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Acute sinusitis in primary care
Professor of Primary Care, University of Ulster
E-mail: f.dobbs{at}ulster.ac.uk
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Abstract |
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Sinusitis is a common diagnosis in primary care, and around the third to fifth commonest reason for prescription of antibiotics. Yet, a recent Cochrane review of effectiveness of antibiotic for acute sinusitis concluded that antibiotics have only a small treatment effect with 80% of patients getting better within 2 weeks without antibiotic as against 90% in those given antibiotic. Why is this, and how can we target appropriate treatment to those who will benefit?
Sinusitis is mentioned as an important disease in the knowledge base of Statement 15.4 of the GP Curriculum - ENT and facial problems. This statement requires GPs to:
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How does sinusitis develop?
Viral upper respiratory tract infections (URTI) involve the whole upper respiratory tract including the sinus cavities. In 2% of cases, a secondary bacterial infection may occur. Some people are more prone to developing sinusitis, probably due to differences in structure and function of the sinus cavities and mucous membrane. Obstruction of the ostium draining a sinus results in hypoxia, acidification of the mucus and paralysis of the cilia pumping system. Usually, this is triggered by a viral infection but allergic rhinitis, swimming and diving, high altitude and dental infections or trauma may also result in blockage. Rarer causes of sinusitis in primary care are listed in Box 1. Sinusitis continuing for longer than 12 weeks is termed chronic sinusitis, and irreversible damage to the sinus epithelium with formation of polyps may have occurred. Referral for specialist assistance allows assessment by flexible rhinoscopy and possible endoscopic surgery.
Box 1. Rare causes of sinusitis
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Reproduced from British Medical Journal, Ah-See, K.W., Evans, A.S. 334: p. 358–61, 2007, with permission from BMJ Publishing Group Ltd.
Diagnosis
Symptoms associated with sinusitis more commonly than with uncomplicated URTI are:
- purulent rhinorrhoea
- pain when bending
- unilateral maxillary pain, and
- tooth pain.
The most common course of presentation is that these specific symptoms come on around a week after a simple URTI. Other symptoms, such as nasal obstruction, hyposmia and fever, occur as commonly in URTI as in sinusitis.
Tests which are positive more commonly with sinusitis are erythrocyte sedimentation rate and C-reactive protein. A scoring system to assist in diagnosis is shown in Table 1. This combines the probabilities of the different symptoms, signs and test results using Bayesian log likelihood ratio scores (B-scores). The score for presence or absence of each data item is added to produce a total score which relates to the probability of sinusitis being present.
A total score of zero or greater indicates a probability of 50% or more in favour of sinusitis. Positive scores correspond to odds in favour of sinusitis doubling with each increase of 2 in the score. So +2 is equivalent to 2 to 1 in favour, +4 is equivalent to 4 to 1 and +6 is equivalent to 8 to 1. Negative scores correspond to odds against sinusitis similarly (i.e. –2 means 2 to 1 against, –6 means 8 to 1 against). The data items contribute approximately independently to the final probability, so that the total without the test results gives an estimated value for the final probability.
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Rarer causes of sinusitis symptoms or complications of an initial sinus infection may be associated with red flag symptoms which are listed in Box 2.
Other tests which are used in secondary care or research include X-ray, ultrasound, rhinoscopy, MRI and CT scan and antral puncture with culture of mucus. They are not useful in primary care as they do not alter treatment.
Box 2. Red flag symptoms/signs
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Reproduced from British Medical Journal, Ah-See, K.W., Evans, A.S. 334: p. 358–61, 2007, with permission from BMJ Publishing Group Ltd.
Treatment
NICE recommendations on the treatment of sinusitis are available at www.nice.org.uk/Guidance/CG69. Antibiotics have little effect in the early stages, so symptomatic treatment with analgesics (paracetamol, ibuprofen, with or without codeine) is the first-line management. Decongestants have not been shown to have any effect.
When symptoms persist beyond a fortnight, a Cochrane review of intranasal steroid spray treatment has shown a slight benefit (73% vs. 66%). The small benefit from antibiotics (90% vs. 80%) might also be worthwhile at this stage. Studies comparing different antibiotics have not found any which are more effective or less effective (from penicillin, augmented penicillin, tetracycline, cephalosporin and macrolide classes). This may be due to the large study population which would be necessary to detect a small difference or may be because of the heterogeneous nature of the bacterial flora present in sinusitis.
With persistence of symptoms beyond 12 weeks (chronic sinusitis), presence of red flag symptoms/signs, or frequent recurrent episodes, referral for ear, nose and throat opinion is worthwhile.
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Summary |
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TOPAbstractThe GP curriculum and...Topic materialSummaryReferences |
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Acute sinusitis commonly occurs a week or so after a URTI, associated with facial pain (often unilateral) and purulent nasal discharge. Initial management is with analgesia (paracetamol, ibuprofen and codeine). Antibiotic and/or intranasal steroid spray may be useful for cases persisting for longer than a fortnight. Red flag symptoms/signs include unilateral polyp/mass, bleeding, diplopia/proptosis, maxillary paraesthesia, orbital swelling or erythema.
Key points
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References |
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Ahovuo-Saloranta A, Borisenko OV, Kovanen N, Varonen H, Rautakorpi UM, Williams JW Jr., Makela M. Antibiotics for acute maxillary sinusitis. Cochrane Database of Systematic Reviews (2008) (2):CD000243. Accessed via www.cochrane.org/reviews/en/ab000243.html [date last accessed 05.10.2008].
Ah-See KW, Evans AS. Sinusitis and its management. British Medical Journal (2007) 334:358–61.
Andre M, Odenholt I, Schwan Å, The Swedish Study Group on antibiotic use. upper respiratory tract infections in general practice: diagnosis, antibiotic prescribing, duration of symptoms and use of diagnostic tests. Scandinavian Journal of Infectious Diseases (2002) 34(12):880–6.[CrossRef][Web of Science][Medline]
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NHS. Clinical Knowledge Summaries (formerly Prodigy) guidance on sinusitis. Accessed via cks.library.nhs.uk/sinusitis [date last accessed 05.10.2008].
NICE. Respiratory tract infections—antibiotic prescribing. Prescribing of antibiotics for self-limiting respiratory tract infections in adults and children in primary care (2008) Accessed via www.nice.org.uk/nicemedia/pdf/CG69FullGuideline.pdf [date last accessed 05.10.2008].
RCGP. Curriculum statement 15.4: ENT and Facial Problems. Accessed via www.rcgp-curriculum.org.uk/pdf/curr_15_4_ENT_&_facial_problems.pdf [date last accessed 22.10.2008].
Patient UK. Acute sinusitis. Accessed via www.patient.co.uk/showdoc/23068821 [date last accessed 05.10.2008].
van Duijn NP, Brouwer HJ, Lamberts H. Use of symptoms and signs to diagnose maxillary sinusitis in general practice: comparison with ultrasonography. British Medical Journal (1992) 305:684–7.
Zalmanovici A, Yaphe J. Steroids for acute sinusitis. Cochrane Database of Systematic Reviews (2007) (2):CD005149. Accessed via www.cochrane.org/reviews/en/ab005149.html [date last accessed 05.10.2008].
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