Copyright © 2000 Australian Prescriber Reproduced with permission from Australian Prescriber The document attached has been archived with permission from the publisher/copyright holderInfections in the nose involve the sinuses because the lining of the nose and the paranasal sinuses is continuous. The major sinuses drain through a common tract – the ostiomeatal complex, which is located under the middle turbinate. Acute sinusitis usually follows a cold and presents with nasal obstruction, facial pain, dental pain, purulent rhinorrhoea, sinus tenderness and in some cases fever and malaise. The diagnosis is made on the history, the patient’s lack of response to topical decongestants and on finding pus in the nose with associated sinus tenderness. Treatment consists of combining topical or systemic decongestants with saline irrigations and an antibiotic, usually amoxycillin. Referral to a specialist should be considered if patients fail to respond to second line antibiotic therapy and for those who get recurrent episodes of sinusitis.Peter John Wormal

Wormald, P.

Australian Prescriber

Adelaide Research & Scholarship

39Australian Prescriber Vol. 23 No. 2 2000Treating acute sinusitisPeter John Wormald, Professor and Head, Department of Otolaryngology Headand Neck Surgery, University of Adelaide and Flinders University, AdelaideSYNOPSISInfections in the nose involve the sinuses because the liningof the nose and the paranasal sinuses is continuous. Themajor sinuses drain through a common tract – theostiomeatal complex, which is located under the middleturbinate. Acute sinusitis usually follows a cold and presentswith nasal obstruction, facial pain, dental pain, purulentrhinorrhoea, sinus tenderness and in some cases fever andmalaise. The diagnosis is made on the history, the patient’slack of response to topical decongestants and on findingpus in the nose with associated sinus tenderness. Treatmentconsists of combining topical or systemic decongestantswith saline irrigations and an antibiotic, usuallyamoxycillin. Referral to a specialist should be consideredif patients fail to respond to second line antibiotic therapyand for those who get recurrent episodes of sinusitis.Index words: decongestants, rhinitis, rhinosinusitis.(Aust Prescr 2000;23:39–42)IntroductionThe lining of the nose and the paranasal sinuses is continuousand inflammation which affects the lining of the nose willspread, to a variable extent, into the sinuses (Fig. 1). Aninflammatory process that is primarily sited in the sinuses willin turn extend to the nasal cavity and result in a variableamount of rhinitis. Most conditions in the nose therefore affectboth the nasal cavity and the sinuses (rhinosinusitis). Acutesinusitis is defined as an infection of the nose which has spreadto the paranasal sinuses, with a duration of between one dayand three weeks. Chronic sinusitis is defined as a patienthaving two or more of the symptoms of nasal obstruction,rhinorrhoea, facial pain or headache or anosmia for longerthan three months. The treatment of chronic sinusitis is differentfrom that of acute sinusitis.AnatomyThe paranasal sinuses consist of four pairs of sinuses. Theseare the maxillary, frontal, ethmoid and sphenoid sinuses(Fig. 1). The maxillary, frontal and anterior ethmoid sinusesopen into the ostiomeatal unit under the middle turbinate whilethe posterior ethmoid and sphenoid sinuses open into thesuperior meatus above the middle turbinate.The nose and sinuses are lined by pseudostratified columnarepithelium similar to that in the lower respiratory tract. Thisepithelium is covered by a mucous blanket which is made upof two layers: the liquid layer in which the cilia move(the sol layer) and a thin more viscous layer (the gel layer)which is moved by the cilia. Inhaled particles normally adhereto the gel layer and are moved out of the sinuses and nose tothe nasopharynx before being swallowed. The health of thenose and paranasal sinuses is primarily dependent on this self-cleaning action of the mucociliary pathways. In the sinusesthese pathways always lead towards the ostiomeatal unit.Blockage of the ostia results in sinus disease.PrevalenceSymptoms of rhinosinusitis are prevalent in 16% of thegeneral population.1,2 Acute sinusitis accounts for up to 4.6%of consultations with young adults.3 Approximately 0.5% ofcommon colds are complicated by sinusitis and the averagenumber of colds for an adult per year is 2–3, so many patientswill present with signs and symptoms of sinusitis.Pathogenesis of acute sinusitisAcute sinusitis usually follows an acute upper respiratory tractinfection (common cold). As the viral infection spreads in thenasal mucosa, swelling and oedema of the mucosa results. Asthe mucosal surfaces of the ostiomeatal unit are in closeproximity to one another (Fig. 1), obstruction of the sinus ostiaresults. In addition, the viral infection may reduce normalFig. 