Acute Rhinosinusitis: A Diagnostic and Therapeutic Challenge

I pride myself on judicious use of antibiotics for acute upper respiratory infections (URIs). The easy patients to treat are those with classic viral symptoms of clear rhinorrhea, nonproductive cough, and a mild to moderate illness of short duration. Most of these patients readily accept my reassurance and advice for symptomatic treatment.

Patients with acute bronchitis are a bit tougher to treat. They often have productive cough and are moderately ill for a longer duration. Even though antibiotics are of marginal, if any, benefit for acute bronchitis,¹ approximately 30% of my patients receive an antibiotic prescription despite my best efforts to the contrary. I usually resort to the popular last-ditch tactic of the backup prescription. If 50% of my patients fill those backup prescriptions as Couchman and colleagues² found, my actual prescribing rate for acute bronchitis is only 15%—not bad for this largely viral syndrome.

The good news is that the anti-antibiotic scuffle with patients may be happening less often. The public campaign by the Centers for Disease Control and Prevention to reduce inappropriate use of antibiotics appears to be reaching some of my patients. They are more likely to accept my advice for symptomatic treatment than they were 5 years ago. However, there is still a great need for educating patients and physicians about appropriate use of antibiotics for respiratory tract infections, as illustrated by the survey of college students by Zoorob and colleagues³ in this issue of JFP. When confronted with scenarios typical of viral URIs, 50% of those bright young adults would seek medical care and an antibiotic prescription.

Antibiotics for Acute Sinusitis

Acute sinusitis is a horse (or discharge, maybe?) of a different color. I used to think that sinusitis was the easy one to handle. Cheek pain plus green discharge equals antibiotic. The patient goes away satisfied, and I go on to the next coughing patient. Not so fast. This last port of refuge for antibiotic advocates is crumbling, too. Consider the following sobering facts:

Sinusitis rarely occurs in isolation and is most often accompanied by nasal cavity inflammation, resulting in the new designation rhinosinusitis.⁴

Most cases of rhinosinusitis are caused by viruses. Maxillary sinus radiographs of young adults with typical viral URIs showed mucosal abnormalities in 39% of cases on the seventh day of illness,⁵ and computed tomography (CT) scans were abnormal in 87% of similar cases.⁶

When based on signs and symptoms, the diagnosis of acute sinusitis is correct in approximately 50% or less of cases.^7-11 We probably are not this accurate in routine practice.

Randomized clinical trials of antibiotic treatment of rhinosinusitis have shown no effect when the diagnosis was based on clinical findings alone¹² or on clinical findings confirmed by plain radiographs.¹³

Despite the negative results of these randomized clinical trials, more than 90% of patients with a diagnosis of sinusitis by primary care physicians receive an antibiotic prescription.^13,14

Antibiotics have little effect on the course of rhinosinusitis, because the clinical diagnosis of bacterial sinusitis is so difficult. The signs and symptoms of viral infection of the paranasal sinuses mimic those of bacterial infection. Several investigators have attempted to identify clinical findings specific to bacterial sinusitis using a high-quality reference standard (sinus puncture and aspiration of purulent secretions, positive bacterial culture of aspirated secretions, or positive CT scan of the sinuses).^7,8,11 Maxillary facial pain, tooth pain, and purulent nasal discharge (ie, white, not green) are most discriminating, but even with these seemingly specific findings the ability to diagnose bacterial sinusitis accurately is poor. Because viral rhinosinusitis and rhinosinusitis with minimal bacterial suprainfection are so much more common than significant bacterial sinusitis, the few truly antibiotic-responsive bacterial infections are diluted out in clinical trials. We therefore see no effect of antibiotic treatment.

When Are Antibiotics Effective?

