Few cases of acute bacterial sinusitis are outside of the treatment capabilities of the primary care physician. Remember that the majority of cases of acute sinusitis occurring in healthy individuals usually follow viral upper respiratory tract infections. With mucosal swelling and altered ciliary function, mucous effusions collect in the sinuses and become secondarily infected. Primary pathogens include Streptococcus pneumoniae, H. Influenzae, Staph, M. Catarrhalis, and anaerobes. Selection of a Beta-lactamase resistant antibiotic increases the coverage for these organisms.

Adjunctive medical treatment modalities include humidification of inspired air, saline nose spray, saline nasal douches, topical and oral decongestants, and in the case of allergic individuals, antihistamines and nasal steroid sprays. Resolution is the rule rather than the exception. Keep in mind that x-ray findings persist beyond the period of acute symptoms and reversal of x-ray findings alone can not always be used to determine a treatment endpoint.

In a patient with recurrent or refractory sinusitis it is important to rule out polyps, a dental abscess, allergy, or septal deviation and turbinate hypertrophy. Refer to an otolaryngologist for definitive treatment.

• Antibiotic resistant cases of acute maxillary sinusitis with opacity and air fluid levels may require irrigation and aspiration of the sinus for relief (much like an abscess anywhere else). Referral to an otolaryngologist is recommended in this case.

• Symptomatic frontal or sphenoid sinusitis persisting beyond 48-hours from initiation of oral antibiotic therapy represents a challenge. Because of the propensity for intracranial spread and complications, aggressive therapy is mandatory. Aggressive topical nasal decongestion with pledgets of cocaine HCL (mixture of 1:1 phenylephrine 1% and Xylocaine 4%), humidity, saline douches, oral decongestants, and IV antibiotics constitutes complete medical therapy. Failure of clinical response after 72 hours of IV antibiotics and medical adjunctive therapy (persistent headache, tenderness to palpation, or any hints of CNS irritation) requires consultation and referral for surgical trephination.

Reference

1. DeWeese and Saunders, Textbook of Otolaryngology

Reviewed by CAPT David H. Thompson, MC, USN, Department of Otolaryngology, National Naval Medical Center, Bethesda, MD (1998).