Sinusitis

OVERVIEW: What every practitioner needs to know

Sinusitis is defined as inflammation of the lining of the sinus cavity. The term rhinosinusitis is often used as the mucosa of the nasal cavity is nearly always involved. In the United States over 15% of the population is affected by sinusitis resulting in over $5.8 billion in health care expenditures. Sinusitis typically follows a viral upper respiratory tract infection (URI). It is estimated that 0.5% to 2% of URIs in adults and 5% in children are complicated by acute bacterial sinusitis (ABS). Sinusitis is one of the most common reasons for prescribing antibiotics in the primary care setting.

ABS results from obstruction of the sinus ostia, decreased or impaired mucociliary clearance, and alteration of sinus secretions.

The organisms responsible for ABS are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Since the implementation of the pneumococcal conjugate vaccine, H. influenzae and M. catarrhalis have been causing a greater proportion of the cases of sinusitis. In addition, the prevalence of β-lactamase producing H. influenzae has increased.

There are three presentations of ABS: prolonged symptoms, worsening symptoms, and severe symptoms.

The diagnosis of ABS is made by the application of strict clinical criteria. These criteria will allow the distinction of patients with ABS from those with viral URI. Imaging is not routinely recommended unless complications are suspected.

Antimicrobial agents provide a more rapid resolution of symptoms than placebo or no treatment. Amoxicillin/clavulanate is the first line choice of antibiotics for the treatment of sinusitis. The duration of treatment should be 5 to 7 days for adults and 10 to 14 days for children. Doxycycline or a respiratory fluoroquinolone is recommended as second line for treatment of adults and levofloxacin or clindamycin plus cefixime is recommended for children.

Adjunctive treatments such as nasal saline irrigation, topical corticosteroids, antihistamines, and decongestants provide minimal relief of symptoms.

Complications of sinusitis include intracranial and orbital infections that usually require surgical drainage.

Are you sure your patient has sinusitis? What should you expect to find?

Most episodes of sinusitis begin with symptoms of a viral URI such as cough or nasal congestion and discharge.

There are three clinical presentations which should prompt the clinician to consider the diagnosis of ABS. The first and most common is that of persistent symptoms. This presentation is characterized by nasal symptoms (discharge or congestion), cough, or both that lasts longer than 10 days without improvement. The lack of improvement is key in distinguishing ABS from an uncomplicated URI, which typically resolves or improves before 10 days. The character of the nasal discharge may be watery, thick, and mucoid or purulent. Accompanying symptoms may include low grade fever, headache, periorbital swelling, malodorous breath, or tooth pain.

The second presentation is that of severe symptoms. High fever (>38.9°C) and purulent nasal discharge are present for at least 3 to 4 consecutive days distinguishing this presentation from a viral URI in which the fever is low grade (or absent) and is present for less than 48 hours.

The third presentation is that of worsening symptoms in which symptoms present in a biphasic pattern. In the Scandinavian literature this is referred to as “double sickening.” The illness begins similarly to an uncomplicated URI and symptoms begin to improve. Within 10 days of onset, however, the symptoms of fever, cough, nasal congestion, or discharge worsen.

Physical exam findings in sinusitis include mucopurulent discharge on the nasal mucosa. The mucosa itself may be erythematous and edematous or at times boggy and pale. Facial tenderness may be found over the maxillary or frontal sinsuses but is an unreliable finding. Malodorous breath may suggest bacterial sinusitis in the absence of dental disease or nasal foreign body. Transillumination lacks specificity in the diagnosis of sinusitis and is not recommended. Overall, the physical exam is of limited usefulness as it will not help distinguish uncomplicated URI from ABS.

How did the patient develop sinusitis? What was the primary source from which the infection spread?

Sinusitis is a direct result of the unique anatomy and physiology of the nose and sinuses. The paranasal sinuses include the frontal, maxillary, ethmoid, and sphenoid sinuses. It is notable that the middle ear cavity and mastoid air cells have the same structural and functional relationship to the nasal passages as the paranasal sinuses. The ethmoid and maxillary sinuses develop during the third month of gestation and thus are present at birth. The frontal sinuses begin to develop and become aerated by the sixth year of life; complete development of the frontal sinuses does not occur until late in adolescence.

