Acute Bacterial Rhinosinusitis (Sinusitis)
Acute bacterial rhinosinusitis (ABRS) is an infection of both your nasal cavity and sinuses. It is caused by bacteria. The nasal cavity is the large air-filled space behind your nose. The sinuses are a group of spaces formed by the bones of your face. They connect with your nasal cavity. ABRS causes the tissue lining these spaces to become inflamed. Mucus may not drain normally. This leads to face pain and other common symptoms.
Edematous mucosa causes obstruction of the complex, resulting in the accumulation of mucus in the sinus cavity that becomes secondarily infected by bacteria. The largest of these ostiomeatal complexes is deep to the middle turbinate in the middle meatus. This complex is actually a confluence of complexes draining the maxillary, ethmoid, and frontal sinuses. The sphenoid drains from a separate complex between the septum and superior turbinate.
The typical pathogens of bacterial rhinosinusitis are S pneumoniae, other streptococci, H influenzae, and less commonly, S aureus and Moraxella catarrhalis. Pathogens vary regionally in both prevalence and drug resistance; about 25% of healthy asymptomatic individuals may, if sinus aspirates are cultured, harbor such bacteria as well.
There are no agreed-upon criteria for the diagnosis of acute bacterial rhinosinusitis in adults. Major symptoms include purulent nasal drainage, nasal obstruction or congestion, facial pain/pressure, altered smell, cough, and fever.
Minor symptoms include headache, otalgia, halitosis, dental pain, and fatigue. Many of the more specific symptoms and signs relate to the affected sinus(es).
Bacterial rhinosinusitis can be distinguished from viral rhinitis by persistence of symptoms for more than 10 days after onset or worsening of symptoms within 10 days after initial improvement. Acute rhinosinusitis is defined as lasting less than 4 weeks, and subacute rhinosinusitis, as lasting 4–12 weeks.
Acute maxillary sinusitis
Acute maxillary sinusitis is the most common form of acute bacterial rhinosinusitis because the maxillary is the largest sinus with a single drainage pathway that is easily obstructed. Unilateral facial fullness, pressure, and tenderness over the cheek are common symptoms, but may not always be present. Pain may refer to the upper incisor and canine teeth via branches of the trigeminal nerve, which traverse the floor of the sinus. Purulent nasal drainage should be noted with nasal airway obstruction or facial pain (pressure). Maxillary sinusitis may result from dental infection, and teeth that are tender should be carefully examined for signs of abscess. Drainage of the periapical abscess or removal of the diseased tooth typically resolves the sinus infection.
Acute ethmoiditis in adults is often accompanied by maxillary sinusitis, and symptoms are similar to those described above. Localized ethmoid sinusitis may present with pain and pressure over the high lateral wall of the nose between the eyes that may radiate to the orbit.
Sphenoid sinusitis is usually seen in the setting of pansinusitis or infection of all the paranasal sinuses on at least one side. The patient may complain of a headache “in the middle of the head” and often points to the vertex.
Acute frontal sinusitis
Acute frontal sinusitis may cause pain and tenderness of the forehead. This is most easily elicited by palpation of the orbital roof just below the medial end of the eyebrow.
Hospital-associated sinusitis is a form of acute bacterial rhinosinusitis that may present without the usual symptoms. Instead, it may be a cause of fever in critically ill patients. It is often associated with prolonged presence of a nasogastric or, rarely, nasotracheal tube causing nasal mucosal inflammation and ostiomeatal complex obstruction. Pansinusitis on the side of the tube is common on imaging studies.
All patients with acute bacterial rhinosinusitis should have careful evaluation of pain. NSAIDs are generally recommended. Sinus symptoms may be improved with oral or nasal decongestants (or both)—eg, oral pseudoephedrine, 30–60 mg every 6 hours, up to 240 mg/day; nasal oxymetazoline, 0.05% or oxymetazoline, 0.05–0.1%, one or two sprays in each nostril every 6–8 hours for up to 3 days. Intranasal corticosteroids (high-dose mometasone furoate 200 mcg each nostril twice daily for 21 days) can help reduce facial pain and congestion.
Between 40% and 69% of patients with acute bacterial rhinosinusitis improve symptomatically within 2 weeks without antibiotic therapy. Antibiotic treatment is controversial in uncomplicated cases of clinically diagnosed acute bacterial rhinosinusitis because only 5% of patients will note a shorter duration of illness with treatment, and antibiotic treatment is associated with nearly twice the number of adverse events compared with placebo.
Antibiotics may be considered when symptoms last more than 10 days or when symptoms (including fever, facial pain, and swelling of the face) are severe or when cases are complicated (such as immunodeficiency). In these patients, administration of antibiotics does reduce the incidence of clinical failure by 50% and represents the most cost-effective treatment strategy
Selection of antibiotics is usually empiric and based on a number of factors, including regional patterns of antibiotic resistance, antibiotic allergy, cost, and patient tolerance.
For adults younger than 65 years with mild to moderate acute bacterial rhinosinusitis, the recommended first-line therapy is amoxicillin-clavulanate (500 mg/125 mg orally three times daily or 875 mg/125 mg orally twice daily for 5–7 days), or in those with severe sinusitis, high-dose amoxicillin-clavulanate (2000 mg/125 mg extended-release orally twice daily for 7–10 days).
In patients with a high risk for penicillin-resistant S pneumoniae (age over 65 years, hospitalization in the prior 5 days, antibiotic use in the prior month, immunocompromised status, multiple comorbidities or severe sinus infection), the recommended first-line therapy is the high-dose amoxicillin-clavulanate option (2000 mg/125 mg extended-release orally twice daily for 7–10 days).
For those with penicillin allergy or hepatic impairment, then doxycycline (100 mg orally twice daily or 200 mg orally once daily for 5–7 days), or clindamycin (150–300 mg every 6 hours) plus a cephalosporin (cefixime 400 mg orally once daily or cefpodoxime proxetil 200 mg orally twice daily) for 10 days are options. Macrolides, trimethoprim-sulfamethoxazole, and second- or thirdgeneration cephalosporins are not recommended for empiric therapy.
Hospital-associated infections in critically ill patients are treated differently from community-acquired infections. Removal of a nasogastric tube and improved nasal hygiene (nasal saline sprays, humidification of supplemental nasal oxygen, and nasal decongestants) are critical interventions and often curative in mild cases without aggressive antibiotic use.
Endoscopic or transantral cultures may help direct medical therapy in complicated cases. In addition, broad-spectrum antibiotic coverage directed at P aeruginosa, S aureus (including methicillin-resistant strains), and anaerobes may be required.