Antibiotics may be effective in some cases of acute sinusitis, but which ones? The dilemma is that we do not have a practical clinical test for ferreting out the few patients with sinusitis-like illness who would truly benefit from antibiotic treatment. (Most patients would prefer a trial of an antibiotic to sinus puncture for definitive diagnosis.) A single randomized trial of antibiotic treatment of rhinosinusitis has shown a modest benefit of such treatment when the diagnosis was made on the basis of a positive CT scan of the sinuses¹⁶ (56% of patients treated with placebo, 82% of those treated with penicillin, and 89% of those treated with amoxicillin were substantially better on day 10 of treatment). But CT sinus scans are expensive and not readily available in outpatient practice.

Until a better test is discovered and because most cases of sinusitis resolve without antibiotic treatment, providing reassurance, analgesics, and perhaps decongestants for symptomatic relief is the preferred treatment for mild to moderate cases of less than 7 days’ duration. Patients with typical sinusitis symptoms and more severe facial pain probably do benefit from early antibiotic treatment.¹⁷

However, I find that watchful waiting is ineffective for patients who complain of recurring sinus infections. These patients present within the first few days of illness, insist that they have a sinus infection just like the last one, and want to “catch it before it gets too bad.” This argument sounds sensible enough, and I find it hard to refuse the request. Are these sinusitis-prone patients more likely to have a bacterial infection than patients with similar complaints and no past history of sinusitis?

Antibiotics for Sinusitis-Prone Patients

Alho and coworkers¹⁸ present results of a rare attempt to explore this question in this issue of JFP. They recruited 23 adults who claimed to have suffered from recurrent sinus infections (sinusitis-prone group) and 25 who did not, all of whom had self-diagnosed colds of 48 to 96 hours’ duration. They compared the clinical courses, CT findings, and viral and bacterial cultures of nasal secretions obtained by nasoendoscopy. The sinusitis-prone group (defined as at least 2 episodes in the past year) had significantly more facial pain and sinusitis-like changes on CT scan (65% vs 36%). However, the sinusitis-prone group was just as likely to have a positive nasal viral culture as the control group (70% vs 64%). Paradoxically, the sinusitis-prone group was less likely to have a positive culture for pathogenic bacteria on nasoendoscopy (9% vs 40%), a finding the authors claim correlates with bacterial growth in the sinuses.

Alho and colleagues suggest that these sinusitis-prone patients usually have viral respiratory tract infections, just like the non-sinusitis–prone patients. They believe that because the sinusitis-prone patients tend to have more severe facial pain from their colds, they are more likely to seek care, and they are therefore more likely to be prescribed antibiotics inappropriately for this viral infection. My equally plausible explanation is that sinusitis-prone patients are truly more likely to develop complicating bacterial sinus infection early in the course of their illnesses, and they should be treated more aggressively with early antibiotic treatment. We cannot know the correct explanation because Alho and coworkers did not randomly assign subjects with respect to antibiotic treatment and because no diagnostic sinus punctures were done to determine who truly had a bacterial sinus infection. In a study of clinical predictors Hansen and colleagues11 found no difference in bacterial sinusitis in patients with and without a history of sinusitis, a finding that supports the interpretation of Alho and coworkers.

Time to Change Prescription Habits?

In light of the findings of Alho and colleagues, should I change my practice of using antibiotics for sinusitis-prone patients? Their findings and those of Hansen and coworkers are intriguing enough for me to think twice before reflexively prescribing an antibiotic. I will delve more carefully into the patient’s history to convince myself that the past episodes sound more like significant sinus infections than allergy or simple URIs. In doubtful cases, a plain Waters sinus radiograph, if normal, effectively rules out bacterial infection (negative predictive value of approximately 90%, meaning that 90% of symptomatic patients with a normal radiograph do not have sinusitis). A positive radiograph, however, does not rule in bacterial infection, and in difficult cases a sinus CT may be helpful. Otherwise, it is necessary to go back to finding common ground with the patient and negotiating treatment. Clearly, a next step on the rhinosinusitis research agenda is a randomized clinical trial of antibiotic treatment for sinusitis-prone patients. Ultimately, an accurate, inexpensive, and convenient diagnostic test is needed before we can base antibiotic treatment of sinusitis-like illness on firm scientific grounds.