The maxillary sinuses drain into the nasal cavity via the ostium of the sinus which is positioned at the most superior portion of the medial wall of the sinus. This anatomic positioning makes gravitational drainage difficult. The sinuses empty into the meatus via the osteomeatal complex. The maxillary sinus drains into the middle meatus, as do the anterior ethmoid air cells and the frontal sinuses. The posterior ethmoid air cells and the sphenoid sinuses empty into the superior meatus. The proximity of the frontal and sphenoid sinuses to the brain and orbit may result in contiguous spread of infection to these areas.

A key factor in the pathogenesis of sinusitis is that the mucosa of the nasal passages is contiguous with the mucosa of the paranasal sinuses. Thus, any process affecting the nasal mucosa may affect the sinus mucosa as well. Under normal conditions the sinuses are considered sterile. The nasal passages however, are heavily colonized with bacteria.

The pathogenesis of acute sinusitis involves three factors: alteration of the sinus secretions, obstruction of the sinus ostia, and disruption of the mucociliary apparatus. The small diameter of the sinus ostia predisposes it to obstruction. Viral URI and allergy are the most common factors that lead to obstruction at the osteomeatal complex. Obstruction of the sinus ostia results in the depletion of oxygen in the sinus cavity. This creates a negative pressure that may allow the introduction of bacteria into the sinus. In addition, obstruction of the sinus ostia results in the accumulation of mucus. Insults such as a viral infection result in damage to the epithelial cells and cilia lining the nose and sinus. The thickening of sinus secretions makes it more difficult for the ciliary apparatus to clear the sinuses of bacteria and debris.

The microbiology of ABS has been determined by performance of sinus aspiration which is considered the gold standard for diagnosis. Endoscopically obtained cultures from the middle meatus are likely to be contaminated with nasal flora and are unreliable, particularly in children. Cultures of the middle meatus in adults may predict sinus pathogens when the interpretation is confined to S. pneumoniae, H. influenzae, and M. catarrhalis.

Based on sinus puncture studies (summarized in
Table I) the most common cause of sinusitis is S. pneumoniae, followed by H. influenzae and M. catarrhalis.

Although S. aureus is recovered frequently from middle meatal and occasionally from sinus puncture studies it likely represents contamination of the specimen from nasal flora.

There have been no microbiological studies of sinusitis using sinus puncture in children since 1984. However, the middle ear cavity is in fact a paranasal sinus and the microbiology of acute otitis media may be used as a surrogate for acute bacterial sinusitis. Since the introduction of the pneumococcal conjugate vaccine (PCV7) the microbiology of acute otitis media has changed. In one study the proportion of cases of acute otitis media in children due to S. pneumoniae decreased from 48% to 31% after the introduction of PCV7. In addition, the rate of β-lactamase production by H. influenzae has increased to as high as 48%. This has significant implications for antibiotic selection as is discussed below.

The role of viruses in sinusitis is poorly understood. It is believed that bacterial sinusitis develops following a viral insult to the nasal and sinus mucosa. Respiratory viruses such as rhinovirus, adenovirus, and parainfluenza virus have been isolated infrequently by viral culture of sinus aspirates. Molecular testing such as the polymerase chain reaction assay has not been performed on sinus aspirate specimens. The role of newly discovered viruses such as human metapneumovirus and bocavirus is unknown.

Table I.

Organism	Adults	Children
Streptococcus pneumoniae	40	40
Haemophilus influenzae	35	25
Moraxella catarrhalis	5	20
Anaerobes	5	–
Streptococcal species	5	5
Other	10	10

Which individuals are at greater risk of developing sinusitis?

Any factor that predisposes to obstruction of the sinus ostia, ciliary dysfunction, or thickening of secretions will predispose the patient to bacterial sinusitis. These factors can be divided into systemic and local factors and are listed in
Table II. The most common factors are viral infection and nasal allergy.

Table II.

Systemic factors	Local factors
Viral URI	Trauma
Allergic inflammation	Deviated septum
Tobacco smoke	Choanal atresia
Immotile cilia	Swimming/diving
Immune disorders	Nasal intubation
Cystic fibrosis	Overuse of nasal decongestants
	Nasal polyps
	Deviated septum
	Foreign body
	Tumor

URI, urinary respiratory tract infection.

