Sinusitis is defined as inflammation of the mucosal lining of the paranasal sinuses.
Acute sinusitis is usually triggered by a viral upper respiratory tract infection and is diagnosed by the presence of nasal blockage (obstruction/congestion) or nasal discharge (anterior/posterior nasal drip) with facial pain (or pressure) and/or reduction of, or loss of, the sense of smell, lasting for less than 12 weeks.
In children, symptoms of rhinitis predominate, with facial pain being less prevalent. There may also be ear discomfort (Eustachian tube blockage).
Examination is of limited value but may reveal the presence of purulent discharge, swelling of the nasal mucosa, tenderness over the sinuses, and fever.
Chronic sinusitis is diagnosed by the presence of nasal blockage (obstruction/congestion) or nasal discharge (anterior/posterior nasal drip) with facial pain (or pressure) and/or reduction of, or loss of, the sense of smell, lasting for longer than 12 weeks.
Compared with acute sinusitis, in chronic sinusitis loss of smell is more commonly described and facial pain is less common.
Recurrent episodes of acute sinusitis may also occur, with worsening symptoms above the normal background level of persistent symptoms.
Management of acute sinusitis involves:
Advising about the natural course of the infection (i.e. that it lasts longer than a common cold and that it is usually viral so antibiotics are unlikely to help and may cause adverse effects).
Recommending measures to relieve symptoms, e.g. analgesia for pain or fever, an intranasal decongestant (for a maximum of 1 week if nasal congestion is a problem), irrigating the nose with saline solution, applying warm face packs, drinking adequate fluid, and rest.
Considering the need for antibiotics, especially in recurrent cases.
Advising that steam inhalation, complementary and alternative medicine, oral and intranasal corticosteroids, antihistamines, and mucolytics are not recommended for acute sinusitis.
Management of chronic sinusitis includes:
Advising that chronic sinusitis may last several months, but does not usually require referral.
Recommending measures to relieve symptoms.
Managing any associated disorder, e.g. allergic rhinitis or asthma to help sinusitis symptoms.
Advising good dental hygiene and smoking cessation, if appropriate.
Considering the need for intranasal corticosteroids, especially if there is suspicion of an allergic cause (such as concomitant allergic rhinitis).
Considering the need for long-term antibiotics (specialist advice should be sought as the evidence for this approach is limited).
Advising that steam inhalation and complementary and alternative medicine are not recommended for chronic sinusitis.
Hospital admission should be arranged if a complication of acute sinusitis develops (e.g. there is intracranial or peri-orbital involvement).
Urgent referral to an Ear, Nose, and Throat (ENT) specialist should be considered if there is a suspected sinonasal tumour (persistent unilateral symptoms, such as bloodstained discharge, crusting, non-tender facial pain, facial swelling, or unilateral nasal polyps).
Routine referral to ENT should be considered if the person has:
Frequent recurrent, troublesome episodes of acute sinusitis.
Unremitting or progressive facial pain.
Nasal polyps which are causing significant nasal obstruction.
Had a trial of intranasal corticosteroids for 3 months which was ineffective.
This CKS topic covers the management of acute and chronic sinusitis.
This CKS topic does not cover the management of the common cold, other upper respiratory tract infections, or other causes of facial pain, nasal polyps, or fungal sinusitis.
There are separate CKS topics on Allergic rhinitis, Headache - assessment, Headache - cluster - COPY OCT 12, Headache - medication overuse - COPY OCT 12, Headache - tension-type, Migraine, and Trigeminal neuralgia.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK, and providing first contact or primary health care.
February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic [NICE, 2013].
October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic [NPC, 2012].
September 2012 — minor update. Ephedrine 0.5% nasal drops are no longer licensed for use in children younger than 12 years of age. Prescriptions have been updated.
July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency [MHRA, 2011]. Prescriptions have been updated to reflect the revised dosing. Issued in July 2011.
May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic [NPC, 2011]. Issued in June 2011.
September 2010 — minor update. The likely causative pathogens have been added to the Causes section, and the rationale for using high-dose amoxicillin (if an antibiotic is indicated) has been added to the Basis for recommendation for the recommendation on Prescribing antibiotics. Issued in September 2010.
August 2009 — minor update. Xylometazoline 0.05% nasal drops (Otrivine Child Nasal Drops®) are no longer licensed for use in children between 2 and 5 years of age. They can be prescribed for children who are 6 years of age and over. Issued in August 2009.
October 2008 to March 2009 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.
Recommendations for the prescribing of antibiotics for acute sinusitis are now based on the clinical guideline Respiratory tract infections — antibiotic prescribing, published by the National Institute for Health and Clinical Excellence [NICE, 2008a].
December 2007 — updated. Macrolide options changed to erythromycin or clarithromycin in line with advice from the Health Protection Agency. Issued in January 2008.
October 2006 — minor update. Analgesia prescriptions updated because new doses of ibuprofen for children are recommend by the British National Formulary. Issued in October 2006.
July–September 2005 — reviewed. Validated in December 2005 and issued in February 2006.
March 2004 — updated with additional information for nurse prescribers. Issued in March 2004.
March 2002 — rewritten and renamed Sinusitis. Validated in June 2002 and issued in July 2002.
August 1998 — written, replacing guidance on Acute sinusitis and Chronic sinusitis. Validated in November 1998 and issued in December 1998.
Evidence-based guidelines published since the last revision of this topic:
Chow, A.W., Benninger, M.S., Brook, I., et al. (2012) IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clinical Infectious Disease 54(8), e72-e112. [Abstract]
HTAs (Health Technology Assessments)
No new HTAs since 1 October 2008.
No new economic appraisals relevant to England since 1 October 2008.
