The diagnosis and management of sinusitis: A practice parameter update

Raymond G. Slavin, Sheldon L. Spector, I. Leonard Bernstein, Michael A. Kaliner, David W. Kennedy, Frank S. Virant, Ellen R. Wald, David A. Khan, Joann Blessing-Moore, David M. Lang, Richard A. Nicklas, John J. Oppenheimer, Jay M. Portnoy, Diane E. Schuller, Stephen A. Tilles, Larry Borish, Robert A. Nathan, Brian A. Smart, Mark L. Vandewalker

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255 Scopus citations

Abstract

Sinusitis, defined as inflammation of one or more of the paranasal sinuses, is characterized as acute when lasting less than 4 weeks, subacute when lasting 4 to 8 weeks, and chronic when lasting longer than 8 weeks. Recurrent sinusitis consists of 3 or more episodes of acute sinusitis per year. A noninfectious form of chronic sinusitis is termed chronic hyperplastic eosinophilic sinusitis. Viral upper respiratory tract infections frequently precede subsequent bacterial invasion of the sinuses by Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. These organisms can also be found in chronic sinusitis, as well as Staphylococcus aureus, Pseudomonas aeruginosa, and certain anaerobes. Fungi are being recognized increasingly as a factor in chronic sinusitis, particularly in the southeast and southwest parts of the country. Prominent symptoms of acute sinusitis include nasal congestion, purulent rhinorrhea, facial-dental pain, postnasal drainage, headache, and cough. Chronic sinusitis symptoms are similar but might be even more subtle. Pain is much less a feature of chronic sinusitis. Clinical signs of both acute and chronic sinusitis include sinus tenderness on palpation, mucosal erythema, purulent nasal secretions, increased pharyngeal secretions, and periorbital edema. There is an overlap in these symptoms with those of perennial rhinitis, and there is a frequent need to perform imaging procedures to confirm the diagnosis. Because of this overlap, some have suggested the use of the term rhinosinusitis. Imaging techniques can provide confirmatory evidence of sinusitis when symptoms are vague, physical findings are equivocal, or clinical disease persists despite optimal medical therapy. The imaging technique of choice is computed tomography (CT) because it can demonstrate abnormalities both in the ostiomeatal complex and the sinus cavities. Laboratory evaluation of acute, chronic, or recurrent sinusitis might include nasal cytology, nasal-sinus biopsy, or tests for immunodeficiency, CF, or ciliary dysfunction. Nasal cytology is useful in the clinical evaluation of conditions associated with sinusitis, including allergic rhinitis (AR), eosinophilic nonallergic rhinitis (NAR), neutrophilic rhinitis, and vasomotor rhinitis (VMR). Sinus secretions can be obtained for culture in adults by means of either an aspiration of the maxillary sinus or an endoscopically directed catheter placed at the middle meatus. For children, sinus secretions should be obtained by means of aspiration only. A number of factors associated with sinusitis should be considered. Probably the most common is viral upper respiratory tract infections. There is both clinical and experimental evidence that ongoing AR might ultimately lead to or augment acute bacterial sinusitis. NAR was found in 26% of patients with chronic sinusitis. Recently, gastroesophageal reflux disease (GERD) has been suggested as a cause of sinusitis, and there are several studies in children and adults indicating that medical treatment of GERD results in significant improvement in sinusitis symptoms. Tests for immunodeficiency, including quantitative immunoglobulin measurement, functional antibody tests, and HIV testing, might be useful if either congenital or acquired immunodeficiency is suspected in cases of recurrent sinusitis. Quantitative sweat chloride tests and genetic testing for diagnosis of CF should be considered in children with nasal polyps, colonization of the nose and sinuses with Pseudomonas species, or both and in those who had chronic sinusitis at an early age. Diseases associated with sinusitis are otitis media and bronchial asthma. Although no direct causal factor between sinusitis and asthma has been found, a number of studies in both children and adults suggest that medical management, surgical management, or both of sinusitis results in objective and subjective improvement of asthma. The primary therapy for acute bacterial sinusitis is antibiotics. The choice is based on predicted efficacy, cost, and side effects. A 10- to 14-day course is generally adequate for acute disease, although shorter courses are indicated for newer antibiotics. If there is no improvement in 3 to 5 days, then an alternative antibiotic should be considered. The role of antibiotics in chronic sinusitis is controversial. For chronic infectious sinusitis, a longer duration of therapy might be required, with possible attention to anaerobic pathogens. In the case of chronic noninfectious sinusitis, sometimes referred to as chronic hyperplastic sinusitis, consideration should be given to systemic corticosteroids. Concern has been raised about the overdiagnosis of sinusitis and unnecessary treatment with antibiotics. Appropriate criteria for the use of antibiotics are symptoms of sinusitis for 10 to 14 days or severe symptoms of acute sinus infection, including fever with purulent nasal discharge, facial pain or tenderness, and periorbital swelling. Intranasal corticosteroids as an adjunct to antibiotic therapy might be helpful in treating recurrent acute and chronic sinusitis. Other adjunctive therapy, such as antihistamines, decongestants, saline irrigation, mucolytics, and expectorants, might provide symptomatic benefit in selected cases. The use of intravenous immunoglobulin (IVIG) is indicated only in patients with proved functional impairment of humoral immunity. The beneficial effects of aspirin desensitization on aspirin-sensitive patients with sinusitis and asthma have been reported. Medically resistant sinusitis might respond to appropriate nasal-sinus surgery. In instances of localized persistent disease within the ostiomeatal complex, functional endoscopic sinus surgery might result in significant improvement. Consultation with a specialist should be sought when (1) there is a need to clarify the allergic or immunologic basis for sinusitis, (2) sinusitis is refractory to the usual antibiotic treatment, (3) sinusitis is recurrent, (4) sinusitis is associated with unusual opportunistic infections, and (5) sinusitis significantly affects performance and quality of life. Consultation is also appropriate when concomitant conditions are present that complicate assessment or treatment, including chronic otitis media, bronchial asthma, nasal polyps, recurrent pneumonia, immunodeficiencies, aspirin sensitivity, allergic fungal disease, granulomas, and multiple antibiotic sensitivities.

Original languageEnglish (US)
Pages (from-to)S13-S47
JournalJournal of Allergy and Clinical Immunology
Volume116
Issue number6 SUPPL.
DOIs
StatePublished - Dec 1 2005

ASJC Scopus subject areas

  • Immunology and Allergy
  • Immunology

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    Slavin, R. G., Spector, S. L., Bernstein, I. L., Kaliner, M. A., Kennedy, D. W., Virant, F. S., Wald, E. R., Khan, D. A., Blessing-Moore, J., Lang, D. M., Nicklas, R. A., Oppenheimer, J. J., Portnoy, J. M., Schuller, D. E., Tilles, S. A., Borish, L., Nathan, R. A., Smart, B. A., & Vandewalker, M. L. (2005). The diagnosis and management of sinusitis: A practice parameter update. Journal of Allergy and Clinical Immunology, 116(6 SUPPL.), S13-S47. https://doi.org/10.1016/j.jaci.2005.09.048