Acute sinusitis is one of the 10 most common diagnoses in ambulatory medical practice – and 5th most common for which an antibiotic is prescribed.  Sinusitis peaks in the fall, winter, and spring.  Children have between 6 to 10 colds per year, of which only about 1% are complicated by acute bacterial sinusitis.  Yet, antibiotics are prescribed for more than 50% of cases.  The authors provide some useful definitions of types of sinusitis:

Acute sinusitis may last as long as 4 weeks.  Recurrent sinusitis is defined as 4 or more episodes per year, of at least 7 days duration.  Subacute sinusitis persists 4 to 12 weeks, and chronic sinusitis lasts longer than 12 weeks – within which there are episodes of acute exacerbation. 

Nearly 90% of patients with the common cold have radiographic evidence of sinus disease.  In clinical sinusitis, no bacteria grow in sinusitis in up to 40% of cases and respiratory viruses appear to be the pathogens (rhinovirus, influenza A, parainfluenza virus).   Bacterial sinusitis is most often caused by Streptococcus pneumoniae and Haemophilus influenzae.  

Recent studies have shown that most primary care physicians diagnose sinusitis on the basis of symptoms that actually do not really predict the likelihood of having sinusitis.   There are very few good studies that help inform us whether antibiotics have significant benefits in sinusitis.  And the few studies with sound methodologies have not shown conclusively that antibiotics do offer any benefit.

Sinusitis is more likely if a cold has lasted longer than one week and fever is present along with: nasal congestion, sinus discomfort, maxillary (upper) toothache, sinus discomfort, facial pain and headache exacerbated by bending forward, purulent nasal discharge and a biphasic illness (two peaks of symptoms).  The authors offer the following recommendations:  Illnesses less than 7-10 days duration should be treated with saline nasal sprays, analgesics, and steam inhalation – not antibiotics (exceptions made for accompanying fevers or immune deficiencies).   Patients should be advised to avoid cigarette smoke, drink plenty of liquids, elevate head of bed and apply warm facial packs to face for 5-10 minutes to promote drainage.  If the symptoms continue beyond 10 days and accompanied by purulent nasal discharge, unilateral facial pain, maxillary toothache, and worsening symptoms after initial improvement, Amoxicillin should be considered.  Other antibiotics are useful if the symptoms do not respond to Amoxicillin or there is a penicillin allergy. 

(Leggett JE.  Postgraduate Med 2004; 115(1):13-19)       -- H.T.