Mercy Family Practice SC

Sinusitis

Table of Contents

Background

Sinus infection is probably one of the most common ailments that we see in private practice. I once had a professor tell me, "behind every dam there is mud." What he meant by that is if you have an orifice that is plugged, fluid and debris accumulates in the space preceding it. In the case of the sinuses, the opening to the outside world is plugged. Bacteria that is trapped there will start to multiply. The accumulation causes pressure, pain, and extension into the surrounding tissues. In the case of sinusitis, this amounts to pain and pressure under the eye sockets, behind the maxillary arch on each side, stuffiness in the nose, pressure in the Eustacian tubes, causing referred pain in the ears and sometimes extension into the lacrimal glands, which may result in yellow or green drainage in the eyes. A common feeling is that you want to drill a hole in your cheek bones to remove the pressure and drain out the junk. Timeframe is important. It takes approximately 10 days to get a sinus infection.

If you call the office, we will go though a quick checklist. It goes something like this:

Symptoms for 2-3 days.

  • Is this a strep throat infection? The three main signs of this include: (1) red or swollen tonsils in the back of the throat, (2) swollen lymph nodes anterior and under the jaw on either side of the larynx, and (3) a fever. If you have two or more of these symptoms, then you should come in.
  • Is this influenza. First, there should be a local outbreak. This occurs usually between December and March every winter. The tel tail sings include (1) Fever, (2) extreme fatigue, (3) Upper respiratory signs with significant cough, phlegm production, difficulty breathing. Since this acts like most other upper respiratory infections, you need to come in and get a nasal swab to test for influenza. Obviously, prevention is best. It has been shown that taking the flu shot every year has a 60% response rate. If you are diagnosed with the flu, you may receive Tamiflu, or a similar antiviral medication.
  • Is this viral gastroenteritis. Often people mistake this for the "flu." It is not the flu. It is a stomach virus--the flu is an upper respiratory virus. Unfortunately it has remained in the vernacular. This virus will inhibit the colon's ability to reabsorb water. This results in stomach cramps and diarrhea. Typically the "stomach flu" last only 48-72 hours in most instances, and then resolves on its own.

Symptoms for over 10 days.

Sinusitis: It takes a while for a sinus infection to occur. At this point, you have reached the point of "no return" so to speak. If you were going to recover, you would have done so by now. The cause is multifactorial. Some people have structural abnormalities that interfere with the bodies abilities to drain the sinuses. A small amount of edema can prevent drainage of the sinuses. Sometimes people have allergies that cause the sinus opening to swell, preventing proper drainage. For whatever reason, if the sinus cavities do not drain properly, then they become infected. Likewise, if it takes a long time for the sinuses to become infected, it often takes a long time for them to resolve. Often it takes from 2-4 weeks of antibiotics to clear a sinus infection. In addition to antibiotics, we often use other medications such as decongestants, antihistamines, and expectorants. The most common decongestant is pseudoephedrine (PSE); common non-sedating antihistamines include clemastine (Tavist), cetirizine (Zyrtec) and fexofenadine (Allegra). Often we recommend a normal saline sinus rinse. Often Ocean Spray nasal or a Netty Pot is often used for the latter. Although there is no study that supports the use of adjunct therapy for sinusitis, it often makes patients feel better and able to tolerate the symptoms until they fully recover from the infection.

Figure 1, Schematic of the sinuses, coronal view

Figure 2, X-ray of the sinuses, coronal view


The asterisk '*' marks the ethmoids, the M the middle turbinates, the 'I'
the Inferior turbinates, and the arrows point to the osteomeatal complex,
an opening that connects the maxillary sinuses to the nasal passage.
Swelling at this location is the leading cause of sinusitis.

Literature

A recent article has looked at an evidence-based approach to the diagnosis and management of acute sinus infection. As the devil's advocate, you may ask, "Why not just treat everyone with suspected sinusitis with antibiotics?" For years, this has been the approach. For the past quarter century, physicians have overtreated patients with antibiotics. The down side has been drug resistance. Now there are several forms of bacteria that cannot be treated with standard antibiotics. The cost of treating indiscriminately has been the emergence of resistant strains of bacteria. There may come a day where there are no new antibiotics that will work. That day is approaching quickly.