1The epithelium lining the nasal cavity and the sinusesis continuous. Infections of the nose will usually affectthe sinuses to some degree and infections of the sinuseswill affect the nose. (The sphenoid sinus isnot shown.)The ostiomeatal unit is the final common pathway formuco-ciliary drainage of the maxillary, frontal and anteriorethmoid sinuses.FrontalsinusMaxillarysinusOstiomeatalunitEthmoidsinusesNasal cavity40Australian Prescriber Vol. 23 No. 2 2000cilial motility. This prevents normal mucociliary clearanceresulting in an accumulation of mucus in the sinuses and thedevelopment of the symptoms of sinusitis. If this mucusbecomes secondarily infected by bacteria, acute bacterialsinusitis develops.DiagnosisThe symptoms and signs of acute sinusitis are nasal obstruction,facial pain, dental pain, purulent rhinorrhoea, sinus tendernessand in some cases systemic manifestations such as fever andmalaise. A review of the literature found that the most sensitivesymptoms and signs for the diagnosis of acute sinusitis weremaxillary toothache, a poor response to decongestants, acoloured nasal discharge (symptoms), purulent nasal dischargeand abnormal maxillary sinus transillumination (signs).4 Oneof the common problems facing the doctor is differentiating anacute upper respiratory tract infection (the common cold)from acute sinusitis as there is considerable overlap of thesymptoms and signs (Table 1).The gold standard for the diagnosis of acute bacterial sinusitisremains aspiration of pus from one of the major sinuses. As themaxillary sinuses are the most accessible to aspiration and alsothe most commonly involved sinus in acute sinusitis, theywere the most commonly aspirated sinuses. Nowadaysmaxillary sinus puncture and aspiration is seldom performedas the procedure can be painful.ExaminationAfter taking the history, the next step is to perform anteriorrhinoscopy. In the normal nasal cavity, a patent nasal airwayand the normal inferior and middle turbinates can be seen(Fig. 2). Note the lining of the nose is not inflamed oroedematous and there is no intranasal discharge. In the case ofthe common cold, the lining of the nose is erythematous andoedematous and there are clear or pale yellow nasal secretions(Fig. 3). In patients with acute sinusitis, often all that can beseen is copious yellow or green nasal discharge (Fig. 4). If thisis cleared, the underlying nasal mucosa is erythematous andoedematous.Frontal sinus or maxillary sinus tenderness is checked bytapping over the forehead just above the eyebrows or on thecheeks below the eyes. Pressure can also be applied in the roofof the orbit, which is the floor of the frontal sinus. The othersinuses are inaccessible for the examination of tenderness.Maxillary sinus transillumination is not commonly used as itrequires experienced personnel and a completely darkenedroom. Only a negative finding (i.e. normal transillumination)is useful. The light is held on the lower rim of the orbit and thepalate examined through the patient’s open mouth. The palatelights up with normal transillumination.Table 1Similarities and differences between the common coldand acute sinusitisSymptoms & signs Common cold Acute sinusitisNasal obstruction +++ +++Rhinorrhoea (clear or pale yellow) ++++ ±Facial pressure ++ ++++ (especially whenbending forward)Poor response to topical decongestants – ++Purulent rhinorrhoea (yellow/green) – +++Facial pain – +++Dental pain – +Sinus tenderness – ++Fever – +Fig. 2Normal inferior turbinate with middle turbinate justvisible in the distanceFig. 3Mucus coming from the ostiomeatal unit under themiddle turbinate41Australian Prescriber Vol. 23 No. 2 2000InvestigationWhen the patient has all the clinical features the diagnosis ofacute sinusitis is clear. It is also usually quite clear when thepatient does not have acute sinusitis if only one symptom orsign, or none, is present. However, the difficulty in thediagnosis of acute sinusitis comes when there are two or threesymptoms and signs present. In these patients plain x-rays ofthe sinuses can be useful. A Waters (straight anteroposterior)view of the skull will allow the maxillary sinuses to beevaluated while a Caldwell (occipitomental) view will allowevaluation of the frontal sinuses. Lateral x-rays can