Health Care Guideline:
Acute Sinusitis in Adults

Copyright © 1998 by Institute for Clinical Systems Integration

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All patients presenting with symptoms of sinusitis would be triaged through the ICSI VURI in Adults guideline before entering this algorithm.

Contents

• Work Group Members
• General Description of Guideline Format
• Targeted Population
• Priority Aims for Medical Groups When Using This Guideline
• Clinical Algorithms & Annotations
• Evidence Grading Systems
• Guideline Development History
• Other Guideline Referenced Within This Guideline
• Instructions for Downloading PDF Verson of This Guideline

Work Group Members

Work Group Leader
Richard Pfohl, MD, HealthSystem Minnesota

Adult Nursing
Marge Lawrence, RN, HealthPartners

Allergy
Richard Morris, MD, HealthSystem Minnesota

ENT
Greg Jones, MD, HealthSystem Minnesota

Family Practice
Dale Duthoy, MD, Family HealthServices Minnesota

Internal Medicine
Tom Bisig, MD, Mayo Clinic

Allan Boyum, MD, HealthPartners

Richard Pfohl, MD, HealthSystem Minnesota

Pharmacy
Peter Marshall, PharmD, Regions Hospital

Health Education
Laurie Jo Vlasak, Mayo Clinic

Measurement Advisor
Margaret Healey, PhD, Institute for Research & Education HealthSystem Minnesota

Buyers Health Care Action Group Representative
Jennifer Bichsel, Ceridian

Facilitator
Jane Erickson, MS, ICSI

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Targeted Population

Patients age 18 and over.

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Priority Aims For Medical Groups When Using This Guideline

1. To increase the use of first line antibiotics when indicated for patients diagnosed with sinusitis.

Possible measures of accomplishing this aim:

a. Percentage of patients with an office visit for acute sinusitis given a first line antibiotic when an antibiotic is prescribed.

b. Percentage of patients with acute sinusitis who receive an antibiotic other than first line for whom one of the following contraindications is documented:

• allergies to first line antibiotics
• failure to respond to first line antibiotics.

2. To decrease the use of sinus x-rays in the diagnosis of acute sinusitis.

Possible measures of accomplishing this aim:

a. Percentage of patients with a sinus x-ray after an initial visit for acute sinusitis.

3. To educate providers about appropriate ENT referral.

Possible measures of accomplishing this aim:

a. Percentage of patients referred to ENT for acute sinusitis who have not received three weeks of continuous antibiotic treatment.

b. Percentage of patients referred to ENT for acute sinusitis who do not have any complicating factors documented.

4. To increase patient knowledge about treatment of sinusitis.

a. Percentage of patients seen for acute sinusitis who have documentation that they have been educated about treatment.

b. Percentage of patients seen for acute sinusitis where symptoms have been present for less than 7 days and there is documentation of patient demand for antibiotics.

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Clinical Algorithms & Annotations

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Algorithm Annotations

All adult patients presenting with symptoms of sinusitis are triaged through the ICSI Viral Upper Respiratory Infection guideline first, and would enter this guideline from the VURI guideline.

• Algorithm Annotation List

2.   Phone Triage Indicates Acute Sinusitis?
3.   Triage for Alternative Diagnosis
4.   Needs Visit?
5.   Phone Management/Home Self Care
6.   Visit
7.   Acute Sinusitis?
8.   Follow-up for Alternative Diagnosis
9.   Treatment/Home Self Care
10. Complete Response?
11. Further Treatment

• Discussion and Reference: Download PDF Version of This Guideline

2. Phone Triage Indicates Acute Sinusitis?

Phone Triage Criteria

Acute sinusitis is indicated when:

• Upper respiratory symptoms have been present for at least 7 days, AND
• 2 or more of the following 4 factors are present at a point 7 days or more after the onset of the illness:
• Colored nasal drainage
• Poor response to decongestant
• Facial pain or sinus pain, particularly if aggravated by postural change or valsalva maneuver
• Headache

An individual reporting symptoms meeting the above phone triage criteria for acute sinusitis has a reasonably high likelihood of having the disease. Such a patient's symptoms and chart should be presented to the physician or nurse practitioner for further action.

• Fever > 102½ and a documented past history of sinusitis in addition to the above symptoms are supportive of a sinusitis diagnosis.
• Tooth pain with any of the above findings is a more specific indication of sinusitis. Patients with tooth pain could be considered for treatment before 7 days.
• Severe symptoms should be considered for treatment before 7 days.
• Known anatomical blockage (e.g., chronic nasal polyps, severely deviated septum, recurrent sinusitis) may need immediate treatment.