Beware: there are other diseases that can mimic sinusitis:

The challenge for the clinician is to distinguish an uncomplicated viral URI from ABS, in order to determine which patients will benefit from an antimicrobial agent. This is reliably done by using stringent clinical criteria for the diagnosis as shown in
Table III. Strict application of these criteria will allow the identification of those patients most likely to benefit from an antimicrobial agent.

Table III.

Persistent symptoms:Nasal congestion/discharge or cough for >10 days without improvement

Severe symptoms:High fever (at least 39°C or 102°F), purulent nasal discharge for more than 3 to 4 days

Worsening symptoms:Worsening of nasal congestion or rhinorrhea, cough and fever after a 3 to 4 day period of improved symptoms

Patients with allergic rhinitis may present with similar symptoms, particularly rhinorrhea, nasal obstruction, and face pain/fullness. However, patients with allergic symptoms frequently have nasal or ocular pruritus and have a seasonal pattern to their symptoms. The nasal mucosa in patients with allergy is typically pale and boggy. Nasal polyps and anatomic variations (such as a deviated septum) may cause chronic nasal obstruction. Nasal foreign bodies, particularly in children, will present with malodorous nasal discharge that is usually unilateral. Chronic use of decongestants may result in rhinitis medicamentosa which may mimic sinus disease.

What laboratory studies should you order and what should you expect to find?

Results consistent with the diagnosis

Laboratory studies are not needed to diagnose sinusitis.

The peripheral white blood cell count may be normal or elevated.

Blood cultures are not necessary and would be expected to be negative unless sepsis is clinically evident.

Results that confirm the diagnosis

An aspirate of the maxillary sinus that yields a high density of bacteria (10⁴ colony forming bacteria/mL) will confirm the diagnosis of ABS. This is not typically done in the primary care setting. If there is a complication of sinusitis such as an intracranial or orbital abscess, then an aspirate of the abscess should be sent for Gram stain and culture.

What imaging studies will be helpful in making or excluding the diagnosis of sinusitis?

The use of imaging in the diagnosis of uncomplicated sinusitis is unnecessary. Plain radiographs consist of an anterior-posterior (Caldwell) view, the occipitomental (Waters) view, a lateral view, and in some cases a submentovertex view. Other modalities used to image the sinuses and surrounding structures include computed tomography (CT), magnetic resonance imaging (MRI) scans, and ultrasound.

The mucous membranes of the nasal passages and nasopharynx are contiguous with those of the sinus cavities. Thus any process that causes inflammation of the nasal passages may also cause inflammation in the sinuses. Patients with uncomplicated URI frequently have abnormalities of the sinuses on plain film or CT. This was demonstrated in a study by Gwaltney et al in which adult volunteers were imaged using CT within 48 to 96 hours of the onset of a cold. Almost 90% of subjects had significant abnormalities of the paranasal sinuses.

Kovatch showed that more than 50% of children with viral URI had abnormal sinus radiographs. Thus abnormal images do not distinguish between ABS and uncomplicated viral URI. However, a negative plain radiograph of the sinuses is reliable in ruling out sinusitis. One study which compared plain radiographs with sinus puncture demonstrated that the sinus puncture was negative 97% of the time when plain radiographs were normal.

Because of the high incidence of abnormalities found on imaging studies performed during viral URI, imaging studies should not routinely be used in the diagnosis of uncomplicated ABS. However, both CT and MRI are useful in the imaging of the complications of sinusitis. CT is useful for identifying bony abnormalities such as periosteal abscess and also for imaging the osteomeatal complex. MRI should be performed when intracranial complications are suspected.

The approximate costs for imaging of the sinuses are: plain film $250; maxillofacial CT $1,500; and MRI scan $4,500.

What consult service or services would be helpful for making the diagnosis and assisting with treatment?

Most cases of ABS may be managed by the primary care provider without consulting a specialist. Patients with chronic sinusitis, particularly those with anatomical abnormalities, may benefit from consultation with an otolaryngologist. Surgical consultation with the appropriate subspecialty (otolaryngology, neurosurgery, or ophthalmology) is necessary when complications such as intracranial or intraorbital abscesses develop.

If you decide the patient has sinusitis, what therapies should you initiate immediately?

The most important principle of therapy is stringency in making the diagnosis. The diagnosis of sinusitis is based on clinical criteria. If overly broad criteria are used (for example purulent rhinorrhea) then patients who have uncomplicated viral URI will be treated and will not benefit from an antimicrobial.