Systematic reviews and meta-analyses
Systematic reviews published since the last revision of this topic:
Cronin, M.J., Khan, S., and Saeed, S. (2013) The role of antibiotics in the treatment of acute rhinosinusitis in children: a systematic review. Archives of Disease in Childhood epub ahead of print. [Abstract]
Hayward, G., Heneghan, C., Perera,R., and Thompson, M. (2012) Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis. Annals of Family Medicine 10(3), 241-249. [Abstract] [Free Full-text]
Isaacs, S., Fakhri, S., Luong, A., and Citardi, M.J. (2011) A meta-analysis of topical amphotericin B for the treatment of chronic rhinosinusitis. International Forum of Allergy and Rhinology 1(4), 250-254. [Abstract]
Kalish, L.H., Arendts, G., Sacks, R., and Craig, J.C. (2009) Topical steroids in chronic rhinosinusitis without polyps: a systematic review and meta-analysis. Otolaryngology - Head and Neck Surgery 141(6), 674-683. [Abstract]
Lal, D., and Hwang, P.H. (2011) Oral corticosteroid therapy in chronic rhinosinusitis without polyposis: a systematic review. International Forum of Allergy and Rhinology 1(2), 136-143. [Abstract]
Lemiengre, M.B., van Driel, M.L., Merenstein, D., et al. (2012) Antibiotics for clinically diagnosed acute rhinosinusitis in adults (Cochrane Review). The Cochrane Library. Issue 10. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Piromchai, P., Thanaviratananich, S., and Laopaiboon, M. (2011) Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults (Cochrane Review). The Cochrane Library. Issue 5. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Poetker, D.M., Jakubowski, L.A., Lal, D., et al. (2013) Oral corticosteroids in the management of adult chronic rhinosinusitis with and without nasal polyps: an evidence-based review with recommendations. International Forum of Allergy and Rhinology 3(2), 104-120. [Abstract]
Pynnonen, M.A., Venkatraman, G., and Davis, G. (2013) Macrolide therapy for chronic rhinosinusitis: a meta-analysis. Otolaryngology - Head and Neck Surgery epub ahead of print. [Abstract]
Rudmik, L., Hoy, M., Schlosser, R.J., et al. (2012) Topical therapies in the management of chronic rhinosinusitis: an evidence-based review with recommendations. International Forum of Allergy and Rhinology epub ahead of print. [Abstract]
Sacks, P.L., Harvey, R.J., Rimmer, J., et al. (2011) Topical and systemic antifungal therapy for the symptomatic treatment of chronic rhinosinusitis (Cochrane Review). The Cochrane Library. Issue 8. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Sacks, P.L., Harvey, R.J., Rimmer, J., et al. (2012) Antifungal therapy in the treatment of chronic rhinosinusitis: a meta-analysis. American Journal of Rhinology and Allergy 26(2), 141-147. [Abstract]
Shaikh, N., Wald, E.R., and Pi, M. (2010) Decongestants, antihistamines and nasal irrigation for acute sinusitis in children (Cochrane Review). The Cochrane Library. Issue 12. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Snidvongs, K., Kalish, L., Sacks, R., et al. (2011) Topical steroid for chronic rhinosinusitis without polyps (Cochrane Review). The Cochrane Library. Issue 8. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Venekamp, R.P., Thompson, M.J., Hayward, G., et al. (2011) Systemic corticosteroids for acute sinusitis (Cochrane Review). The Cochrane Library. Issue 12. John Wiley & Sons, Ltd. www.thecochranelibrary.com [Free Full-text]
Randomized controlled trials published since the last revision of this topic:
Bachert, C., Schapowal, A., Funk, P., et al. (2009) Treatment of acute rhinosinusitis with the preparation from Pelargonium sidoides EPs 7630: a randomized, double-blind, placebo-controlled trial. Rhinology 47(1), 51-58. [Abstract]
Mukerji, S.S., Pynnonen, M.A., Kim, H.M., et al. (2009) Probiotics as adjunctive treatment for chronic rhinosinusitis: a randomized controlled trial. Otolaryngology – Head and Neck Surgery 140(2), 202-208. [Abstract]
Ozturk, F., Bakirtas, A., Ileri, F. and Turktas, I. (2011) Efficacy and tolerability of systemic methylprednisolone in children and adolescents with chronic rhinosinusitis: a double-blind, placebo-controlled randomized trial. Journal of Allergy and Clinical Immunology 128(2), 348-352. [Abstract]
Vaidyanathan, S., Barnes, M., Williamson, P., et al. (2011) Treatment of chronic rhinosinusitis with nasal polyposis with oral steroids followed by topical steroids. A randomized trial. Annals of Internal Medicine 154(5), 293-302. [Abstract] [Free Full-text]
Venekamp, R.P., Bonten, M.J.M., Rovers, M.M., et al. (2012) Systematic corticosteroid monotherapy for clinical diagnosed acute rhinosinusitis: a randomized controlled trial. CMAJ 184(14), E751-E757. [Abstract] [Free Full-text]
Wald, E.R., Nash, D., and Eickhoff, J. (2009) Effectiveness of amoxicillin/clavulanate potassium in the treatment of acute bacterial sinusitis in children. Pediatrics 124(1), 9-15. [Abstract] [Free Full-text]
No new national policies or guidelines since 1 October 2008.
No new safety alerts since 1 October 2008.
No changes in product availability since 1 October 2008.
Diagnose and assess the severity of the sinusitis
Provide self-care advice on managing symptoms and pain relief, and educate about antibiotic use
Prescribe antibiotics only in people who have systemic illness, or who are at high risk of complications because of comorbidities
Manage chronic sinusitis, including a trial of treatment of intranasal corticosteroids in selected people
Admit people with severe complications, and refer people with chronic or recurrent disease that is not adequately managed in primary care to an Ear, Nose, and Throat department
Non-steroidal anti-inflammatory drugs (NSAIDs)
Review the appropriateness of NSAID prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (e.g. older patients).
If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).
Review patients currently prescribed NSAIDs. If continued use is necessary, consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).
Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or low back pain (for people over 45 years) in accordance with NICE guidance [NICE, 2008b; NICE, 2009a; NICE, 2009b].
Take account of drug interactions when co-prescribing NSAIDs with other medicines (see Summaries of Product Characteristics). For example, co-prescribing NSAIDs with ACE inhibitors or angiotensin receptor blockers (ARBs) may pose particular risks to renal function; this combination should be especially carefully considered and regularly monitored if continued.
Sinusitis is defined as inflammation of the mucosal lining of the paranasal sinuses. The term 'rhinosinusitis' has been adopted by most specialists, as it is considered more accurate because rhinitis (inflammation of the nasal mucosa) usually precedes and often accompanies sinusitis. However, for the purpose of this topic, the term sinusitis is considered to be better recognized by primary healthcare professionals, and should be regarded as synonymous with rhinosinusitis.
Acute sinusitis refers to sinusitis that completely resolves within 12 weeks.
Chronic sinusitis refers to sinusitis that causes symptoms that last for more than 12 weeks.
Although the sinuses are not fully developed in younger children, computed topography has shown that symptoms of a runny nose frequently indicate sinus involvement, especially in the autumn months. Chronic symptoms tend to predominate.
Acute sinusitis — is usually triggered by a viral upper respiratory tract infection. Although it is estimated that only about one third of people will subsequently develop a bacterial infection, sinusitis is one of the most common reasons a healthcare professional will prescribe an antibiotic. The most commonly implicated bacteria are Streptococcus pneumonia and Haemophilus influenzae. Moraxella catarrhalis may also be a cause.
Chronic sinusitis — although it usually follows an acute episode of sinusitis, chronic sinusitis may be caused by long-term alterations in the structure of the paranasal sinuses, and it may be related to atopy and asthma. Some people may also develop nasal polyps, but the reason for this is unknown.
Acute sinusitis nearly always follows an upper respiratory tract infection and is diagnosed by the presence of nasal blockage (obstruction/congestion) or nasal discharge (anterior/posterior nasal drip) with facial pain (or pressure) and/or reduction of, or loss of, the sense of smell, lasting for less than 12 weeks.
Nasal discharge — a thick, purulent, coloured discharge (especially green) is more likely to indicate bacterial involvement (unlikely with a clear discharge).
Nasal blockage or congestion — usually bilateral and caused by rhinitis.
Facial pain — may be described as pressure and localized over the infected sinus, or it may affect teeth, the upper jaw, or other areas (such as eye, side of face, forehead). Pain in the absence of other symptoms is unlikely to be sinusitis.
In children, symptoms of rhinitis predominate, with facial pain being less prevalent. There may also be ear discomfort (Eustachian tube blockage).
Examination is of limited value but may reveal the presence of purulent discharge, swelling of the nasal mucosa, tenderness over the sinuses, and fever.