3. Triage for Alternative Diagnosis

Patients not meeting the triage criteria for sinusitis would be triaged for an alternative diagnosis.

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4. Needs Visit?

• A pattern over time of telephone requests for antibiotics by the same patient should be replaced by a provider visit.
• Patients on antibiotics for 2 or more days whose sinus symptoms are worsening should be scheduled for a provider visit.
• Patients with any one of the following complicating factors should be seen urgently:
• Orbital pain
• Visual disturbances
• Periorbital swelling or erythema
• Facial swelling or erythema

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5. Phone Management/Home Self Care

Patients who are in generally good health and only mildly ill may be appropriate candidates for phone management of presumed acute sinusitis. Both the patient and the provider should be comfortable with phone management. The following factors are also supportive of phone management:

• Established patient (has been seen by primary care physician within the past year)
• History of previous sinusitis treated successfully
• Earlier visit with viral upper respiratory infection that has progressed to probable acute sinusitis

Patients who meet the criteria for phone management should receive the same treatment and instructions outlined in Annotation #9 for visiting patients.

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6. Visit

• Review history
  Confirm history as in phone triage.
• Regional exam of the head and neck
  The following physical findings may be present:
• Purulent nasal drainage
• Sinus tenderness
• Decreased transillumination (optional)
• Review complicating factors - further evaluation needed

Local

• External facial swelling/erythema over involved sinus

Orbital

• Visual changes
• Extraocular motion abnormal
• Proptosis
• Periorbital inflammation/soft tissue edema
• Periorbital erythema/cellulitis
• subperiosteal abscess
• orbital cellulitis
• orbital abscess

Intracranial, CNS Complications

• Cavernous sinus thrombosis
• Meningitis
• Subdural empyema
• Brain abscess
• Plain sinus x-rays and other imaging are usually not necessary in making the diagnosis of acute sinusitis.
• Maxillary antrum aspiration for culture is indicated only when precise microbial identification is required.

Strength of the evidence for this recommendation:

Sinus x-rays: C

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7. Acute Sinusitis?

The diagnosis of acute sinusitis is based primarily on the patient's presenting symptoms and history, and is supported by the physical exam.

8. Follow-up for Alternative Diagnosis

Follow-up for an alternative diagnosis should take place if the patient's symptoms, history, and physical exam are not indicative of acute sinusitis.

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9. Treatment/Home Self Care

Provide Patient Education

The patient should be instructed to implement the following comfort and prevention measures:

Home Self Care Measures

• Maintain adequate hydration (drink 6_10 glasses of liquid a day to thin mucus)
• Steamy shower or increase humidity in your home
• Apply warm facial packs (warm wash cloth, hot water bottle, or gel pack for 5-10 minutes 3 or more times per day)
• Analgesics (acetaminophen, ibuprofen, ASA as needed)
• Saline irrigation (see HealthPartners patient education brochure #201081 for details)
• homemade (1/4 teaspoon salt dissolved in 1 cup of water; use bulb syringe or dropper purchased from drug store)
• Decongestants (topically or orally)
• pseudoephedrine HCL (e.g., Sudafed) 60 mg. q 4-6 hours, not to exceed 4 doses per 24 hours.
• decongestant nasal sprays for no longer than 3 days, e.g., oxymetazoline (e.g., Afrin), phenylephrine HCl (Neosynephrine)
• Adequate rest
• Saline nasal drops/spray
• commercial (e.g., Ocean, Salinex, Nasal)
• Sleep with head of bed elevated
• Avoid cigarette smoke and extremely cool or dry air

Prevention Measures

Appropriate treatment of allergies and viral upper respiratory infections can prevent the development of sinusitis.

Environmental factors which affect the sinuses include cigarette smoke, pollution, swimming in contaminated water, and barotrauma.

Nasal steroid spray

Intranasal corticosteroid spray is a rational but unproved adjunctive therapy for acute sinusitis.

Antibiotics

• Amoxicillin
• 500 mg TID 10 days

-or-

• Trimethoprim-sulfamethoxazole (TMP/SMX)
• one double strength tab BID 10 days

For patients allergic to both amoxicillin and TMP/SMX, macrolides can be prescribed. A cephalosporin could be considered but there is approximately a 10% cross-reaction between cephalosporins and amoxicillin. (Refer to Annotation #11.)

It is important to instruct the patient to complete the course of antibiotics.

The duration of antibiotic therapy is controversial. Studies have shown effectiveness with 3-14 days. Most studies have used a 10 day course of antibiotics.

Call Back Instructions

The patient should be instructed to call back if symptoms worsen, or if symptoms have not resolved within one week.