The spectrum of the antimicrobial chosen should match the spectrum of the bacteria causing sinusitis. Agents should have good activity against S. pneumoniae and M. catarrhalis. In addition, because of the increase in prevalence of β-lactamase producing H. influenzae, antimicrobials should be β-lactamase stable or contain a β-lactamase inhibitor. The most narrow spectrum agent that covers these bacterial species should be used.

Cost, adverse effect profile, and palatability should also influence antibiotic selection. In most patients treated for sinusitis the risks of treatment are mainly antibiotic-associated diarrhea and the potential development of antibiotic resistance.

Patients who have signs of systemic toxicity, are unable to take antibiotics orally, or have complications of sinusitis should be hospitalized and treated with intravenous antimicrobials.

Clinical improvement is noted within 49 to 72 hours of starting therapy. If patients are not improved or are worsened by this time the patient should be re-evaluated. If the diagnosis of sinusitis is confirmed and the patient has been adherent to therapy a second-line antimicrobial agent should be considered. Sinus aspiration for precise identification of the causative organism should be considered.

The exact duration of treatment for ABS is controversial and poorly studied. A recent meta-analysis of short vs long duration antimicrobial trials in adults concluded that 3 to 7 days of therapy was equivalent in efficacy and adverse event rate to 6 to 10 days. The duration of treatment for children has not been studied in a rigorous fashion.

We recommend treating adults for 5 to 7 days and children for 10 to 14 days. If a patient responds slowly, the duration of therapy should be extended until the patient is symptom free plus 7 days.

1. Anti-infective agents

If I am not sure what pathogen is causing the infection, what anti-infective should I order?

Because of the invasiveness of sinus puncture the specific pathogen causing sinusitis is rarely known. Thus nearly all therapy for sinusitis is empirical. The exception is when complications of sinusitis allow for the sampling of a fluid collection that can be sent for culture. Treatment options are summarized in Table IV.

Table IV.

Antimicrobial	Adult dosage	Pediatric dosage
Amoxicillin/clavulanate	875 or 2,000mg orally twice a day*	45–90mg/kg/day orally in two divided doses daily*
Doxycycline	100–200mg orally twice a day	Not indicated if aged <8 years
Levofloxacin	500mg orally once daily	10–20mg/kg/day orally one to two times daily
Moxifloxacin	400mg orally once daily	Not indicated
Cefpodoxime orCefixime +Clindamycin	NA	10mg/kg/day orally in two divided doses8mg/kg/day orally once daily30–40mg/kg/day orally in three divided doses daily
Ceftriaxone	1–2 g IV every 12–24 hours	50 mg/kg/day every 12–24 hours
Cefotaxime	2g IV every 6–8 hours	150–200mg/kg/day divided every 6–8 hours

Instruction Text [Tier 1]

*Amoxicillin component

IV, intravenously; NA, not applicable.

Amoxicillin/clavulanate should be the first line of therapy for ABS. This agent will have excellent activity against H. influenzae and M. catarrhalis. The use of high dose amoxicillin/clavulanate (2g of amoxicillin twice a day for adults and 90mg/kg/day in two divided doses for children) will provide coverage for all S. pneumoniae that are sensitive or intermediate in resistance to penicillin and most but not all penicillin-resistant S. pneumoniae (see Table IV).

In the the patient with severe (type I) allergy to penicillin or in those who fail amoxicillin/clavulanate the following should be used as second-line agents:

In adults, doxycycline or a respiratory fluoroquinolone such as levofloxacin or moxifloxacin

In children, cefixime plus clindamycin or levofloxacin as a single agent

For those patients with severe infection requiring hospitalization ampicillin/sulbactam should be used. Alternative agents include a third-generation cephalosporin (ceftriaxone or cefotaxime), or a respiratory fluoroquinolone (levofloxacin or moxifloxacin for adults and levofloxacin for children)

2. Other therapeutic modalities

Nasal saline irrigation, spray, and drops have been popularized for symptomatic relief of sinusitis. A Cochrane review of nasal saline irrigation for acute respiratory infections included three randomized controlled trials. One study showed a nonsignificant (0.3) day difference in symptom resolution favoring saline. Nasal saline was associated with less time lost from work in one study. The authors concluded that there is limited evidence of benefit with nasal irrigation in adults. Though these benefits are fairly minimal, nasal saline is associated with very little harm in adults. Infants, however, frequently do not tolerate nasal drops.

