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Australian Family Physician Jun 2016Acute and chronic sinusitis are common primary care presentations. They are caused by mucosal inflammation, which inhibits mucociliary function of the nose and paranasal... (Review)
Review
BACKGROUND
Acute and chronic sinusitis are common primary care presentations. They are caused by mucosal inflammation, which inhibits mucociliary function of the nose and paranasal sinuses.
OBJECTIVE
This article provides an overview of acute and chronic sinusitis, and a guide to workup and management in a primary care setting. Complications and other indications for referral are discussed.
DISCUSSION
Sinusitis involves a wide spectrum of presentations, both acute and chronic. It is primarily a medical condition, and surgical management is reserved for complicated or refractory cases.
Topics: Acute Disease; Adult; Child; Chronic Disease; Humans; Primary Health Care; Sinusitis
PubMed: 27622225
DOI: No ID Found -
Current Allergy and Asthma Reports Jun 2020The purposes of the review are as follows: (1) to define acute rhinosinusitis (ARS) and their phenotypes, (2) to highlight the ARS management according to international... (Review)
Review
PURPOSE OF REVIEW
The purposes of the review are as follows: (1) to define acute rhinosinusitis (ARS) and their phenotypes, (2) to highlight the ARS management according to international guidelines, (3) to compare the physicians' management with the ARS guideline recommendations, and (4) to report ARS socioeconomic burden.
RECENT FINDINGS
Bacterial and non-bacterial ARS have similar symptoms, although they can be discriminated by using a combination of specific signs and symptoms. The prescription of antibiotics should be limited to clearly suspected bacterial ARS. There is an overuse of diagnosis tools and treatment prescriptions. The total cost per ARS episode in Europe is over €1000. ARS is mainly an inflammatory disease triggered by viral infection, and few cases end up developing bacterial infection. In most of the cases, it is a self-resolving disease which diagnosis is mainly clinical and the treatment symptomatic. The incidence of complications is low and independent of antibiotic use. There is a high socioeconomic burden associated to ARS.
Topics: Acute Disease; Common Cold; History, 21st Century; Humans; Rhinitis; Sinusitis; Virus Diseases
PubMed: 32495003
DOI: 10.1007/s11882-020-00917-5 -
JAMA Jul 2023The large overlap between symptoms of acute sinusitis and viral upper respiratory tract infection suggests that certain subgroups of children being diagnosed with acute... (Randomized Controlled Trial)
Randomized Controlled Trial
IMPORTANCE
The large overlap between symptoms of acute sinusitis and viral upper respiratory tract infection suggests that certain subgroups of children being diagnosed with acute sinusitis, and subsequently treated with antibiotics, derive little benefit from antibiotic use.
OBJECTIVE
To assess if antibiotic therapy could be appropriately withheld in prespecified subgroups.
DESIGN, SETTING, AND PARTICIPANTS
Randomized clinical trial including 515 children aged 2 to 11 years diagnosed with acute sinusitis based on clinical criteria. The trial was conducted between February 2016 and April 2022 at primary care offices affiliated with 6 US institutions and was designed to evaluate whether symptom burden differed in subgroups defined by nasopharyngeal Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis on bacterial culture and by the presence of colored nasal discharge.
INTERVENTIONS
Oral amoxicillin (90 mg/kg/d) and clavulanate (6.4 mg/kg/d) (n = 254) or placebo (n = 256) for 10 days.
MAIN OUTCOMES AND MEASURES
The primary outcome was symptom burden based on daily symptom scores on a validated scale (range, 0-40) during the 10 days after diagnosis. Secondary outcomes included treatment failure, adverse events including clinically significant diarrhea, and resource use by families.