I pride myself on judicious use of antibiotics for acute upper respiratory infections (URIs). The easy patients to treat are those with classic viral symptoms of clear rhinorrhea, nonproductive cough, and a mild to moderate illness of short duration. Most of these patients readily accept my reassurance and advice for symptomatic treatment.

Patients with acute bronchitis are a bit tougher to treat. They often have productive cough and are moderately ill for a longer duration. Even though antibiotics are of marginal, if any, benefit for acute bronchitis,¹ approximately 30% of my patients receive an antibiotic prescription despite my best efforts to the contrary. I usually resort to the popular last-ditch tactic of the backup prescription. If 50% of my patients fill those backup prescriptions as Couchman and colleagues² found, my actual prescribing rate for acute bronchitis is only 15%—not bad for this largely viral syndrome.

The good news is that the anti-antibiotic scuffle with patients may be happening less often. The public campaign by the Centers for Disease Control and Prevention to reduce inappropriate use of antibiotics appears to be reaching some of my patients. They are more likely to accept my advice for symptomatic treatment than they were 5 years ago. However, there is still a great need for educating patients and physicians about appropriate use of antibiotics for respiratory tract infections, as illustrated by the survey of college students by Zoorob and colleagues³ in this issue of JFP. When confronted with scenarios typical of viral URIs, 50% of those bright young adults would seek medical care and an antibiotic prescription.

Antibiotics for Acute Sinusitis

Acute sinusitis is a horse (or discharge, maybe?) of a different color. I used to think that sinusitis was the easy one to handle. Cheek pain plus green discharge equals antibiotic. The patient goes away satisfied, and I go on to the next coughing patient. Not so fast. This last port of refuge for antibiotic advocates is crumbling, too. Consider the following sobering facts:

Sinusitis rarely occurs in isolation and is most often accompanied by nasal cavity inflammation, resulting in the new designation rhinosinusitis.⁴

Most cases of rhinosinusitis are caused by viruses. Maxillary sinus radiographs of young adults with typical viral URIs showed mucosal abnormalities in 39% of cases on the seventh day of illness,⁵ and computed tomography (CT) scans were abnormal in 87% of similar cases.⁶

When based on signs and symptoms, the diagnosis of acute sinusitis is correct in approximately 50% or less of cases.^7-11 We probably are not this accurate in routine practice.

Randomized clinical trials of antibiotic treatment of rhinosinusitis have shown no effect when the diagnosis was based on clinical findings alone¹² or on clinical findings confirmed by plain radiographs.¹³

Despite the negative results of these randomized clinical trials, more than 90% of patients with a diagnosis of sinusitis by primary care physicians receive an antibiotic prescription.^13,14

Antibiotics have little effect on the course of rhinosinusitis, because the clinical diagnosis of bacterial sinusitis is so difficult. The signs and symptoms of viral infection of the paranasal sinuses mimic those of bacterial infection. Several investigators have attempted to identify clinical findings specific to bacterial sinusitis using a high-quality reference standard (sinus puncture and aspiration of purulent secretions, positive bacterial culture of aspirated secretions, or positive CT scan of the sinuses).^7,8,11 Maxillary facial pain, tooth pain, and purulent nasal discharge (ie, white, not green) are most discriminating, but even with these seemingly specific findings the ability to diagnose bacterial sinusitis accurately is poor. Because viral rhinosinusitis and rhinosinusitis with minimal bacterial suprainfection are so much more common than significant bacterial sinusitis, the few truly antibiotic-responsive bacterial infections are diluted out in clinical trials. We therefore see no effect of antibiotic treatment.

When Are Antibiotics Effective?