Studies examining the role of intranasal corticosteroids in acute sinusitis have shown conflicting results. A meta-analysis of the use of steroids for acute sinusitis demonstrated a 73% symptom resolution rate in corticosteroid-treated patients vs 66.4% in those receiving placebo. Given such a modest benefit, it is difficult to recommend intranasal corticosteroids. However, patients who have underlying allergic rhinitis may benefit from this therapy.

Neither topical nor systemic decongestants and/or antihistamines have shown a consistent benefit in symptom relief in patients with ABS and may be associated with significant adverse events.

Surgical intervention is indicated for the intracranial and intraorbital complications of ABS. Although small abscesses may be given a trial of medical therapy, many localized fluid collections require drainage.

Specific treatment

The use of antimicrobial agents to treat sinusitis has been controversial. The literature is filled with studies showing both positive effect and no effect of antimicrobials. There have been mutiple studies of the treatment of sinusitis with antibacterial agents in the past 40 years. Many of these studies suffer from serious methodological problems. The most common issue is the use of entry criteria and definitions of sinusitis that are overly broad. If such criteria are employed in an antimicrobial trial, then the study group will include many patients who actually have viral URIs rather than a bacterial infection. An example of this is using the criteria of purulent nasal discharge and face pain as qualifications for entry into a study. Both of these criteria are nonspecific and occur in viral URI. Since an antibacterial agent will have no effect on a viral URI including such patients will bias a study against the effect of antibiotics.

In adults there have been over 18 controlled trials of antibiotics versus placebo. Even with methodological problems, a recent review of many of these trials showed a consistent benefit to antibiotics. Five meta-analyses have also shown consistent benefit to antimicrobials.

In children there have been five placebo-controlled trials of antimicrobials in ABS. Meta-analysis of the studies in children showed that five patients would need to be treated before antibiotics would benefit one patient. These results are likely diluted by the inclusion of patients with uncomplicated viral URI. In two studies, in which patients were included in the studies only if strict clinical criteria were met, and appropriate antibiotic dosing was used, a significant benefit was demonstrated in patients receiving antimicrobial treatment compared with placebo. A recent double-blinded, randomized, controlled study compared amoxicillin/clavulanate with placebo. Children were diagnosed with sinusitis based on prolonged or severe symptoms using stringent clinical criteria. Fourteen percent of children in the amoxicillin/clavulanate group of patients experienced treatment failure vs 68% in the placebo group. This study demonstrated that only three children would need to be treated with antimicrobial to benefit one patient.

The Infectious Diseases Society of America has recently released comprehensive guidelines using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system for the diagnosis and treatment of sinusitis. A summary of this document is as follows:

The clinical criteria of persistent, severe, or worsening symptoms should be used to identify patients with ABS vs uncomplicated viral URI (see Table III). Radiographic confirmation of sinusitis is not necessary for patients with uncomplicated ABS. GRADE: strong, low-moderate

Empiric antimicrobial therapy should be initiated as soon as the clinical diagnosis of sinusitis is made. GRADE: strong, moderate

Standard dose amoxicillin/clavulanate rather than amoxicillin alone is recommended as empirical antimicrobial therapy. GRADE: strong, moderate for children; GRADE: weak, low for adults

High dose (2g orally twice a day for adults and 90mg/kg/day in two divided doses) is recommended for patients who have risk factors for penicillin nonsusceptible S. pneumoniae. These include:
living in a geographic region with more than 10% endemic rate of penicillin nonsusceptible S. pneumoniae

severe infection (evidence of systemic toxicity with fever of 39°C or higher

attendance at daycare

age <2 years or >65 years

recent hospitalization

antibiotic use within the past month

immunocompromised state

Respiratory fluoroquinolones (moxifloxacin, levofloxacin, and gatifloxacin) are not recommended for first-line therapy for ABS as there is no evidence that they are superior to β-lactam agents. GRADE: weak, moderate

For second-line therapy or in the penicillin allergic patient:
Macrolides (clarithromycin and azithromycin) are not recommended due to high rates of pneumococcal resistance. GRADE: strong, moderate

Trimethoprim/sulfamethoxazole is not recommended due to the high rate of pneumococcal and H. influenzae resistance. GRADE: strong, moderate

Doxycycline may be used in adults. GRADE: weak, low

In children with non-type I penicillin allergy the combination of an oral, third-generation cephalosporin (cefixime or cefpodoxime) plus clindamycin may be used. GRADE: weak, moderate

A respiratory fluoroquinolone (levofloxacin or moxifloxacin in adults or levofloxacin in children) may be used.

