By: Dr. Geoffrey Modest
The Am Acad of Otolaryngology — Head and Neck Surgery just published a clinical practice guideline on adult sinusitis (for exec summary, see Otolaryng Head Neck Surg. 2015, Vol. 152(4) 598–609), updating their 2007 guideline.
General background and definitions:
–Sinusitis is common, affecting 1 in 8 adults in the US and with more than 30 million annual diagnoses
–More than 20% of antibiotics prescribed for adults are for sinusitis (fifth most common diagnosis responsible for antibiotic prescriptions).
–Acute rhinosinusitis (ARS) definition: up to 4 weeks of purulent nasal discharge accompanied by nasal obstruction, facial pain/pressure/fullness, or both:
–purulent nasal discharge is cloudy or colored
–nasal obstruction is reported by patient as obstruction, congestion, blockage, or stuffiness, or may be found on PE
–facial pain/pressure/fullness involves anterior face or periorbital region, and may present as headache which is localized or diffuse
–Viral rhinosinusitis (VRS): when symptoms of acute rhinosinusitis are present < 10 days and are not worsening
–Acute bacterial rhinosinusitis (ABRS): symptoms of acute rhinosinusitis fail to improve in 10 days beyond the onset of upper respiratory symptoms, or worsen within 10 days after an initial improvement
–Chronic rhinosinusitis (CRS): symptoms last > 12 weeks
–Recurrent rhinosinusitis: 4 or more annual episodes of acute rhinosinusitis
Recommendations:
–differentiate ABRS from VRS as per the definition above (strong recommendation)
–radiology: not get imaging for ABRS or VRS unless a complication or alternative diagnosis is suspected (eg severe headache, proptosis, cranial nerve palsies, facial swelling)
–symptomatic relief of VRS or ABRS: by analgesics, topical steroids or saline irrigation (optional)
–initial management of uncomplicated ABRS: offer watchful waiting (without antibiotics, but only if there is reasonable assurance that the patient will get antibiotics if the condition fails to improve by 7 days after the ABRS diagnosis or sooner if it worsens), or give antibiotics (recommendation)
–choice of antibiotics: amoxicillin with or without clavulanate is first-line therapy, for 5-10 days (recommendation). Systematic review does not show consistent benefit of longer course
–treatment failure for ABRS: reassess patient to confirm diagnosis, change antibiotics (recommendation). not mention what would be their suggested next drug
–CRS diagnosis: differentiate CRS from recurrent ARS; if CRS, confirm sinonasal inflammation by rhinoscopy, nasal endoscopy, or CT scan (strong recommendation)
–Modifying factors: assess patient with CRS or recurrent ARS for chronic conditions that would modify management: asthma, cystic fibrosis, immunocompromise, ciliary dyskinesia (recommendation)
–allergy and immune functioning testing: optional
–polyps: examine for polyps if CRS, and treat with saline nasal irrigation, topical steroids or both (recommendation)
–don’t give topical or systemic antifungal therapy for CRS
Also, there is a useful patient information sheet (their table 4)
Major changes were:
–an extension of watchful waiting as initial management of ABRS regardless of severity (not just in mild cases, as in prior guideline)
–change in antibiotics recommended from amoxacillin to amoxacillin with or without clavulanate
–addition of asthma as a chronic condition that modifies management for CRS (chronic rhinosinusitis)
–treating nasal polyps as a modifying factor with topical intranasal therapy (saline irrigations, steroids)
So, to me these recommendations seem pretty reasonable. The data on the utility of nasal steroids and/or antibiotics is quite mixed, with some good studies showing no benefit of either. So the move to less aggressive antibiotic therapy seems to be a good one. I have been promoting watchfully waiting for the past couple of years, often giving the patient an antibiotic prescription but suggesting that they take them only if the symptoms don’t improve by 10 days or get worse, and indicating the downside of antibiotics (adverse effects, general effects on microbiome, potential for developing resistant organisms). Not exactly sure what the patients do with the prescriptions, but my sense is that patients are coming here with lower expectations of getting antibiotics for likely viral infections than they used to.
A point of clarification: Acute rhinosinusitis can last up to 4 weeks (with chronic after 12 weeks, and the amorphous “subacute” in between). That being said, most acute rhinosinusitis is only 1-2 weeks. Viral is presumed if the purulent discharge lasts <10 days and is improving over time. Bacterial is presumed if it lasts >10 days or is getting worse. The purpose of watchful waiting is that even their presumptive bacterial rhinosinusitis may still get better over the next week on its own (Because it never really was bacterial, vs. the body handling the bacterium by itself without the assistance of antibiotics).