helpevaluate the sphenoid sinuses. The patient should be upright inall radiographs so that air-fluid levels can be seen. As themaxillary sinuses are involved in nearly 90% of patients withacute sinusitis, a single Waters view may be all that is requiredto confirm the diagnosis of acute sinusitis.4 If this is inconclusivethe other views may be added.MicrobiologyAcute sinusitis is thought to be caused by the secondarybacterial invasion of inflamed sinuses that can occur in anacute viral upper respiratory tract infection. However, thepresence of bacteria in the sinuses can only be confirmed bydirect aspiration of the sinus. This is only possible in themaxillary sinus and can only be done with some discomfort tothe patient.The most commonly involved organisms are Haemophilusinfluenzae and Streptococcus pneumoniae. Other organismsinvolved include other streptococci, anaerobes, Moraxellacatarrhalis and Staphylococcus aureus.5 Beta-lactamaseproduction by Haemophilus influenzae has dramaticallyincreased over the last 15 years and is found in up to 50% oforganisms in certain areas of the world.5TreatmentThere are no good data on the treatment of sinusitis. Commonpractice includes decongestants which shrink the nasal mucosaloedema and help open the natural ostia of the sinuses and allowre-aeration and muco-ciliary drainage. For exampleoxymetazoline 0.5% in the form of a nasal spray gives goodnasal mucosal decongestion with symptomatic relief. Inaddition, irrigation of the nose with normal saline nasal sprayhas also been found to improve symptomatology and outcome.Antihistamines, topical and systemic steroids have not beenshown to give any additional benefit.The use of antibiotics to treat all suspected cases of acutesinusitis is controversial. Many of the studies have hadconflicting results. In general practice it can be difficult to becertain that the patient’s symptoms are caused by sinusitis. Ifthe diagnostic criteria are strict, acute bacterial sinusitis shouldbe treated with antibiotics as they are significantly moreeffective than placebo alone.6 Amoxycillin is still consideredfirst-line treatment. The adult dose is amoxycillin 500 mgthree times a day for a period of between 10 and 14 days.7Patients allergic to penicillin should be treated with eithertrimethoprim-sulfamethoxazole or cefaclor. Should the patientfail to respond to this regimen, second line therapy should beselected from an amoxycillin-clavulanate combination,cefaclor, cefuroxime axetil, loracarbef or cefixime.Surgical interventionThis is usually only considered if complications of acutesinusitis develop. These include periorbital cellulitis, intra-orbital abscesses, osteitis or intracranial sepsis. Surgery wouldinclude drainage of affected sinuses plus management of thecomplication.Specialist referralMost cases of acute sinusitis can be managed by the generalpractitioner. However, referral should occur if complicationsdevelop or if the patient fails to respond to second-linetherapy. Referral should also be made for patients with recurrentacute sinusitis.The specialist will perform nasal endoscopy with a rigid nasaltelescope to confirm the presence of pus in the middle meatusand/or spheno-ethmoidal recess. An endoscopically guidedpus swab will be taken for culture and sensitivity. This willguide further antibiotic therapy. In addition to the antibiotics,a history of possible contributing factors such as allergy willbe sought. If tests confirm the presence of an allergy, additionaltherapy will be needed. If the patient still fails to respond, a CTscan of the sinuses will be performed and endoscopic sinussurgery may be offered to the patient.R E F E R E N C E S1. Jones NS. Rhinosinusitis. British Association of OtorhinolaryngologistsHead and Neck Surgeons; Aug 1998.http://www.orl-baohns.org/members/clinframe.html2. Sibbald B, Rink E. Epidemiology of seasonal and perennial rhinitis:clinical presentation and medical history. Thorax 1991;46:895-901.3. Norrby R. Clinical aspects on bacterial infections in the upper respiratorytract. Scand J Infect Dis 1983;39(Suppl):14-8.Fig. 4Thick mucopus from the ostiomeatal unit lying on theanterior end of the middle turbinate42Australian Prescriber Vol. 23 No. 2 20004. Stafford CT. The clinician’s view of sinusitis. Otolaryngol Head NeckSurg 1990;103:870-4.5. Gwaltney JM Jr, Scheld WM, Sande MA, Sydnor A. The microbialetiology and antimicrobial therapy of adults with acute community-acquired sinusitis: a fifteen-year experience at the University of Virginiaand review of other selected studies (review). J Allergy Clin