It is not necessary to cover S. aureus during empiric therapy. GRADE: strong, moderate

The recommended duration of therapy for ABS is:
5 to 7 days in adults. GRADE: weak, low to moderate

10 to 14 days in children. GRADE: weak, low to moderate

What complications could arise as a consequence of sinusitis?

The complications of sinusitis arise because of the close proximity of the sinuses to important structures in the skull and face and are classified as either intracranial or extracranial. Most are a result of direct extension of infection from the frontal or ethmoidal sinuses. Infection extends to surrounding structures when osteitis of the wall of the sinus results in bony erosion. The lamina papyracea of the ethmoid sinuses are very thin bony structures that are particularly vulnerable to erosion.

Intracranial complications include epidural and subdural empyema, intraparenchymal brain abscess, meningitis, and cavernous or sagittal sinus thrombosis. Intracranial complications should be suspected in any patient presenting with fever, altered mental status, severe headache, focal neurological signs, or seizures.

Extracranial complications mainly involve orbital structures and include periorbital inflammatory edema, orbital abscess, subperiosteal abscess, orbital cellulitis, and optic neuritis.

S. pneumoniae, S.aureus, viridans streptococci, anaerobes, and gram-negative organisms are typically isolated from material obtained from abscesses formed as a result of extension of infection from the sinuses.

Patients who have suspected complications should have urgent imaging performed. MRI provides better resolution of intracranial structures while orbital contents are best visualized by CT.

WHAT’S THE EVIDENCE for specific management and treatment recommendations?

Guidelines

Chow, AW, Benninger, MS, Brook, I. “IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults”. Clin Infect Dis. vol. 54. 2012. pp. e72-e112. (This is the recently published guideline for the diagnosis and treatment of sinusitis from the Infectious Disease Society of America.)

Meltzer, EO, Hamilos, DL, Hadley, JA. “Rhinosinusitis: Establishing definitions for clinical research and patient care”. Otolaryngol Head Neck Surg. vol. 131. 2004. pp. S1-62. (This guideline is from a consortium of allergists, otolaryngologists, and infectious disease physicians.)

Epidemiology

Benninger, MS, Payne, SC, Ferguson, BJ, Hadley, JA, Ahmad, N. “Endoscopically directed middle meatal cultures versus maxillary sinus taps in acute bacterial maxillary rhinosinusitis: a meta-analysis”. Otolaryngol Head Neck Surg.. vol. 134. 2006. pp. 3-9. (This article compares endoscopically obtained cultures of the middle meatus with sinus aspirates.)

Anand, VK. “Epidemiology and economic impact of rhinosinusitis”. Ann Otol Rhinol Laryngol Suppl. vol. 193. 2004. pp. 3-5. (This article describes the epidemiology of sinusitis and its economic impact in the United States.)

Gwaltney, JM, Hendley, JO, Simon, G, Jordan, WS. “Rhinovirus infections in an industrial population. II. Characteristics of illness and antibody response”. JAMA. vol. 202. 1967. pp. 494-500. (This classic reference desribes the epidemiology of the viral URI in the United States.)

Wald, ER, Guerra, N, Byers, C. “Upper respiratory tract infections in young children: duration of and frequency of complications”. Pediatrics. vol. 87. 1991. pp. 129-33. (This is one of the few studies that documents the rate of sinusitis following URI in a population of children.)

Microbiology

Wald, ER, Milmoe, GJ, Bowen, A, Ledesma-Medina, J, Salamon, N, Bluestone, CD. “Acute maxillary sinusitis in children”. N Engl J Med. vol. 304. 1981. pp. 749-54. (This article is one of the original sinus puncture studies that describe the microbiology of sinusitis in children.)

Gwaltney, JM, Scheld, WM, Sande, MA, Sydnor, A. “The microbial etiology and antimicrobial therapy of adults with acute community-acquired sinusitis: a fifteen-year experience at the University of Virginia and review of other selected studies”. J Allergy Clin Immunol. vol. 90. 1992. pp. 457-61. (This article summarizes the microbiology of sinusitis in adults over a 15 year history of doing sinus aspirates.)

