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Rhinology, Nasal Obstruction, and Sinusitis

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Acute Bacterial Rhinosinusitis

Prolonged mucosal edema, from whatever etiology causes sinus obstruc-

tion and retention of secretions, may lead to

acute bacterial rhinosinus-

itis

. Patients may exhibit several of the

major symptoms

(facial pressure/

pain, facial congestion/fullness, purulent nasal discharge, nasal obstruc-

tion, anosmia) and one or more of the

minor symptoms

(headache, fever,

fatigue, cough, toothache, halitosis, ear fullness/pressure).

Radiographic

studies

(plain films or CT scans) do not differentiate acute bacterial rhi-

nosinusitis from a viral upper respiratory infection (URI). More than 80

percent of patients with a viral URI also have an abnormal sinus CT scan.

Time will usually differentiate a bacterial from a viral infection. It usually

takes 7–10 days for a viral infection to resolve. Symptoms lasting beyond

7–10 days, or worsening after 5 days, suggest that bacterial infection is

being established. The organisms responsible are similar to the organisms

that cause acute otitis media and include

Streptococcus pneumoniae

Haemophilus

influenzae

, and

Moraxella catarrhalis

. By definition, acute

rhinosinusitis persists less than one

month, and

subacute rhinosinusitis

lasts more than one month but less

than three months.

Chronic sinusitis

is defined by symptoms that persist

more than three months, and usually

has a different underlying microbiol-

ogy with increased numbers of anaer-

obic organisms.

The treatment of choice for acute rhi-

nosinusitis (as well as acute otitis

media) has been a 10-day course of

either amoxicillin or trimethoprim/

sulfamethoxazole. Resistance to

amoxicillin has prompted some physi-

cians to consider using amoxicillin/

clavulanate or a second-generation

cephalosporin or macrolide or a qui-

nolone instead of amoxicillin as the

first-line therapy. More recently, the

appearance of penicillin resistance in

S. pneumoniae

infection (which has

a different resistance mechanism than beta-lactamase production) has

resulted in the recommendation that higher doses of amoxicillin be used

routinely. Drugs that do not adequately cover

H. influenzae

are inappro-

priate treatment for either otitis media or rhinosinusitis.

Adjunctive

Figure 9.1.

Acute rhinosinusitis. Note purulent drainage

extending from the middle meatus over the

inferior turbinate. Symptoms persisting longer

than 7–10 days suggest bacterial infection, and

antibiotic therapy is indicated.