Immunol1992;90:457-61.6. Lindbaek M, Hjortdahl P, Johnsen UL-H. Randomised, double blind,placebo controlled trial of penicillin V and amoxycillin in treatment ofacute sinus infections in adults. Br Med J 1996;313:325-9.7. Casiano RR. Azithromycin and amoxicillin in the treatment of acutemaxillary sinusitis. Am J Med 1991;91(suppl):27S-30S.Self-test questionsThe following statements are either true or false (answers on page 47)7. Amoxycillin is the drug of first choice for patientswith sinusitis who are not sensitive to penicillin.8. Antihistamines have a significant effect on thesymptoms of acute bacterial sinusitis.Book reviewCancer facts: a concise oncology textEdited by James F. Bishop. London: HarwoodAcademic Publishers; 1999. 411 pages.Price $65.00 soft cover; $120.00 hard coverIan Kerridge, Hunter Haematology Unit, MaterMisericordiae Hospital, Newcastle, NSWApproximately 25–30% of the Australian population will diefrom cancer or its various complications and one in four willbe diagnosed with cancer by age 75. An understanding of thebasics of clinical oncology and of the impact of the majorscientific advances in oncology is therefore of criticalimportance to all practising clinicians. For not only mustclinicians suspect, investigate, diagnose and manage cancer –they must also transmit accurate information to patients andtheir carers in a respectful, empathic and collaborative manner.Cancer facts is a concise text written by 55 experts in the field,collated and edited by an international authority in clinical andacademic oncology. The stated objective of the text is toprovide a concise but comprehensive summary of the essentialsof oncology and cancer management.In general terms the text succeeds admirably in achieving itsstated aim and provides an accessible, clinically relevantoverview of clinical oncology and the related sciences. Thebook comprises 62 chapters divided into 14 parts coveringsymptom control and quality of life, lung cancer, breast cancer,gastrointestinal cancer, urogenital cancers, gynaecologicalcancers, head and neck cancers, melanoma, haematologicalmalignancies, miscellaneous cancers, complications in cancerpatients and psychosocial issues in cancer. Each chapterprovides an evidence-based synopsis of the field and includes areading list designed to allow wider, more detailed reading onthe essential elements of each chapter.Cancer facts provides an overview of an extremely broad andcomplex area of medicine and as such is more likely to be ofbenefit to the non-oncologist than the specialist oncologist.The structure of the text is generally clear and consistent, butat times seems to be determined more by the organisation ofmedical specialties than by the need to provide a precise,coherent integration of cancer management. One must wonderwhether having separate chapters on the surgical, radiationand chemotherapy management of non-small cell lung cancerwould be more ambiguous or confusing to the non-oncologistthan a single chapter on non-small cell lung cancer writtencollaboratively by a radiation oncologist, medical oncologistand surgeon.The book concludes with nine colour plates of skin cancers, anessential part of any substantive review of cutaneousmalignancies. However, aside from a single mammogram,there are no colour illustrations, reproductions of medicalimaging or diagrams to help readers gain an understandingof anatomy, pathology or staging. As with all similar multi-authored texts, there is some unevenness in the quality andreferencing of the chapters, and inevitably there will bequestions raised about those topics omitted from the text.Research and clinical ethics, patient education resources,evidence-based medicine, decision-analysis, oncology on theinternet and environmental/occupational oncology could allarguably be included within an expanded text.For the most part, however, these are minor objections andCancer facts is likely to find a valued place in many doctors’library or desk. James Bishop has taken on an ambitious taskand his text is highly recommended for all oncologists andnon-oncologists, be they students, trainees or practisingclinicians.Australian Prescriber web sitenewsThe full text of each issue is now available in PDF formatas well as in HTML. This means you can now read andprint Australian Prescriber exactly as it appears in theprinted copy. Click on ‘print version’ for individualarticles or the full issue. PDF format is not available forissues prior to December 1999.

Treating acute sinusitis

Peter John Wormald

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