Investigations are not necessary to diagnose acute sinusitis.
If signs and symptoms are not typical of sinusitis, rule out an alternative diagnosis.
Other conditions presenting with similar signs and symptoms to acute sinusitis include:
Allergic rhinitis — usually restricted to nasal symptoms. Consider this especially if symptoms have not directly followed an upper respiratory tract infection or are persistent.
Nasal foreign body — typically causes a unilateral mucopurulent discharge or blockage (more common in children).
Adenoiditis and tonsillitis (particularly in children) — causes nasal blockage, breathing through the mouth, nasal speech, and snoring.
Sinonasal tumour — especially if there are chronic symptoms, unilateral nasal obstruction or discharge (especially if bloodstained). Progressive unilateral facial swelling in an adult should raise the suspicion of malignancy.
Other causes of facial pain or headache:
Tension-type headache may present with bilateral symptoms of pressure but with no other nasal symptoms.
Temporomandibular joint dysfunction, or habitual teeth clenching.
Neuropathic or atypical facial pain.
Dental pain (typically, pain made worse by hot and cold drinks or by chewing).
Recommendations for the assessment of sinusitis are based on expert opinion derived from the European position paper on rhinosinusitis and nasal polyps [Fokkens et al, 2007], a UK guideline [Scadding et al, 2007], and a narrative review [Ah-See and Evans, 2007].
Investigations are not required in primary care because:
Plain radiographs are not cost-effective [Benninger et al, 2000], and have been found to be only moderately sensitive and specific for identifying bacterial sinusitis [Brooks et al, 2000; Piccirillo, 2004].
Blood tests to look for inflammation, such as full blood count, C-reactive protein, or erythrocyte sedimentation rate (ESR) are non-specific; they may be raised in many other conditions.
Nasal swabs for culture have a poor diagnostic yield and are frequently contaminated (or bacteria found are commensal) [Elies and Huber, 2004].
Chronic sinusitis is diagnosed by the presence of nasal blockage (obstruction/congestion) or nasal discharge (anterior/posterior nasal drip) with facial pain (or pressure) and/or reduction of, or loss of, the sense of smell, lasting for longer than 12 weeks. Compared with acute sinusitis, in chronic sinusitis:
Loss of smell is more commonly described.
Facial pain is less common.
Recurrent episodes of acute sinusitis may also occur, with worsening symptoms above the normal background level of persistent symptoms.
Investigations are not required to diagnose chronic sinusitis in primary care.
Recommendations for the assessment of sinusitis are based on expert opinion derived from the European position paper on rhinosinusitis and nasal polyps [Fokkens et al, 2007] and a UK guideline [Scadding et al, 2007].
Pathophysiology of chronic sinusitis
Compared with acute sinusitis, there are considerably fewer epidemiological data for chronic sinusitis. However, experts consider that the persistence of symptoms beyond 3 months indicates altered nasal pathology (although this time period is arbitrary).
Acute infection of the sinuses can lead to blockage and loss of ostial patency (ability of the sinus to drain), mucus and bacterial build up, and resultant inflammation.
This can lead to a vicious cycle occurring, ultimately leading to chronic sinusitis.
Investigations are not generally recommended for the diagnosis of chronic sinusitis in primary care, although computed tomography or endoscopy may be employed in secondary care.
Scenario: Acute sinusitis: covers the management of people with acute sinusitis.
Scenario: Chronic sinusitis: covers the management of people with chronic sinusitis.
Reassure the person:
About the natural course of the infection, and that on average sinusitis takes 2.5 weeks to resolve (that is, longer than a common cold).
That sinusitis is usually caused by a virus, and antibiotics are unlikely to help and may cause adverse effects.
Recommend measures to relieve symptoms, including:
Paracetamol or ibuprofen — to reduce pain and fever.
An intranasal decongestant (for a maximum of 1 week) — may help if nasal congestion is problematic. Oral decongestants, commonly found in combination products with an analgesic, are generally not recommended for sinusitis.
Irrigating the nose with saline solution — may relieve congestion and nasal discharge.
Applying warm face packs — may provide localized relief.
Drinking adequate fluids and rest (if tired).
Consider whether an antibiotic is appropriate.
The following treatments are not recommended:
Steam inhalation (due to a danger of burns).
Complementary and alternative medicine (as the benefits have not been proven).
The evidence base for first-line management of acute sinusitis is poor, and is largely derived from expert opinion and the historical use of self-care measures and symptomatic treatment.
Prognosis and advice on antibiotics
The National Institute for Health and Clinical Excellence estimate that the average duration of acute sinusitis is 2.5 weeks [NICE, 2008a]. A systematic review analysed the placebo arms of several randomized controlled trials (RCTs), and found that, after 7–15 days, 73% of people taking placebos experienced some improvement in their symptoms, and 30% had complete recovery [Rosenfeld et al, 2007].
Current UK policy aims to decrease unnecessary antibiotic prescribing: informing the person of the limited benefit of antibiotics, together with the real risk of adverse effects, may encourage this [NICE, 2008a].
The effectiveness of paracetamol or ibuprofen in the symptomatic relief of the common cold and influenza has been confirmed by RCTs [Eccles, 2006]. It is reasonable to extrapolate these data to the management of sinusitis, which has similar symptoms and causative pathogens [ICSI, 2008].
Intranasal decongestants are thought to promote mucociliary clearance and sinus drainage, and may be of benefit in people with nasal congestion [Fokkens et al, 2007]. However, evidence from RCTs to support their use is conflicting.
It is important that nasal decongestants are not used for more than 7 days, as prolonged use is associated with rebound nasal congestion when treatment is stopped. This encourages continued use, which can result in hypertrophy of the nasal mucosa (rhinitis medicamentosa) [BNF 56, 2008].
Although oral decongestants have been found to be of some benefit in relieving nasal congestion associated with the common cold [Taverner and Latte, 2007], there is a lack of evidence for their effectiveness in sinusitis [Fokkens et al, 2007], and they may cause systemic adverse effects or interact with other drugs [BNF 56, 2008].
Rest and increased fluid intake
Adequate rest is recommended by experts if the person feels fatigued during the course of the infection. However, in general, the benefits of rest have not been investigated by controlled studies.
There is very little evidence to support increased fluid intake in acute sinusitis. A Cochrane review (search date: July 2005) investigated this intervention but found no controlled trials suitable for inclusion [Guppy et al, 2005]. Nevertheless, it is important to keep the body hydrated at all times, and as fluid loss is likely to be greater when fever and nasal discharge are present, it is prudent to drink more fluid than normal.
Measures for symptomatic relief
Self-care measures are consistent with recommendations made by the Institute for Clinical Systems Improvement [ICSI, 2008], as they are not usually suitable for investigation by RCTs; instead they are based on consensus statements and medical opinion, according to physiological principles.
Irrigation of the nose with saline solution has been found to be of benefit in the treatment of chronic sinusitis by a Cochrane review [Harvey et al, 2007]. However, it may also give symptomatic relief of nasal congestion in acute sinusitis [ICSI, 2008].
Face packs may promote drainage of mucus and provide localized symptomatic relief, although the evidence for this is anecdotal [ICSI, 2008].