RESULTS
Most of the 510 included children were aged 2 to 5 years (64%), male (54%), White (52%), and not Hispanic (89%). The mean symptom scores were significantly lower in children in the amoxicillin and clavulanate group (9.04 [95% CI, 8.71 to 9.37]) compared with those in the placebo group (10.60 [95% CI, 10.27 to 10.93]) (between-group difference, -1.69 [95% CI, -2.07 to -1.31]). The length of time to symptom resolution was significantly lower for children in the antibiotic group (7.0 days) than in the placebo group (9.0 days) (P = .003). Children without nasopharyngeal pathogens detected did not benefit from antibiotic treatment as much as those with pathogens detected; the between-group difference in mean symptom scores was -0.88 (95% CI, -1.63 to -0.12) in those without pathogens detected compared with -1.95 (95% CI, -2.40 to -1.51) in those with pathogens detected. Efficacy did not differ significantly according to whether colored nasal discharge was present (the between-group difference was -1.62 [95% CI, -2.09 to -1.16] for colored nasal discharge vs -1.70 [95% CI, -2.38 to -1.03] for clear nasal discharge; P = .52 for the interaction between treatment group and the presence of colored nasal discharge).
CONCLUSIONS
In children with acute sinusitis, antibiotic treatment had minimal benefit for those without nasopharyngeal bacterial pathogens on presentation, and its effects did not depend on the color of nasal discharge. Testing for specific bacteria on presentation may represent a strategy to reduce antibiotic use in this condition.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT02554383.
Topics: Child; Humans; Male; Acute Disease; Amoxicillin; Anti-Bacterial Agents; Clavulanic Acid; Common Cold; Sinusitis; Female; Child, Preschool; Nasopharynx; Streptococcus pneumoniae; Haemophilus influenzae; Moraxella catarrhalis
PubMed: 37490085
DOI: 10.1001/jama.2023.10854 -
American Family Physician Oct 2017Chronic rhinosinusitis is an inflammatory disease of the paranasal sinuses that occurs in 1% to 5% of the U.S. (Review)
Review
UNLABELLED
Chronic rhinosinusitis is an inflammatory disease of the paranasal sinuses that occurs in 1% to 5% of the U.S.
POPULATION
It may significantly decrease quality of life. Chronic rhinosinusitis is defined by the presence of at least two out of four cardinal symptoms (i.e., facial pain/pressure, hyposmia/anosmia, nasal drainage, and nasal obstruction) for at least 12 consecutive weeks, in addition to objective evidence. Objective evidence of chronic rhinosinusitis may be obtained on physical examination (anterior rhinoscopy, endoscopy) or radiography, preferably from sinus computed tomography. Treatment is directed at enhancing mucociliary clearance, improving sinus drainage/outflow, eradicating local infection and inflammation, and improving access for topical medications. First-line treatment is nasal saline irrigation and intranasal corticosteroid sprays. There may be a role for antibiotics in patients with evidence of an active, superimposed acute sinus infection. If medical management fails, endoscopic sinus surgery may be effective. Patients not responding to first-line medical therapy should be referred to an otolaryngologist, and selected patients with a history suggestive of other comorbidities (e.g., vasculitides, granulomatous diseases, cystic fibrosis, immunodeficiency) may also benefit from referral to an allergist or pulmonologist.
Topics: Administration, Intranasal; Administration, Oral; Administration, Topical; Anti-Bacterial Agents; Chronic Disease; Female; Humans; Male; Nasal Sprays; Quality of Life; Rhinitis; Sinusitis; Sodium Chloride; Therapeutic Irrigation; United States
PubMed: 29094889
DOI: No ID Found -
Otolaryngologia Polska = the Polish... Aug 2021Understanding the appropriate use of diagnostics and treatment in acute rhinosinusitis is of immense importance given the high prevalence of this disease in the general...