Antibiotics may be effective in some cases of acute sinusitis, but which ones? The dilemma is that we do not have a practical clinical test for ferreting out the few patients with sinusitis-like illness who would truly benefit from antibiotic treatment. (Most patients would prefer a trial of an antibiotic to sinus puncture for definitive diagnosis.) A single randomized trial of antibiotic treatment of rhinosinusitis has shown a modest benefit of such treatment when the diagnosis was made on the basis of a positive CT scan of the sinuses¹⁶ (56% of patients treated with placebo, 82% of those treated with penicillin, and 89% of those treated with amoxicillin were substantially better on day 10 of treatment). But CT sinus scans are expensive and not readily available in outpatient practice.

Until a better test is discovered and because most cases of sinusitis resolve without antibiotic treatment, providing reassurance, analgesics, and perhaps decongestants for symptomatic relief is the preferred treatment for mild to moderate cases of less than 7 days’ duration. Patients with typical sinusitis symptoms and more severe facial pain probably do benefit from early antibiotic treatment.¹⁷

However, I find that watchful waiting is ineffective for patients who complain of recurring sinus infections. These patients present within the first few days of illness, insist that they have a sinus infection just like the last one, and want to “catch it before it gets too bad.” This argument sounds sensible enough, and I find it hard to refuse the request. Are these sinusitis-prone patients more likely to have a bacterial infection than patients with similar complaints and no past history of sinusitis?

Antibiotics for Sinusitis-Prone Patients

Alho and coworkers¹⁸ present results of a rare attempt to explore this question in this issue of JFP. They recruited 23 adults who claimed to have suffered from recurrent sinus infections (sinusitis-prone group) and 25 who did not, all of whom had self-diagnosed colds of 48 to 96 hours’ duration. They compared the clinical courses, CT findings, and viral and bacterial cultures of nasal secretions obtained by nasoendoscopy. The sinusitis-prone group (defined as at least 2 episodes in the past year) had significantly more facial pain and sinusitis-like changes on CT scan (65% vs 36%). However, the sinusitis-prone group was just as likely to have a positive nasal viral culture as the control group (70% vs 64%). Paradoxically, the sinusitis-prone group was less likely to have a positive culture for pathogenic bacteria on nasoendoscopy (9% vs 40%), a finding the authors claim correlates with bacterial growth in the sinuses.

Alho and colleagues suggest that these sinusitis-prone patients usually have viral respiratory tract infections, just like the non-sinusitis–prone patients. They believe that because the sinusitis-prone patients tend to have more severe facial pain from their colds, they are more likely to seek care, and they are therefore more likely to be prescribed antibiotics inappropriately for this viral infection. My equally plausible explanation is that sinusitis-prone patients are truly more likely to develop complicating bacterial sinus infection early in the course of their illnesses, and they should be treated more aggressively with early antibiotic treatment. We cannot know the correct explanation because Alho and coworkers did not randomly assign subjects with respect to antibiotic treatment and because no diagnostic sinus punctures were done to determine who truly had a bacterial sinus infection. In a study of clinical predictors Hansen and colleagues11 found no difference in bacterial sinusitis in patients with and without a history of sinusitis, a finding that supports the interpretation of Alho and coworkers.

Time to Change Prescription Habits?

In light of the findings of Alho and colleagues, should I change my practice of using antibiotics for sinusitis-prone patients? Their findings and those of Hansen and coworkers are intriguing enough for me to think twice before reflexively prescribing an antibiotic. I will delve more carefully into the patient’s history to convince myself that the past episodes sound more like significant sinus infections than allergy or simple URIs. In doubtful cases, a plain Waters sinus radiograph, if normal, effectively rules out bacterial infection (negative predictive value of approximately 90%, meaning that 90% of symptomatic patients with a normal radiograph do not have sinusitis). A positive radiograph, however, does not rule in bacterial infection, and in difficult cases a sinus CT may be helpful. Otherwise, it is necessary to go back to finding common ground with the patient and negotiating treatment. Clearly, a next step on the rhinosinusitis research agenda is a randomized clinical trial of antibiotic treatment for sinusitis-prone patients. Ultimately, an accurate, inexpensive, and convenient diagnostic test is needed before we can base antibiotic treatment of sinusitis-like illness on firm scientific grounds.