Steam inhalation has been found to be effective for the symptomatic treatment of the common cold [Singh, 2006], although trial data for acute sinusitis are lacking. It is not generally recommended due to concerns about the risk of scalding, or direct steam burns, especially when used in children. If used, the recommended technique is to sit in the bathroom with a hot shower running. The use of boiling kettles or bowls of hot water should always be avoided [Murphy et al, 2004].
Complementary and Alternative Medicine (CAM)
CKS found insufficient evidence to recommend CAM for acute sinusitis, owing to the limited number and quality of controlled trials for these interventions. Potential harms of CAM should also be considered before they are tried.
A review of complementary therapies found no convincing evidence for the use of dietary supplements, bromelain (pineapple extract), zinc, or vitamin C for the treatment of sinusitis. Some studies have reported evidence for the effectiveness of Echinacea in the treatment of upper respiratory tract infections, but these have generally been small and of poor quality [Asher et al, 2001].
A systematic review (search date: October 2005) identified a total of 10 RCTs that investigated the effectiveness of herbal medicines for acute and chronic sinusitis. The authors concluded that the evidence of benefit for these interventions was limited, but there was some encouraging evidence to support the use of Sinupret® and bromelain, specifically in acute sinusitis [Guo et al, 2006].
Intranasal corticosteroids, antihistamines, and mucolytics
Although there is some evidence from RCTs that intranasal corticosteroids are effective for acute sinusitis, they are not routinely recommended, as the clinical benefits are small and take several days to develop (most trials assessed outcomes after 2–3 weeks) [Zalmanovici and Yaphe, 2007].
Oral corticosteroids have been found to improve symptoms of pain in two RCTs [Fokkens et al, 2007], but are not recommended because of the risk of systemic adverse effects.
Antihistamines are not recommended unless the person has a coexisting allergic disorder, such as allergic rhinitis. Although one RCT suggested that loratadine may be of benefit for repeat exacerbations of sinusitis, the results from this trial are difficult to interpret as both groups also received both oral prednisolone and co-amoxiclav [Braun et al, 1997].
There is no convincing evidence that mucolytics are of benefit for acute sinusitis. One trial compared two mucolytics with each other (neither are available in the UK), but without a placebo comparator the results are difficult to interpret [Garrubba and Smussi, 1988].
Antibiotics are not required for most people presenting with acute sinusitis; instead the mainstay of treatment is symptomatic relief.
Admit if the person is suspected of having a serious localized or systemic illness that requires further assessment or administration of intravenous antibiotics (for example, if there is evidence of peri-orbital or intracranial complications).
Consider an immediate antibiotic prescription only if it is not appropriate to admit the person and they are:
Systemically unwell, or
At high risk of complications because of a pre-existing comorbidity.
Consider a delayed prescribing strategy for all other people, especially if symptoms are causing significant discomfort (such as marked pain or profuse, purulent discharge).
If an antibiotic is required, prescribe according to local protocols where available:
Amoxicillin is a good first-line choice. Prescribe the maximum oral dose (1 g three times a day) for 1 week.
Doxycycline (not in children less than 12 years of age) or a macrolide (erythromycin or clarithromycin for 1 week) are options if the person has a known allergy to penicillin (consider erythromycin for pregnant women).
People at high risk of a complication of sinusitis due to comorbidities
The National Institute for Health and Clinical Excellence (NICE) defines this group as:
People with a pre-existing comorbidity, such as: significant heart, lung, renal, liver, or neuromuscular disease; immunosuppression; or cystic fibrosis.
People with acute cough who are older than 65 years of age with two of the following risk factors, or older than 80 years of age with one of the following risk factors:
Hospitalization in the previous year.
Type 1 or Type 2 diabetes.
Congestive heart failure.
Current use of oral corticosteroids.
Delayed prescribing strategy
A delayed prescription strategy aims to reduce the usage of antibiotics while providing a safety net for people who genuinely need antibiotics. Usually the person should be advised to use the antibiotic prescription only if their condition has deteriorated within 3 days or not improved after 3 days. The strategy can be implemented in a number of ways including:
Patients may be issued a script and advised not to redeem it unless it is required. If necessary, the prescription can be post-dated.
Patients can be asked to re-attend the GP surgery reception after 3 days to collect the prescription (if required). If symptoms significantly deteriorate before this time, a telephone consultation can be considered.
Always give advice and reassure the person as well as giving the prescription. Consider giving written advice (such as a patient information leaflet).
These recommendations are largely based on expert opinion according to known disease progression and bacterial sensitivities to antibiotics.
Identifying people to treat with antibiotics
Recommendations for the prescribing of antibiotics for acute sinusitis are based on the clinical guideline Respiratory tract infections — antibiotic prescribing, published by the National Institute for Health and Clinical Excellence (NICE) [NICE, 2008a]. This can be downloaded from www.nice.org.uk (pdf).
The NICE Guideline Development Group stated that, due to a lack of published evidence, it is not possible to identify subgroups of people who require immediate treatment with antibiotics, but they do list groups of people for whom no treatment or delayed treatment is unsuitable. For these people, immediate antibiotics 'and/or further appropriate investigation and management' is necessary. CKS infers from this that:
People with serious systemic infection, or intra-orbital or intracranial complications, should be admitted to hospital immediately.
For people who are systemically unwell but are in not in immediate danger of complications, an immediate antibiotic prescription should be considered.
Antibiotics are recommended in people who have serious comorbidities, or other combinations of risk factors, as these people are more likely to develop complications.
Delayed prescribing strategy
There is some evidence from randomized controlled trials (RCTs) for other upper respiratory tract infections that delayed prescriptions can significantly reduce the amount of antibiotics taken, without adversely affecting other outcomes such as patient satisfaction.
Although NICE did not identify any studies specifically on delayed prescribing in sinusitis, the Guideline Development Group reached a consensus opinion that sinusitis should be treated in the same way as for the other upper respiratory conditions (acute otitis media, pharyngitis, bronchitis, and common cold).
NICE do not offer clear guidance on who should be offered delayed treatment, but CKS believes profuse purulent discharge and severe facial pain are likely to be at least partly selective for bacterial infection, and warrant consideration for this strategy [Klossek and Federspil, 2005]. There is evidence from RCTs that antibiotics are twice as likely to benefit people with purulent discharge compared with those without this symptom.
Antibiotic effectiveness and harms
There is some evidence from RCTs that antibiotics are of limited benefit in the treatment of sinusitis, with between 7 and 14 people requiring treatment for one person to benefit (NNT 7–14), depending mainly on the initial accuracy of diagnosis.
There is similar evidence of antibiotic effectiveness in the treatment of children.
However, there is some evidence that the likelihood of harms occurring due to adverse effects is in a similar range.
There is no evidence from RCTs to support the use of one antibiotic over another. In the absence of trial data, antibiotic selection should be made with respect to local resistance patterns, with consideration given to practical issues such as convenience of the regimen, adverse effects, and cost.
Amoxicillin is usually considered as the first-line antibiotic because it has the most clinical data associated with it, having been used extensively as the comparator drug in many RCTs, and it has good activity against the pathogens most commonly implicated in bacterial sinusitis, Streptococcus pneumoniae and Haemophilus influenzae [Klossek and Federspil, 2005]. In addition, it is well tolerated by most people and is inexpensive.