Understanding the appropriate use of diagnostics and treatment in acute rhinosinusitis is of immense importance given the high prevalence of this disease in the general population. The ability to differentiate between the principal phenotypes of acute sinusitis, namely acute viral infection (cold), acute post-viral sinusitis and acute bacterial sinusitis, determines the future management and is fundamental to providing rational therapeutic recommendations - especially as regards antibiotic treatment, which is very often overused in acute sinusitis even though bacterial phenotypes only account for 0.5-2% of all cases of the disease. The latest therapeutic recommendations contained in the EPOS2020 position paper introduce a system based on integrated care pathways (ICPs), which comprise pharmacy-supported self-care and e-health as the first level, followed by primary care as the second, with specialist care being reserved for patients who develop a more severe course of the disease, have suspected complications or suffer from recurrent acute sinusitis. Management of acute sinusitis is primarily based on symptomatic treatment modalities, with phytotherapeutic support, as well as on antiinflammatory treatment, while antibiotic therapy is used in very specific and limited indications. Complications are relatively rare in acute sinusitis and they are not considered to be associated with antibiotic intake. Considering the high prevalence of acute forms of sinusitis, their significant impact on quality of life and high direct and indirect costs of treatment, the right diagnosis and management, without unnecessary escalation of therapy, can substantially translate into a number of public health benefits.
Topics: Acute Disease; Anti-Bacterial Agents; Bacterial Infections; Humans; Quality of Life; Rhinitis; Sinusitis
PubMed: 34552023
DOI: 10.5604/01.3001.0015.2378 -
JAMA Sep 2023Acute sinusitis is one of the most common indications for antibiotic prescribing in children, with an estimated 4.9 million such prescriptions in the US annually.... (Comparative Study)
Comparative Study
IMPORTANCE
Acute sinusitis is one of the most common indications for antibiotic prescribing in children, with an estimated 4.9 million such prescriptions in the US annually. Consensus does not exist regarding the optimal empirical antibiotic.
OBJECTIVE
To compare amoxicillin-clavulanate vs amoxicillin for the treatment of acute sinusitis in outpatient children.
DESIGN, SETTING, AND PARTICIPANTS
Cohort study of children and adolescents aged 17 years or younger with a new outpatient diagnosis of acute sinusitis and a same-day new prescription dispensation of amoxicillin-clavulanate or amoxicillin in a nationwide health care utilization database. Propensity score matching was used to mitigate confounding.
EXPOSURE
A new prescription dispensation of amoxicillin-clavulanate or amoxicillin.
MAIN OUTCOMES AND MEASURES
Treatment failure, defined as an aggregate of a new antibiotic dispensation, emergency department or inpatient encounter for acute sinusitis, or inpatient encounter for a sinusitis complication, was assessed 1 to 14 days after cohort enrollment. Adverse events were evaluated, including gastrointestinal symptoms, hypersensitivity and skin reactions, acute kidney injury, and secondary infections.
RESULTS
The cohort included 320 141 patients. After propensity score matching, there were 198 942 patients (99 471 patients per group), including 100 340 (50.4%) who were female, 101 726 (51.1%) adolescents aged 12 to 17 years, 52 149 (26.2%) children aged 6 to 11 years, and 45 067 (22.7%) children aged 0 to 5 years. Treatment failure occurred in 1.7% overall; 0.01% had serious failure (an emergency department or inpatient encounter). There was no difference in the risk of treatment failure between the amoxicillin-clavulanate and amoxicillin groups (relative risk [RR], 0.98 [95% CI, 0.92-1.05]). The risk of gastrointestinal symptoms (RR, 1.15 [95% CI, 1.05-1.25]) and yeast infections (RR, 1.33 [95% CI, 1.16-1.54]) was higher with amoxicillin-clavulanate. After patients were stratified by age, the risk of treatment failure after amoxicillin-clavulanate was an RR of 0.98 (95% CI, 0.86-1.12) for ages 0 to 5 years; RR was 1.06 (95% CI, 0.92-1.21) for 6 to 11 years; and RR was 0.87 (95% CI, 0.79-0.95) for 12 to 17 years. The age-stratified risk of adverse events after amoxicillin-clavulanate was an RR of 1.23 (95% CI, 1.10-1.37) for ages 0 to 5 years; RR was 1.19 (95% CI, 1.04-1.35) for 6 to 11 years; and RR was 1.04 (95% CI, 0.95-1.14) for 12 to 17 years.