Therefore, a new conservative approach has emerged to balance the need for antibiotic treatment against the likelihood when it will do the most good. Figure 3 illustrates and algorithm which is the summary of current thinking:

Figure 3, Algorithm for the management of acute sinusitis


Click here for larger image

The diagnosis of sinusitis, even among otorhinolaryngologists, can be difficult to make. Specialists are often only able to make a correct diagnosis in 60% of cases. This makes the diagnosis elusive. Often we rely on the types of symptoms, the onset of the illness in days (at least 10), clinical impression, and sometimes a CT scan of the sinuses.

Table 1, Common Symptoms of Sinusitis

Major Symptoms Minor Symptoms
  • Purulent anterior nasal discharge
  • Purulent or discolored posterior nasal discharge
  • Nasal congestion or obstruction
  • Facial congestion or fullness
  • Facial pain or pressure
  • Hyposmia or anosmia; unable to smell
  • Fever (for acute sinusitis only)
  • Headache
  • Ear pain, pressure, or fullness
  • Halitosis; bad breath
  • Dental pain
  • Cough
  • Fever (for subacute or chronic sinusitis)
  • Fatigue

Predictors of Infection

The best predictors of an acute sinusitis come from a study by Hanset et al in which symptoms were correlated with positive sinus cultures. The two most common bacteria are Streptococcus pneumoniae and Hemophilus influenzae.

Table 2, Predictive Value of Clinical Findings

Clinical Sign Relative Risk Ratio
Temperature >100F (38C) 4.63
History of maxillary toothache 2.86
Self-reported history of previous sinusitis 0.40

A value of 1.00 means that you are no more likely to have an infection.
A value above 1.00 means her are likely to have an infection and vise verse.

Figure 4, Natural History of the Course of Sinusitis

Treatment

The mainstay of treatment in the US has been antibiotics. This still remains the main modality. In Europe, myringotomy (aspiration of fluid by piercing the ear drum) has been shown to be equally effective. For children and adults, the antibiotic with the highest effectiveness is amoxicillin-clavulanic acid (Augmentin). There are many second line agents that work as well. Often treatment has to be given up to a month for clearing of the infection (the range is 10-36 days).

There has been an ongoing debate regarding the overuse of antibiotics for approximately 15 years. Many feel we are entering a new era in which antibiotics will no longer work. The reason for this is that due to overuse, many bacteria have been able to produce enzymes that counteract the antibiotics mechanism. A recent article suggests that antibiotics only help in 2-10% of the upper respiratory illnesses, and the 90-98% are due to viruses.[2] The author suggests using the following red flags to note when antibiotics may be helpful: "symptoms persisting at least 10 days without improvement, or signs of a worsening infection, such as a fever of 102-plus degrees, increased nasal discharge and facial pain lasting at least three days."

Table 3, Antibiotics for Sinusitis in Children

Indication & Antibiotic Dosage
First-line agent  
amoxicillin-clavulanate (Augmentin) 45-90 mg/kg/day orally twice a day
Penicillin Allergic  
levofloxacin (Levoquin) 10-20 mg/kg/day orally once to twice a day
clindamycin + cefixime (Suprax) 30-40 mg/kg/day orally three times per day + 8 mg/kg/day orally twice a day
clindamycin + cefpodoxime (Vantin) 30-40 mg/kg/day orally three times per day + 10 mg/kg/day orally twice a day

Table 4, Antibiotics for Sinusitis in Adults

Indication & Antibiotic Dosage
First-line agent  
amoxicillin-clavulanate (Augmentin) 500 mg/125 mg orally three times a day, or 875 mg/125 mg orally twice a day
doxycycline (Vibramycin) 100-200 mg orally once a day
Penicillin Allergic  
doxycycline (Vibramycin) 100-200 mg orally once a day
levofloxacin (Levoquin) 500 mg once a day
Moxifloxacin (Avelox) 400 mg once a day

Reference

1. Chow,Anthony W. et al, IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults, Clinical Infectious Diseases, March 20, 2012 (full article)

2. Huff, Charlotte, 'Unlearning' How to Prescribe Antibiotics, American College of Physicians, Sept 2012, 32(8), p 1-16 (full article)

 

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Phone 920-347-1990 . Fax 920-347-1991