A high dose of amoxicillin is recommended because antibiotics are only recommended for consideration for people with very severe symptoms, a high dose has most chance of success if the causative pathogen is bacterial, and a high dose may also overcome low-level beta-lactamase resistance, also increasing the chance of success if the pathogen is bacterial [Livermore, Personal Communication, 2010].
Doxycycline, erythromycin, or clarithromycin are recommended if there is a known history of allergy to penicillin.
Doxycycline is active against both S. pneumoniae and Haemophilus influenzae [Chopra, 2003]. It is available as a convenient, once-daily regimen (after an initial loading dose), is well tolerated by most people, and is relatively inexpensive.
Erythromycin and clarithromycin are active against most of the bacterial pathogens involved in sinusitis [Bryskier and Butzler, 2003], although resistance to them is increasing, especially in H. influenzae.
Erythromycin is the preferred choice in pregnant women as there is extensive experience of its use in pregnancy. Paediatric formulations of erythromycin are also less expensive than clarithromycin [BNF 56, 2008].
Antibiotic duration and dose
CKS recommends a 7-day course of high-dose antibiotics for most people:
There is evidence from RCTs that suggests shorter courses of antibiotics (typically 5 days) are probably as effective as longer courses (typically 10 days).
A 7-day course is a reasonable choice, especially as many antibiotics come in pack sizes that last for a week (this may encourage compliance and reduce wastage), and it has also been suggested that courses lasting for longer than 1 week are less likely to be completed [Elies and Huber, 2004].
Higher doses of antibiotics are recommended (where applicable, such as amoxicillin) because these are appropriate for 'severe' infections [BNF 56, 2008], and less severe infections should not usually be treated.
If antibiotics have not been prescribed:
Consider prescribing antibiotics if symptoms are marked and continue for more than 7 days, or the person is deteriorating significantly.
Amoxicillin (maximum dose), doxycycline, or a macrolide (erythromycin or clarithromycin) for 1 week are suitable first-line options.
If antibiotics have been tried but were ineffective or poorly tolerated, check compliance and consider a second-line antibiotic. Suitable options are:
Co-amoxiclav (give the maximum dose, that is 500/125 mg three times a day) for 7 days.
Azithromycin for 3 days (if the person is allergic to penicillin).
CKS recommends the use of antibiotics to treat acute sinusitis if symptoms persist for more than 7 days, or if the person is deteriorating, as evidence suggests this increases the likelihood of bacterial involvement, and antibiotics are more likely to be effective. This is accordance with narrative guidelines [Hickner et al, 2001; Klossek and Federspil, 2005].
First-line antibiotics (amoxicillin, doxycycline, erythromycin, or clarithromycin) are appropriate in this situation.
Co-amoxiclav is usually recommended as second-line treatment in people who are not allergic to penicillin because it is effective against the bacteria implicated in sinusitis, including Moraxella catarrhalis and penicillin-resistant strains of Streptococcus pneumoniae, and is probably as effective as other antibiotics that are beta-lactamase resistant (for example, third-generation cephalosporins) [Karageorgopoulos et al, 2008].
Azithromycin is a suitable choice if another macrolide was unsuccessful because of treatment failure or compliance issues (such as gastrointestinal adverse effects). It has greater activity against Haemophilus influenzae than erythromycin (which has poor activity [DTB, 1995]), it causes less gastrointestinal effects than erythromycin [DTB, 1991], and compliance is less of an issue as it is taken over the course of 3 days rather than a week.
Admit to hospital if there is severe systemic infection, or if a complication of sinusitis is suspected. Suspect:
Intra-orbital involvement if there is peri-orbital oedema, a displaced globe, double vision, ophthalmoplegia, or reduced visual acuity.
Intracranial involvement if there is a severe frontal headache, frontal swelling, symptoms or signs of meningitis, or focal neurological signs.
Consider urgent referral to an Ear, Nose, and Throat (ENT) department if the person is suspected of having a sinonasal tumour (persistent unilateral symptoms, such as bloodstained discharge, crusting, non-tender facial pain, facial swelling, or unilateral nasal polyps).
Consider routine referral to ENT if the person has frequent recurrent episodes of sinusitis which are troublesome (such as more than three episodes requiring antibiotics in a year).
Seek specialist advice if second-line antibiotics have been ineffective.
The most important concern with sinusitis is the development of a complication, which can lead to blindness or even death. Complications are estimated to occur with a frequency of 1 in 10,000 cases of sinusitis [Balk et al, 2001].
Options available in secondary care include:
Administration of intravenous antibiotics.
Sinus puncture and irrigation, which allows a sample of sinus fluid to be taken for bacterial culture, and may provide some symptomatic relief [Blomgren et al, 2005]. However, this procedure is no longer commonly performed, has a poor diagnostic yield, and carries the risk of secondary contamination.
Surgery may be indicated for severe acute sinusitis, but is more commonly used for chronic sinusitis that is refractory to medical treatment. Surgery is increasingly performed using endoscopic techniques [Evans, 1998].
Inspect the nose for the presence of septal deviation and nasal polyps. Polyps can be distinguished from the inferior turbinate by their lack of sensitivity to painful stimuli, their yellow-grey colour, and the fact that they can be compressed with a cotton wool bud. Usually, only significant polyposis is detectable in primary care.
Assess for other predisposing factors of chronic sinusitis. These include allergic rhinitis, asthma, immunosuppression, chronic dental infection, and the presence of a foreign body (especially in children).
Nasal polyps commonly coexist with chronic sinusitis, especially in people with asthma (7–14% are estimated to have polyps) or hypersensitivity to nonsteroidal anti-inflammatory drugs (36–60% have polyps). The presence of nasal polyps may require referral for surgery.
Risk factors for chronic sinusitis:
Atopic disorders are known to coexist or be risk factors for chronic sinusitis, and require separate management [Smart and Slavin, 2005]. For more information, see the CKS topics on Allergic rhinitis and Asthma.
The suspected presence of immunosuppression should prompt referral or the seeking of expert advice.
Dental infection is estimated to be associated with 5–10% of cases of chronic sinusitis and requires assessment by a dentist or otolaryngologist [Gwaltney, 1995].
Inform the person of the natural course of chronic sinusitis, and that it may last several months, but does not usually require referral.
If the person has an associated disorder, such as allergic rhinitis or asthma, advise them that good control of these is also likely to benefit their sinusitis symptoms.
Advise the person to practise good dental hygiene and stop smoking (and avoid passive smoking), where applicable. Underwater diving may be best avoided if there are prominent symptoms.
Consider a course of intranasal corticosteroids for up to 3 months, especially if there is suspicion of an allergic cause (such as concomitant allergic rhinitis).
Chronic sinusitis with nasal polyps should be treated in the same way as chronic sinusitis without polyps, although polyps causing severe obstruction may require referral for surgery.
Seek specialist advice before prescribing long-term antibiotics, as the evidence for this approach is limited.
If the person suffers from recurrent acute episodes:
Recommend measures to relieve symptoms:
Paracetamol or ibuprofen — to reduce pain and fever.
Occasional use of an intranasal decongestant (for a maximum of 1 week) — can help if nasal congestion is problematic. Oral decongestants, commonly found in combination products with an analgesic, are generally not recommended for sinusitis.