CONCLUSIONS AND RELEVANCE
In children with acute sinusitis who were treated as outpatients, there was no difference in the risk of treatment failure between those who received amoxicillin-clavulanate compared with amoxicillin, but amoxicillin-clavulanate was associated with a higher risk of gastrointestinal symptoms and yeast infections. These findings may help inform decisions for empirical antibiotic selection in acute sinusitis.
Topics: Adolescent; Child; Child, Preschool; Female; Humans; Infant; Infant, Newborn; Male; Acute Disease; Amoxicillin; Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Cohort Studies; Mycoses; Sinusitis; Treatment Failure
PubMed: 37721610
DOI: 10.1001/jama.2023.15503 -
The Cochrane Database of Systematic... Apr 2015Acute upper respiratory tract infections (URTIs), including the common cold and rhinosinusitis, are common afflictions that cause discomfort and debilitation and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acute upper respiratory tract infections (URTIs), including the common cold and rhinosinusitis, are common afflictions that cause discomfort and debilitation and contribute significantly to workplace absenteeism. Treatment is generally by antipyretic and decongestant drugs and sometimes antibiotics, even though most infections are viral. Nasal irrigation with saline is often employed as an adjunct treatment for URTI symptoms despite a relative lack of evidence for benefit in this clinical setting. This review is an update of the Cochrane review by Kassel et al, which found that saline was probably effective in reducing the severity of some symptoms associated with acute URTIs.
OBJECTIVES
To assess the effects of saline nasal irrigation for treating the symptoms of acute URTIs.
SEARCH METHODS
We searched CENTRAL (2014, Issue 7), MEDLINE (1966 to July week 5, 2014), EMBASE (1974 to August 2014), CINAHL (1982 to August 2014), AMED (1985 to August 2014) and LILACS (1982 to August 2014).
SELECTION CRITERIA
Randomised controlled trials (RCTs) comparing topical nasal saline treatment to other interventions in adults and children with clinically diagnosed acute URTIs.
DATA COLLECTION AND ANALYSIS
Two review authors (DK, BM) independently assessed trial quality with the Cochrane 'Risk of bias' tool and extracted data. We analysed all data using the Cochrane Review Manager software. Due to the large variability of outcome measures only a small number of outcomes could be pooled for statistical analysis.
MAIN RESULTS
We identified five RCTs that randomised 544 children (three studies) and 205 adults (exclusively from two studies). They all compared saline irrigation to routine care or other nose sprays, rather than placebo. We included two new trials in this update, which did not contribute data of sufficient size or quality to materially change the original findings. Most trials were small and we judged them to be of low quality, contributing to an unclear risk of bias. Most outcome measures differed greatly between included studies and therefore could not be pooled. Most results showed no difference between nasal saline treatment and control. However, one larger trial, conducted with children, did show a significant reduction in nasal secretion score (mean difference (MD) -0.31, 95% confidence interval (CI) -0.48 to -0.14) and nasal breathing (obstruction) score (MD -0.33, 95% CI -0.47 to -0.19) in the saline group. However, a MD of -0.33 on a four-point symptom scale may have minimal clinical significance. The trial also showed a significant reduction in the use of decongestant medication by the saline group. Minor nasal discomfort and/or irritation was the only side effect reported by a minority of participants.
AUTHORS' CONCLUSIONS
Nasal saline irrigation possibly has benefits for relieving the symptoms of acute URTIs. However, the included trials were generally too small and had a high risk of bias, reducing confidence in the evidence supporting this. Future trials should involve larger numbers of participants and report standardised and clinically meaningful outcome measures.