Changing microbiology

Casey, JR, Adlowitz, DG, Pichichero, ME. “New patterns in the otopathogens causing acute otitis media six to eight years after introduction of pneumococcal conjugate vaccine”. Pediatr Infect Dis J. vol. 29. 2010. pp. 304-9. (This study describes the increase in isolation of H. influenzae from isolates of middle ear fluid in children with acute otitis media.)

Payne, SC, Benninger, MS. ” is a major pathogen in acute bacterial rhinosinusitis: a meta-analysis”. Clin Infect Dis. vol. 45. 2007. pp. e121-127. (This meta-analysis reviews the evidence for S. aureus as a pathogen in ABS. Many of the studies included in the analysis had serious methodological flaws casting doubt on this hypothesis.)

Casey, JR, Pichichero, ME. “Changes in frequency and pathogens causing acute otitis media in 1995-2003”. Pediatr Infect Dis J. vol. 23. 2004. pp. 824-8. (This study describes the increase in isolation of H. influenzae from middle ear fluid and the increase in β-lactamase producing strains.)

Imaging

Kovatch, AL, Wald, ER, Ledesma-Medina, J, Chiponis, DM, Bedingfield, B. “Maxillary sinus radiographs in children with nonrespiratory complaints”. Pediatrics. vol. 73. 1984. pp. 306-8. (This study demonstrates the high frequency of sinus abnormality on plain films of the sinuses in children with uncomplicated URI.)

Gwaltney, JM, Phillips, CD, Miller, RD, Riker, DK. “Computed tomographic study of the common cold”. N Engl J Med. vol. 330. 1994. pp. 25-30. (This study demonstrates the high frequency of abnormalities of the sinuses on CT scan in adults with uncomplicated URI.)

Diagnosis

Ueda, D, Yoto, Y. “The ten-day mark as a practical diagnostic approach for acute paranasal sinusitis in children”. Pediatr Infect Dis J. vol. 15. 1996. pp. 576-9. (This study supports the use of 10 days of persistent respiratory symptoms as diagnostic criteria for ABS.)

Trials

Gwaltney, JM, Wiesinger, BA, Patrie, JT. “Acute community-acquired bacterial sinusitis: the value of antimicrobial treatment and the natural history”. Clin Infect Dis. vol. 38. 2004. pp. 227-33. (This is an excellent review of treament trials with particular attention to dignostic methods.)

Wald, E, Nash, D, Eickhoff, J. “Effectiveness of amoxicillin/clavulanate potassium in the treatment of acute bacterial sinusitis in children”. Pediatrics. vol. 124. 2009. pp. 9-15. (This recent randomized-controlled trial shows benefit to amoxicillin/clavulanate over placebo in children with sinusitis.)

Falagas, ME, Giannopoulou, KP, Vardakas, KZ, Dimopoulos, G, Karageorgopoulos, DE. “Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis of randomised controlled trials”. Lancet Infect Dis. vol. 8. 2008. pp. 543-52. (This study shows a small therapeutic benefit to antibiotics over placebo in the treatment of sinusitis.)

Ahovuo-Saloranta, A, Borisenko, OV, Kovanen, N. “Antibiotics for acute maxillary sinusitis”. Cochrane Database Syst Rev. 2008. pp. CD000243(This Cochrane meta-analysis shows a small therapeutic benefit to antibiotics over placebo in the treatment of sinusitis.)

Symptomatic treatment

Kassel, JC, King, D, Spurling, GK. “Saline nasal irrigation for acute upper respiratory tract infections”. Cochrane Database Syst Rev. 2010. pp. CD006821(This study shows minimal benefit to nasal saline irrigation as adjunctive treatment of URI.)

McCormick, DP, John, SD, Swischuk, LE, Uchida, T. “A double-blind, placebo-controlled trial of decongestant-antihistamine for the treatment of sinusitis in children”. Clin Pediatr (Phila). vol. 35. 1996. pp. 457-60. (The above studies demonstrate minimal effect of symptomatic treatment of sinusitis.)

Complications

DeMuri, GP, Wald, ER. “Complications of acute bacterial sinusitis in children”. Pediatr Infect Dis J. vol. 30. 2011. pp. 701-2. (This article reviews the complications of sinusitis.)

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