Irrigating the nose with saline solution — may relieve congestion and nasal discharge.
Applying warm (not hot) face packs — may provide localized relief.
Steam inhalation is not recommended (due to the danger of burns), and the benefits of complementary and alternative medicine have not been proven.
Consider whether a short-course of an antibiotic is appropriate (see Prescribing antibiotics).
Referral may be necessary if these episodes are frequent.
Recommendations for information and advice are largely based on expert opinion and observational studies, rather than controlled trials. Treatment recommendations are consistent with the European position paper on rhinosinusitis and nasal polyps [Fokkens et al, 2007], and reflect historical UK practice for the treatment of chronic sinusitis.
The natural course of chronic sinusitis is poorly documented, but persistent symptoms are likely to last months or longer without appropriate management (intranasal corticosteroids or referral for secondary care options). However, it is widely believed that good control of predisposing factors, such as allergic rhinitis and asthma, will benefit sinusitis symptoms [Blomgren et al, 2005].
Dental hygiene, smoking, and diving
Dental infection is associated with chronic sinusitis in about 5–10% of people [Gwaltney, 1995], so dental hygiene should be encouraged.
Although there is no strong evidence that smoking causes chronic sinusitis, there is a hypothetical risk that tobacco smoke may exacerbate chronic sinusitis symptoms, particularly in people with allergies [Benninger, 1999].
If the person is considering underwater diving, consider seeking specialist advice, as there is a risk of sinus barotrauma (tissue injury resulting from pressure differences). Potential complications of barotrauma include cerebral empyema, pneumocephalus, blindness, and cranial nerve palsies [Parell and Becker, 2000].
Self-care measures for acute episodes
Recommendations for symptomatic relief of acute symptoms are consistent with those made by the Institute for Clinical Systems Improvement [ICSI, 2008]. For further information, see Basis for management of acute sinusitis.
Intranasal corticosteroids for chronic sinusitis
In general, there is a lack of good-quality evidence on the treatment of chronic sinusitis, with relatively few placebo-controlled trials of interventions on which to base recommendations.
Intranasal corticosteroids are recommended by the European guideline, with the authors stating that 'nasal corticosteroid treatment represents one of the long-term treatment modalities in patients with chronic sinus disease' [Fokkens et al, 2007].
The anti-inflammatory properties of corticosteroids are well documented in other conditions, and they have been used historically to treat chronic sinusitis. There is also evidence from placebo-controlled trials to support the use of intranasal corticosteroids in people with chronic sinusitis both with and without co-existing nasal polyps.
Intranasal corticosteroids are likely to be well tolerated, with minimal adverse effects even after prolonged use. Inhaled corticosteroids, used by many people with asthma, are more likely to cause systemic adverse effects than intranasal corticosteroids [Fokkens et al, 2007].
Prolonged use of antibiotics
The evidence for prolonged use of antibiotics is lacking because of an absence of placebo-controlled trials.
Open-label studies have indicated that low-dose macrolides may have cure rates of 60–80% in people who are refractory to surgery, but this needs to be confirmed by further studies [Scadding et al, 2007].
CKS recommends that, because of the lack of evidence of efficacy, the potential for adverse effects, and the concern of increasing bacterial resistance, specialist advice should be sought before long-term antibiotics are initiated.
Admit to hospital if a complication of acute sinusitis develops (for example, there is intracranial or peri-orbital involvement).
If there is a suspected sinonasal tumour (persistent unilateral symptoms, such as bloodstained discharge, crusting, non-tender facial pain, facial swelling, or unilateral nasal polyps) consider urgent referral to an Ear, Nose, and Throat (ENT) department.
Consider routine referral to ENT if the person has:
Frequent recurrent episodes of acute sinusitis which are troublesome (such as more than three episodes requiring antibiotics in a year).
Unremitting or progressive facial pain (but refer urgently if a tumour is suspected).
Nasal polyps which are causing significant nasal obstruction.
Had a trial of intranasal corticosteroids for 3 months which was ineffective.
Routine referral is recommended if a trial of intranasal corticosteroids has not proved adequately effective, as this effectively represents maximal treatment in primary care. There are also limited treatment options for unremitting facial pain or frequent, severe, acute episodes of sinusitis in primary care.
Options that are available in secondary care include:
Endoscopic surgery to drain sinuses and restore normal mucociliary function [Khalil and Nunez, 2006].
Removal of nasal polyps.
Surgery to correct nasal septum deviation and other nasal abnormalities (such as turbinate diathermy or reduction).
Initiation of other drug treatments (such as antibiotics or anti-leukotrienes) or aspirin desensitization (although this is rarely practised in the UK).
The best available evidence from randomized controlled trials (RCTs) suggests that antibiotics are only of limited benefit for the treatment of acute sinusitis in terms of clinical improvement and cure. However, this benefit is likely to be even less in people who have been diagnosed in primary care, with between seven and fifteen people requiring treatment for one person to benefit (NNT = 7–15). Most authors therefore conclude that, considering the potential harms, the standard use of antibiotics for uncomplicated sinusitis is not justified.
Sinusitis diagnosed by clinical, imaging, or microbiological methods
A Cochrane review (search date: May 2007) identified a total of 57 RCTs suitable for inclusion; of these, six studies compared antibiotics with placebo [Ahovuo-Saloranta et al, 2008].
Antibiotics were found to be of limited benefit:
Five studies (n = 631) were pooled in a meta-analysis to compare clinical failure (defined as lack of cure or improvement after 7–15 days) in people treated with antibiotics compared with placebo. Antibiotics were found to be of benefit, with a relative risk (RR) of clinical failure of 0.66 (95% CI 0.44 to 0.98). However, the clinical relevance of this is uncertain, with 80% of people on placebo experiencing improvement, compared with 90% in the treatment groups.
Six studies (n = 747) were pooled that used lack of total cure as an outcome. Antibiotics were found to be of significant benefit (RR 0.74, 95% CI 0.65 to 0.84).
The authors concluded that the benefits of antibiotics for uncomplicated sinusitis are small, and that clinicians should take into account the potential of harms to the individual and the community before prescribing.
A systematic review (search date: January 2007) identified 17 double-blind placebo-controlled trials suitable for inclusion to investigate the effectiveness of antibiotics for acute sinusitis [Falagas et al, 2008].
Sixteen RCTs (n = 2648) found that treatment with antibiotics significantly improved cure or improvement rate (OR 1.64, 95% CI 1.35 to 2.00). Twelve RCTs (n = 1963) found that treatment with antibiotics significantly improved total cure rate (OR 1.87, 95% CI 1.21 to 2.90).
The authors concluded that antibiotics confer a small therapeutic benefit compared with placebo, but should be reserved for people who have a higher probability of bacterial disease.
A systematic review (search date: February 2007) investigated the natural history of sinusitis with and without antibiotics, and identified 13 placebo-controlled trials that met its inclusion criteria [Rosenfeld et al, 2007].
The results were:
In the placebo groups, 8% of people experienced complete cure after 3–5 days, rising to 35% and 45% after 7–12 and 14–15 days respectively. Clinical improvement was experienced in 30% of people after 3–5 days, rising to 73% after 7–15 days.