I pride myself on judicious use of antibiotics for acute upper respiratory infections (URIs). The easy patients to treat are those with classic viral symptoms of clear rhinorrhea, nonproductive cough, and a mild to moderate illness of short duration. Most of these patients readily accept my reassurance and advice for symptomatic treatment.

Patients with acute bronchitis are a bit tougher to treat. They often have productive cough and are moderately ill for a longer duration. Even though antibiotics are of marginal, if any, benefit for acute bronchitis,¹ approximately 30% of my patients receive an antibiotic prescription despite my best efforts to the contrary. I usually resort to the popular last-ditch tactic of the backup prescription. If 50% of my patients fill those backup prescriptions as Couchman and colleagues² found, my actual prescribing rate for acute bronchitis is only 15%—not bad for this largely viral syndrome.

The good news is that the anti-antibiotic scuffle with patients may be happening less often. The public campaign by the Centers for Disease Control and Prevention to reduce inappropriate use of antibiotics appears to be reaching some of my patients. They are more likely to accept my advice for symptomatic treatment than they were 5 years ago. However, there is still a great need for educating patients and physicians about appropriate use of antibiotics for respiratory tract infections, as illustrated by the survey of college students by Zoorob and colleagues³ in this issue of JFP. When confronted with scenarios typical of viral URIs, 50% of those bright young adults would seek medical care and an antibiotic prescription.

Antibiotics for Acute Sinusitis

Acute sinusitis is a horse (or discharge, maybe?) of a different color. I used to think that sinusitis was the easy one to handle. Cheek pain plus green discharge equals antibiotic. The patient goes away satisfied, and I go on to the next coughing patient. Not so fast. This last port of refuge for antibiotic advocates is crumbling, too. Consider the following sobering facts:

Sinusitis rarely occurs in isolation and is most often accompanied by nasal cavity inflammation, resulting in the new designation rhinosinusitis.⁴

Most cases of rhinosinusitis are caused by viruses. Maxillary sinus radiographs of young adults with typical viral URIs showed mucosal abnormalities in 39% of cases on the seventh day of illness,⁵ and computed tomography (CT) scans were abnormal in 87% of similar cases.⁶

When based on signs and symptoms, the diagnosis of acute sinusitis is correct in approximately 50% or less of cases.^7-11 We probably are not this accurate in routine practice.

Randomized clinical trials of antibiotic treatment of rhinosinusitis have shown no effect when the diagnosis was based on clinical findings alone¹² or on clinical findings confirmed by plain radiographs.¹³

Despite the negative results of these randomized clinical trials, more than 90% of patients with a diagnosis of sinusitis by primary care physicians receive an antibiotic prescription.^13,14

Antibiotics have little effect on the course of rhinosinusitis, because the clinical diagnosis of bacterial sinusitis is so difficult. The signs and symptoms of viral infection of the paranasal sinuses mimic those of bacterial infection. Several investigators have attempted to identify clinical findings specific to bacterial sinusitis using a high-quality reference standard (sinus puncture and aspiration of purulent secretions, positive bacterial culture of aspirated secretions, or positive CT scan of the sinuses).^7,8,11 Maxillary facial pain, tooth pain, and purulent nasal discharge (ie, white, not green) are most discriminating, but even with these seemingly specific findings the ability to diagnose bacterial sinusitis accurately is poor. Because viral rhinosinusitis and rhinosinusitis with minimal bacterial suprainfection are so much more common than significant bacterial sinusitis, the few truly antibiotic-responsive bacterial infections are diluted out in clinical trials. We therefore see no effect of antibiotic treatment.

When Are Antibiotics Effective?