Strength of the evidence for this recommendation:

Antibiotics: A

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10. Complete Response?

Complete Response

Patient is symptomatically improved to near normal.

Partial Response

Patient is symptomatically improved but not back to normal at the end of the first course of antibiotics.

Failure or No Response

Patient has little or no symptomatic improvement after finishing a 10 day course of first line antibiotic therapy (amoxicillin or TMP/SMX).

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11. Further Treatment

Partial Response

• An additional 10-14 days of amoxicillin 500 mg TID

or

• Trimethoprim-sulphamethoxazole (TMP/SMX)
• one double strength tab BID x 10-14 days

Reinforce the comfort and prevention measures outlined in Annotation #9.

Partial response is assessed at the end of 10-14 days by provider visit or phone call.

Failure or No Response

After 10-14 days of failure of first line antibiotic (amoxicillin or TMP/SMX), an antibiotic should be prescribed which covers resistant bacteria:

• TMP/SMX if failed on amoxicillin
• one double strength tab BID x 10-14 days
• Amoxicillin/clavulanate (Augmentin®)
• 875 mg BID x 14 days

For patients allergic to both amoxicillin and TMP/SMX, macrolides can be prescribed. A cephalosporin could be considered but there is approximately a 10% cross-reaction between cephalosporins and amoxicillin.

• Second generation cephalosporin
• cefuroxime (Ceftin®) 250 mg BID x 10-14 days
• cefpodoxime (Vantin®) 200 mg BID x 10-14 days
• cefprozil (Cefzil®*) 500 mg QD x 10-14 days
• cefaclor (Ceclor®*) 500 mg TID x 10-14 days
• loracarbef (Lorabid®*) 400 mg q 12 hours x 10-14 days
• Macrolides
• azithromycin (Zithromax®) 500 mg 1st day, 250 mg x 4 days
• clarithromycin (Biaxin®*) 500 mg BID x 10 days
• Ciprofloxacin (Cipro®) 500 mg BID

Newer medications presently approved by the FDA for the treatment of sinusitis include the following:

• Amoxicillin/clavulanate (Augmentin®) 875 mg BID x 14 days
• Cefuroxime (Ceftin®) 250 mg BID x 10 days
• Clarithromycin (Biaxin®) 500 mg BID x 14 days
• Levofloxacin (Levaquin®) 500 mg qd x 10-14 days
• Loracarbef (Lorabid® ) 400 mg BID x 10 days

Reinforce the comfort and prevention messages outlined in Annotation #9.

In patients who have not responded to three weeks of continuous antibiotic therapy:

• Consider sinus x-ray series or limited coronal CT scan and/or referral to ENT provider

* Cefzil, Ceclor, Lorabid and Biaxin are not currently in the HealthPartners formulary. Ceftin, Cefzil, Ceclor, and Lorabid are not currently in the Mayo Clinic formulary.

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Evidence Grading System

Grade A: Conclusion based on a randomized, controlled trial that has been published in a peer-reviewed journal.

Grade B: Conclusion based on one of the following study types published in a peer-reviewed journal (but not on a randomized, controlled trial):

• a trial using historical or other non-randomized controls;
• a prospective cohort study;
• a case-control study; or
• a meta-analytic study.

Grade C: Conclusion based on one of the following (but not on any studies of the types mentioned above):

• an uncontrolled case series; or
• medical opinion.

Guidelines obtained from the Agency for Health Care Policy and Research (AHCPR) or other sources, position statements, panel consensus statements from the National Institutes of Health (NIH) or elsewhere, review articles, and textbook chapters that cite primary evidence are not assigned a grade because they are not primary evidence. The individual studies cited in such secondary sources can be graded according to the categories presented above.

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Guideline Development History

• Document Drafted Apr-Aug 1994
• Critical Review Period Sep-Oct 1994
• Revision/Approval Oct-Dec 1994
• Pilot Implementation Period Dec 1994-Feb 1995
• Revision/Approval Mar-Jun 1995
• General Implementation (First cycle) Jul 1995-May 1996
• Revision/Approval Jun-Aug 1996
• General Implementation (Second cycle) Sep 1996-Sep 1997
• Revision/Approval Oct-Dec 1997
• General Implementation (Third cycle) Jan-Jun 1998
• Revision/Approval Jul-Oct 1998
• General Implementation (Fourth cycle) Begins Nov 1998

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Other Guideline Referenced Within This Guideline

• Viral Upper Respiratory Infection (VURI) guideline

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Downloading the PDF Version of This Guideline

Click here to download the full version of this Guideline in PDF format. You will need ADOBE Acrobat reader to view the file. The reader may be found here.

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