Antibiotics improved the rate of improvement and cure. Compared with placebo, there was an absolute rate difference in clinical cure of 15% (95% CI 4 to 25) after 7–12 days. In terms of clinical improvement, there was an absolute rate difference of 14% (95% CI 1 to 28) after 7–12 days, and 7% (95% CI 2 to 13) after 14–15 days.
The authors concluded that although antibiotics were of modest benefit for people with acute sinusitis, about 70% of people would recover anyway. This means that, on average, for every seven people treated with an antibiotic, one person would benefit (NNT = 7).
Sinusitis diagnosed by clinical means only
A systematic review used individual patient data from nine RCTs (n = 2547) to investigate the effectiveness of antibiotics in people with sinusitis diagnosed by clinical means (trials that recruited people on the basis of imaging or microbiological findings were excluded) [Young et al, 2008].
Results indicated that 15 people would need to take antibiotics for one person to benefit (NNT = 15, 95% CI 7 to 190). However, antibiotics were more effective in people who had purulent discharge of the pharynx, with seven people requiring treatment for one person to benefit (NNT = 7, 95% CI 4 to 47).
The authors concluded that the use of antibiotics cannot be justified in people with sinusitis-like complaints, even in people who have had symptoms for longer than 7–10 days.
A systematic review (search date: November 2005) identified seven RCTs suitable for inclusion to address the effectiveness of antibiotics in people with symptoms of purulent rhinitis [Arroll and Kenealy, 2006].
The pooled RR of benefit after 5–8 days for antibiotics compared with placebo was 1.18 (95% CI 1.05 to 1.33). This means that, on average, between 7 and 15 people would need to be treated with an antibiotic for one person to benefit (NNT = 7–15). It was noted that this range overlapped with the potential for harm from antibiotics (NNH = 12–78).
The authors concluded that the results support current recommendations for not using antibiotics in the first-line treatment of acute purulent rhinitis.
Randomized controlled trials (RCTs) have shown that antibiotics cause an increased risk of adverse effects compared with placebo, with some studies indicating the rate of harm may be as high as the rate of benefit. Gastrointestinal adverse effects are most common, especially diarrhoea, but skin rash, vaginal candidiasis, headache, and dizziness may also occur. Although serious adverse effects have not been detected by RCTs, and adverse effects do not appear to significantly affect drug compliance, the over-prescribing of antibiotics is thought to increase bacterial resistance to antibiotics in the community.
Adverse effects in the individual
Antibiotics cause adverse effects in some individuals. These are mainly gastrointestinal in nature (such as diarrhoea, nausea and vomiting), but may also include skin rash, vaginal candidiasis and discharge, headache, and dizziness. The risk of adverse effects above that seen with placebo has been estimated by several systematic reviews using meta-analyses.
A systematic review of purulent rhinitis found that the number needed to harm (NNH) with antibiotic use overlapped with the number needed to treat (NNT) with ranges of 12–78 (NNH) and 7–15 (NNT) respectively [Arroll and Kenealy, 2006].
A systematic review found that antibiotics increased the relative risk of an adverse effect by 83%. This means that for every nine people treated with an antibiotic, one would suffer an adverse effect (NNH = 9). Diarrhoea was the most common adverse effect associated with antibiotics (NNH = 20) [Rosenfeld et al, 2007].
A systematic review found that adverse effects were significantly more likely to occur in people treated with antibiotics compared with placebo (OR 1.87, 95% CI 1.21 to 2.90). However, there was no difference between the groups in terms of withdrawal from the study because of adverse effects [Falagas et al, 2008]. A Cochrane review also did not detect any significant withdrawal due to adverse effects from antibiotics [Ahovuo-Saloranta et al, 2008].
Bacterial resistance to antibiotics
The relationship between antibiotic consumption in the community and bacterial resistance has been largely assumed, rather than proven categorically, but it is an assumption that is likely to be true [Fokkens et al, 2007].
Surveillance studies around the world have consistently shown an increase in the prevalence of antibiotic resistant bacteria for several decades [Cohen, 1992; Kunin, 1993]. However, these studies studies do not provide information on the cause of the increase.
Antibiotic prescribing in the European Union varies four-fold [Cars et al, 2001]. However, CKS found no studies that correlated prescribing data in different countries with the emergence of bacterial resistance to antibiotics.
There is no consistent evidence from randomized controlled trials (RCTs) to support the superiority of one antibiotic compared with another in the treatment of acute sinusitis. Therefore, empirical choice should be based on the known sensitivities of the likely infecting pathogen.
A Cochrane review (search date: May 2007) identified a total of 51 RCTs that compared one antibiotic with another antibiotic. Despite extensive analysis, no antibiotic or class of antibiotic was found to be superior to another [Ahovuo-Saloranta et al, 2008].
A systematic review (search date: March 2007) identified eight RCTs that compared a newer fluoroquinolone antibiotic (for example, moxifloxacin or levofloxacin) with an older beta-lactam type antibiotic (such as co-amoxiclav) [Karageorgopoulos et al, 2008].
There was no clinical benefit seen with the newer antibiotics compared with the older antibiotics.
The authors concluded that the use of fluoroquinolones in the first-line treatment of acute sinusitis cannot be endorsed.
In conclusion, data from RCTs do not support the superiority of one antibiotic over another. Therefore the choice of antibiotic should be made according to the antibiotic sensitivity of the likely infecting pathogen; that is Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, or Staphylococcal aureus [Payne and Benninger, 2007]. UK protocols recommend the use of a beta-lactam antibiotic (such as amoxicillin) or tetracycline first-line, or a macrolide if these are contraindicated.
Traditionally, longer courses of antibiotics (that is 10 days or more) have been used to treat acute sinusitis. However, limited evidence from poor-quality RCTs suggests that shorter courses (such as 5 days) are as effective as longer courses.
There is little evidence on which to base recommendations for optimal duration of treatment of acute sinusitis with antibiotics. Most randomized controlled trials (RCTs) have used relatively long courses of treatment (typically 10–14 days) [de Ferranti et al, 1998; Williams et al, 2003].
A narrative review identified 10 RCTs (n = 3715) that compared different durations for a range of antibiotics (including penicillins, macrolides, cephalosporins, and quinolones) [Elies and Huber, 2004]. Most of the studies (7/10) included different length courses of the same antibiotic (that is, compared like with like), and most of the studies (9/10) compared 5 days treatment with 10 days treatment:
The results were not pooled in a meta-analysis. No studies found any significant advantage in terms of clinical or microbiological cure with the use of longer courses of treatment (8–10 days) compared with shorter courses of treatment (5 days), although seven RCTs found non-significant trends in favour of the longer course (three RCTs showed exact equivalence).
The authors concluded that 'the evidence strongly supports reduction of the traditional 10-day course of antibacterial therapy to a 5-day course for uncomplicated acute maxillary sinusitis in adults'.
Evidence to support the use of antibiotics in children is limited, but the available randomized controlled trials (RCTs) suggest that antibiotics are likely to be of similar effectiveness in children as they are in adults, with about eight children requiring treatment for one to benefit.
A Cochrane review (search date: February 2002) identified six RCTs (n = 562) that compared antibiotics with placebo, in children with persistent nasal discharge (both acute and chronic rhinosinusitis) [Morris and Leach, 2007].
