the mucosal surfaces of the paranasal sinuses and nasal cavity.1,3,9 It usually occurs secondary to an upper respiratory tract infection, but may develop from several other causes including swimming in contaminated water, the introduction of a nasal foreign body, or an ascending dental infection.9 Frequently what is seen is an increased colonization of some of the common respiratory pathogens such as S pneumoniae, H influenzae, or M catarrhalis. The presentation of sinusitis is highly variable, and is usually difficult to distinguish from simple rhinitis.4,6 Allergy testing may be helpful, since perennial allergic rhinitis can mimic sinusitis symptoms.9 No single symptom or sign is diagnostic and it is important to look at the overall presentation of history and physical findings in order to make the diagnosis of uncomplicated sinusitis.4,5,10When selecting an antibiotic regimen for sinusitis, one must consider the cost, safety, and local patterns of bacterial resistance in order to maximize therapy.4,7 The recommended antibiotic regimens listed below under acute and chronic sinusitis are for uncomplicated cases and it is assumed that the patient does not have any intracranial or orbital complications and that the patient’s immune function is not compromised. Complicated cases usually require hospitalization and the use of broad-spectrum intravenous antibiotics in order to cover for MRSA, Pseudomonas, anaerobes, gram negative rods, and fungal pathogens. Patients who are diagnosed with uncomplicated sinusitis and do not respond to initial therapy should be referred to an infectious disease specialist or otorhinolaryngologist in order to guide continued therapy.5,7
The principal bacterial pathogens in acute sinusitis are: Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. These particular bacteria are frequently referred to as “respiratory pathogens.” Other potential organisms include: Streptococcus pyogenes, Staphylococcus aureus, as well as mixed anaerobic bacteria (Peptostreptococcus, Fusobacterium, Bacteroides, Prevotella). The infection is polymicrobial in about one third of the cases. Anaerobic bacteria are likely to be seen in dental disease from an extension of the infection from the roots of the premolar or molar teeth to the sinuses.3,4Therapeutic Alternatives
Adjunct therapies may include: 1. topical vasoconstrictor such as phenylephrine to treat sinus drainage (limit therapy to 72 hours or less). 2. Topical or oral decongestants to treat nasal congestion. 3. Nasal or oral corticosteroids, to reduce inflammation. 4. Normal Saline nasal irrigation – provides some local symptomatic relief. 5. Analgesics or antipyretics as needed.1,2,4,5,10
Typical organisms isolated in chronic sinusitis include the respiratory pathogens listed above, as well as Staphylococcus epidermidis, Staphylococcus aureus, anaerobes, and gram-negative rods. Pseudomonas aeruginosa may also be present.1,2,4,5,7 To further complicate matters, chronic sinusitis is often a polymicrobial disease with cultures usually growing multiple pathogens.4,5,9
Chronic sinusitis usually presents as a persistent low-grade infection involving the paranasal sinuses and a persistent mucosal thickening, nasal obstruction and drainage.9 Impaired drainage may be a major contribution to the development of chronic sinusitis, and correction of the obstruction helps alleviate the infection and prevent recurrence.4,5,9,10 In contrast to acute uncomplicated sinusitis, chronic sinusitis that relies solely on the use of antimicrobial therapy without surgical drainage of collected pus may not result in clearance of the infection.4,5,9 Many physicians believe that surgical drainage is the mainstay of therapy in chronic sinusitis.4,5,9 When the patient does not respond to medical therapy, the physician should consider surgical drainage.9
|References (Alphabetical order)|
1. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Dis Mon – 2001 Nov; 47(11); 537.2. Brook I. Microbiology and antimicrobial management of sinusitis. Otolaryngol Clin North Am – 2004 Apr; 37(2); 253.
3. Cohen J., Powderly W. Infectious Diseases, 2nd ed. Mosby 2003.
4. Dykewicz MS. Rhinitis and sinusitis. J Allergy Clin Immunol. 2003 Feb; 111(2 Suppl): S520-9.
5. Ferri, Fred F., Ferri’s clinical advisor : instant diagnosis. Mosby 2002.
6. Gwaltney JM Jr. Acute community-acquired sinusitis. Clin Infect Dis 1996;23:1209-23.
7. Maccabee M. Medical therapy of acute and chronic frontal rhinosinusitis. Otolaryngol Clin North Am. 2001 Feb; 34(1): 41-7.
8. Mandell et al., eds., Principles and Practice of Infectious Diseases, 5th ed., vol. 2, pp. 676-683. New York: Churchill Livingston.
9. Noble J, ed. Textbook of Primary Care Medicine. Third ed. St. Louis: Mosby; 2001:1747-1753.
10. Osguthorpe JD. Adult rhinosinusitis: diagnosis and management. Am Fam Physician. Jan 2001; 63(1): 69-76.
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