Antibiotics may be effective in some cases of acute sinusitis, but which ones? The dilemma is that we do not have a practical clinical test for ferreting out the few patients with sinusitis-like illness who would truly benefit from antibiotic treatment. (Most patients would prefer a trial of an antibiotic to sinus puncture for definitive diagnosis.) A single randomized trial of antibiotic treatment of rhinosinusitis has shown a modest benefit of such treatment when the diagnosis was made on the basis of a positive CT scan of the sinuses¹⁶ (56% of patients treated with placebo, 82% of those treated with penicillin, and 89% of those treated with amoxicillin were substantially better on day 10 of treatment). But CT sinus scans are expensive and not readily available in outpatient practice.

Until a better test is discovered and because most cases of sinusitis resolve without antibiotic treatment, providing reassurance, analgesics, and perhaps decongestants for symptomatic relief is the preferred treatment for mild to moderate cases of less than 7 days’ duration. Patients with typical sinusitis symptoms and more severe facial pain probably do benefit from early antibiotic treatment.¹⁷

However, I find that watchful waiting is ineffective for patients who complain of recurring sinus infections. These patients present within the first few days of illness, insist that they have a sinus infection just like the last one, and want to “catch it before it gets too bad.” This argument sounds sensible enough, and I find it hard to refuse the request. Are these sinusitis-prone patients more likely to have a bacterial infection than patients with similar complaints and no past history of sinusitis?

Antibiotics for Sinusitis-Prone Patients

Alho and coworkers¹⁸ present results of a rare attempt to explore this question in this issue of JFP. They recruited 23 adults who claimed to have suffered from recurrent sinus infections (sinusitis-prone group) and 25 who did not, all of whom had self-diagnosed colds of 48 to 96 hours’ duration. They compared the clinical courses, CT findings, and viral and bacterial cultures of nasal secretions obtained by nasoendoscopy. The sinusitis-prone group (defined as at least 2 episodes in the past year) had significantly more facial pain and sinusitis-like changes on CT scan (65% vs 36%). However, the sinusitis-prone group was just as likely to have a positive nasal viral culture as the control group (70% vs 64%). Paradoxically, the sinusitis-prone group was less likely to have a positive culture for pathogenic bacteria on nasoendoscopy (9% vs 40%), a finding the authors claim correlates with bacterial growth in the sinuses.

Alho and colleagues suggest that these sinusitis-prone patients usually have viral respiratory tract infections, just like the non-sinusitis–prone patients. They believe that because the sinusitis-prone patients tend to have more severe facial pain from their colds, they are more likely to seek care, and they are therefore more likely to be prescribed antibiotics inappropriately for this viral infection. My equally plausible explanation is that sinusitis-prone patients are truly more likely to develop complicating bacterial sinus infection early in the course of their illnesses, and they should be treated more aggressively with early antibiotic treatment. We cannot know the correct explanation because Alho and coworkers did not randomly assign subjects with respect to antibiotic treatment and because no diagnostic sinus punctures were done to determine who truly had a bacterial sinus infection. In a study of clinical predictors Hansen and colleagues11 found no difference in bacterial sinusitis in patients with and without a history of sinusitis, a finding that supports the interpretation of Alho and coworkers.

Time to Change Prescription Habits?

In light of the findings of Alho and colleagues, should I change my practice of using antibiotics for sinusitis-prone patients? Their findings and those of Hansen and coworkers are intriguing enough for me to think twice before reflexively prescribing an antibiotic. I will delve more carefully into the patient’s history to convince myself that the past episodes sound more like significant sinus infections than allergy or simple URIs. In doubtful cases, a plain Waters sinus radiograph, if normal, effectively rules out bacterial infection (negative predictive value of approximately 90%, meaning that 90% of symptomatic patients with a normal radiograph do not have sinusitis). A positive radiograph, however, does not rule in bacterial infection, and in difficult cases a sinus CT may be helpful. Otherwise, it is necessary to go back to finding common ground with the patient and negotiating treatment. Clearly, a next step on the rhinosinusitis research agenda is a randomized clinical trial of antibiotic treatment for sinusitis-prone patients. Ultimately, an accurate, inexpensive, and convenient diagnostic test is needed before we can base antibiotic treatment of sinusitis-like illness on firm scientific grounds.