The main results after 2–6 weeks were:
Antibiotics increased the rate of 'clinical success', with a risk ratio (RR) of 0.75 (95% CI 0.61 to 0.92). On average, eight children required treatment with an antibiotic for one to benefit (NNT = 8, 95% CI 5 to 29).
Adverse effects were not significantly greater in the antibiotic group (RR 1.75, 95% CI 0.63 to 4.82).
The authors concluded that the available evidence suggests that treatment with antibiotics confers a modest reduction in persistent symptoms in the short-to-medium term.
An earlier systematic review largely concurs with the Cochrane review [Ioannidis and Lau, 2001]. Five RCTs (n = 255) were identified that investigated the effectiveness of antibiotics in children with acute sinusitis.
Overall, the clinical improvement rate in children who used antibiotics was 88%, compared with 66% in children who received no antibiotic.
No antibiotic was found to be more effective than any other.
There is evidence from randomized controlled trials (RCTs) that delayed prescribing strategies may reduce antibiotic use for upper respiratory tract infections. However, there is also limited evidence that delayed prescribing may lead to persistence of acute otitis media and sore throat symptoms, and may result in reduced patient satisfaction.
A Cochrane review (search date: January 2007) addressed the effectiveness of delayed prescribing strategies for respiratory tract infection, and identified nine RCTs suitable for inclusion [Spurling et al, 2007]. The studies were heterogeneous in terms of outcomes and inclusion criteria; sinusitis was not specifically investigated in any study.
The main results were:
Antibiotics prescribed immediately were more effective than delayed treatment for relief of fever, pain, and malaise in acute otitis media and sore throat, but not for the common cold or bronchitis.
There was some evidence that using a delayed strategy reduced prescription use, but it also reduced patient satisfaction in some studies.
The authors concluded that 'delaying antibiotics seems to have little advantage over avoiding them altogether where it is safe to do so'.
An earlier systematic review (search date: April 2003) identified five RCTs suitable for inclusion and found that the use of delayed prescribing consistently and significantly reduced antibiotic prescribing [Arroll et al, 2003].
Limited evidence from randomized controlled trials (RCTs) suggests that intranasal corticosteroids may have a beneficial effect in the treatment of acute sinusitis. However, CKS considers that, given the high degree of natural resolution, the modest benefits observed, and the timescales involved, intranasal corticosteroids are not a suitable option for most people with acute sinusitis.
A Cochrane review (search date: December 2006) identified four RCTs (n = 1943) suitable for inclusion that investigated the effectiveness of intranasal corticosteroids [Zalmanovici and Yaphe, 2007]. Three placebo-controlled trials (n = 1792) were described as 'well designed' and were pooled in a meta-analysis.
The results were as follows:
Intranasal corticosteroids were found to be more effective than placebo after 15–21 days, with 73% of people experiencing improvement of symptoms or cure, compared with 66% (RR 1.11, 95% CI 1.04 to 1.18).
There was some evidence that higher doses of intranasal corticosteroids were more effective than lower doses.
There were no reports of adverse effects and no significant difference in the drop-out and recurrence rates between the two groups.
The authors concluded that, based on limited evidence, intranasal corticosteroids could be considered as an option for the treatment of acute sinusitis, either as monotherapy or as an adjuvant to antibiotics.
Anecdotal reports suggest that intranasal decongestants may be of benefit in the treatment of acute sinusitis. However, there is little evidence from randomized controlled trials (RCTs) to support this.
Two controlled trials investigated the efficacy of oxymetazoline administered through a 'bellows' system compared with placebo [Wiklund et al, 1994]. No difference was reported between the groups, which was complicated by the fact that the subjects also received oral phenoxymethyl penicillin.
One small unblinded RCT (n = 60) compared intranasal oxymetazoline with no treatment, intranasal corticosteroids, or sodium chloride solution in people with acute sinusitis [Inanli et al, 2002]. Due to the small size of the treatment arms, and the presence of confounding factors (all participants also received co-amoxiclav), no firm conclusions can be drawn.
There is a lack of good-quality evidence from randomized controlled trials (RCTs) to support interventions for the treatment of chronic sinusitis. In the absence of trial data, the use of intranasal corticosteroids is mainly based on historical and clinical experience of the effectiveness and safety of these drugs. Experience in the use of long-term antibiotics is more limited and therefore should only be considered by specialists.
The European position paper on rhinosinusitis and nasal polyps (EPOS) is an evidence-based guideline that searched for relevant controlled studies for interventions in chronic sinusitis [Fokkens et al, 2007]. The authors found:
The evidence for the use of intranasal corticosteroids for chronic rhinosinusitis without nasal polyps was limited.
A double-blind RCT compared treatment with fluticasone propionate for 16 weeks with placebo but found no difference between the groups. However, the small number of people involved (n = 22) means a type two error cannot be discounted.
A double-blind RCT (n = 26) compared budesonide (administered through a sinus catheter) with placebo and found budesonide to be superior. Budesonide was also shown to be superior to placebo by another RCT (n = 134) in terms of discharge and facial pain, but not quality of life.
A double-blind RCT found tixocortol pivalate to be superior to placebo, but both groups also received neomycin.
An RCT divided 50 people into three groups: one group received dexamethasone, tramazoline, and neomycin; another received dexamethasone and tramazoline; and the final group received placebo. Both the active groups were found to be superior to placebo but not each other.
Several RCTs (generally small in size) have shown that treatment with intranasal corticosteroids is of benefit in people with chronic rhinosinusitis with nasal polyps in terms of reducing symptoms and polyp size.
Antibiotics may be be of benefit in chronic rhinosinusitis:
A number of small RCTs have suggested that long-term treatment with antibiotics (particularly low-dose macrolides) may be of benefit for people with chronic rhinosinusitis. These trials are also supported by retrospective and prospective, uncontrolled studies.
However, no double-blind RCTs have shown repeated short-term use of antibiotics to be of benefit in the management of acute exacerbations of chronic rhinosinusitis.
Scope of search
A literature search was conducted for guidelines and systematic reviews on primary care management of Sinusitis.
January 2005 – September 2008
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp sinusitis/, sinusitis.tw, rhinosinusitis.tw
|/||indicates a MeSH subject heading with all subheadings selected|
|.tw||indicates a search for a term in the title or abstract|
|exp||indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree|
|$||indicates that the search term was truncated (e.g. wart$ searches for wart and warts)|
Sources of guidelines
Medline (with guideline filter)
Sources of systematic reviews and meta-analyses
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NHS Economic Evaluations
Health Technology Assessments
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Sources of national policy
Health Management Information Consortium (HMIC)
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Ah-See, Kim W. and Evans, Andrew S. (2007) Sinusitis and its management. British Medical Journal 334(7589), 358-361.
Aronson, J.K. (Ed.) (2006) Meyler's side effects of drugs. The international encyclopedia of adverse drug reactions and interactions. 15th edn. Oxford: Elsevier.
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DTB (1991) Clarithro- and azithromycin: better erythromycins? Drug & Therapeutics Bulletin 29(26), 101-102.
DTB (1995) Management of acute otitis media and glue ear. Drug & Therapeutics Bulletin 33(2), 12-15.
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