Topics: Acute Disease; Adult; Child; Common Cold; Humans; Laryngitis; Nasal Lavage; Pharyngitis; Randomized Controlled Trials as Topic; Respiratory Tract Infections; Rhinitis; Sinusitis; Sodium Chloride
PubMed: 25892369
DOI: 10.1002/14651858.CD006821.pub3 -
The Cochrane Database of Systematic... Sep 2018Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Acute rhinosinusitis is an acute infection of the nasal passages and paranasal sinuses that lasts less than four weeks. Diagnosis of acute rhinosinusitis is generally based on clinical signs and symptoms in ambulatory care settings. Technical investigations are not routinely performed, nor are they recommended in most countries. Some trials show a trend in favour of antibiotics, but the balance of benefit versus harm is unclear.We merged two Cochrane Reviews for this update, which comprised different approaches with overlapping populations, resulting in different conclusions. For this review update, we maintained the distinction between populations diagnosed by clinical signs and symptoms, or imaging.
OBJECTIVES
To assess the effects of antibiotics versus placebo or no treatment in adults with acute rhinosinusitis in ambulatory care settings.
SEARCH METHODS
We searched CENTRAL (2017, Issue 12), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (January 1950 to January 2018), Embase (January 1974 to January 2018), and two trials registers (January 2018). We also checked references from identified trials, systematic reviews, and relevant guidelines.
SELECTION CRITERIA
Randomised controlled trials of antibiotics versus placebo or no treatment in people with rhinosinusitis-like signs or symptoms or sinusitis confirmed by imaging.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data about cure and side effects and assessed the risk of bias. We contacted trial authors for additional information as required.
MAIN RESULTS
We included 15 trials involving 3057 participants. Of the 15 included trials, 10 appeared in our 2012 review, and five (631 participants) are legacy trials from merging two reviews. No new studies were included from searches for this update. Overall, risk of bias was low. Without antibiotics, 46% of participants with rhinosinusitis, whether or not confirmed by radiography, were cured after 1 week and 64% after 14 days. Antibiotics can shorten time to cure, but only 5 to 11 more people per 100 will be cured faster if they receive antibiotics instead of placebo or no treatment: clinical diagnosis (odds ratio (OR) 1.25, 95% confidence interval (CI) 1.02 to 1.54; number needed to treat for an additional beneficial outcome (NNTB) 19, 95% CI 10 to 205; I² = 0%; 8 trials; high-quality evidence) and diagnosis confirmed by radiography (OR 1.57, 95% CI 1.03 to 2.39; NNTB 10, 95% CI 5 to 136; I² = 0%; 3 trials; moderate-quality evidence). Cure rates with antibiotics were higher when a fluid level or total opacification in any sinus was found on computed tomography (OR 4.89, 95% CI 1.75 to 13.72; NNTB 4, 95% CI 2 to 15; 1 trial; moderate-quality evidence). Purulent secretion resolved faster with antibiotics (OR 1.58, 95% CI 1.13 to 2.22; NNTB 10, 95% CI 6 to 35; I² = 0%; 3 trials; high-quality evidence). However, 13 more people experienced side effects with antibiotics compared to placebo or no treatment (OR 2.21, 95% CI 1.74 to 2.82; number needed to treat for an additional harmful outcome (NNTH) 8, 95% CI 6 to 12; I² = 16%; 10 trials; high-quality evidence). Five fewer people per 100 will experience clinical failure if they receive antibiotics instead of placebo or no treatment (Peto OR 0.48, 95% CI 0.36 to 0.63; NNTH 19, 95% CI 15 to 27; I² = 21%; 12 trials; high-quality evidence). A disease-related complication (brain abscess) occurred in one participant (of 3057) one week after receiving open antibiotic therapy (clinical failure, control group).
AUTHORS' CONCLUSIONS
The potential benefit of antibiotics to treat acute rhinosinusitis diagnosed either clinically (low risk of bias, high-quality evidence) or confirmed by imaging (low to unclear risk of bias, moderate-quality evidence) is marginal and needs to be seen in the context of the risk of adverse effects. Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis. We could not draw conclusions about children, people with suppressed immune systems, and those with severe sinusitis, because these populations were not included in the available trials.
Topics: Acute Disease; Adult; Anti-Bacterial Agents; Humans; Radiography; Randomized Controlled Trials as Topic; Rhinitis; Sinusitis; Time Factors
PubMed: 30198548
DOI: 10.1002/14651858.CD006089.pub5