ISSN:2250-0359 Volume 4 Issue 1 2014

An Update of Rhinosinusitis.
*Vishwambhar Singh *Krishna urari !iwari
"a#en$ra Ins%i%u%e &' e$i(al S(ien(es) "an(hi.
Abstract: "hinosinusi%is is one o' mos% (ommon $isease worl$wi$e) a''e(%ing %he *uali%+
o' li'e o' %he ,erson a''li(%e$ b+ i%. I%s (auses an$ ,a%ho,h+siolog+ has been well
$elinea%e$ so 'ar) bu% i%s %rea%men% is (hanging 'as% $ue %o (hange in organisms (ausing i%
an$ also emergen(e o' resis%an(e %o an%imi(robial agen%s) %hus ma-ing %he managemen%
(hallenging. !his ar%i(le highligh%s %he (hanging mi(robial ,a%%ern) (lassi'i(a%ion o' %he
$isease) i%s so(io-e(onomi( bur$en) me$i(al %rea%men% an$ e.er e.ol.ing surgi(al
%rea%men%) wi%h i%s in$i(a%ions.
Keywords: "hinosinusi%is) /(u%e 0a(%erial "hinosinusi%is) 1hroni( "hino sinusi%is)
2aranasal sinus) 3"!I.
INTRODUCTION: - "hinosinusi%is 4"S5 is su(h a (ommon en%i%+ al%hough gi.en %he
wi$e range o' (lini(al ,resen%a%ion. !he mul%i,le ,o%en%ial %+,es 6 .arie$ e%iologi(al 6
asso(ia%e$ 'a(%ors. !his $iagnosis o'%en in(lu$es se.eral ,a%ho 7 ,h+siologi( (on$i%ions.
In or$er %o be%%er $e'ine %he in(i$en(e 6 ,re.alen(e) %he more s,e(i'i( (ri%eria shoul$ be
a,,lie$. !he ,re.alen(e ra%e has also been 'oun$ %o .er+ subs%an%iall+ $e,en$ing on %he
%+,e o' ,ra(%i%ioner 6 me%ho$ o' $iagnosis use$. 2re.alen(e in (hil$ren in 2rimar+ 1are
se%%ing wi%h s+m,%oms o' on a(u%e 3"!I is 9%o 189 in .arious s%u$ies. !he number
in(reases 309 'or ,a%ien%s ,resen%ing %o a general me$i(al (lini( 6 %his 'ur%her in(reases
%o :39 o' ,a%ien%s ,resen%ing wi%h a(u%e 3"!I ha.ing /0"S in an o%olar+ngolog+
(lini(;1)2 <. !he im,ro,er $iagnosis 6 managemen% o' "S has gi.en wa+ %o emergen(e o'
/n%imi(robial resis%an(e 6 %hus %he o.erall in(rease in ,re.alen(e o' "S. 3, %o 509
resis%an(e ra%es %o ma(roli$es 6 be%ala(%ams ha.e been no%e$. =uali%+ o' li'e wi%h "S is
reall+ ,oor. I% is one o' %he mos% (ommon reasons 'or an in$i.i$ual see-ing me$i(al (are.
"e(en% e''or%s %o e.alua%e %he im,a(% o' $isease on =uali%+ &' >i'e 4 =&>5 6 %he
ou%(ome o' $isease ha.e (lari'ie$ %he im,or%an(e o' su(h im,a(%s. ?li(-li(h e%.al ;3< ha.e
shown %ha% "S has a signi'i(an% =&> im,a(%. @.en in (om,arison %o (hroni( $ebili%a%ing
$isease su(h as $iabe%es melli%us an$ (onges%i.e hear% 'ailure. !he "S $isabili%+ in$eA is
.ali$a%e$ ins%rumen% %ha% measures %he ,h+si(al) 'un(%ional an$ emo%ional im,a(% o' "S
on ,ersons =&> ;4)5<.
RHINOSINUSITIS:
Sinusi%is is $e'ine$ as grou, o' $isor$ers (hara(%eriBe$ b+ in'lamma%ion o'
mu(osa o' ,aranasal sinuses $ue %o .arious e%iologies. Sin(e in'lamma%ion o' sinuses
nearl+ alwa+s also in.ol.es %he nose 6 nasal mu(osa. C"hinosinusi%isD is now generall+
,re'erre$ %erm 'or %his (on$i%ion. / 'airl+ big number o' 'a(%ors) in(lu$ing bo%h hos% 6
en.ironmen%) ,la+ a role in $e.elo,men% o' rhino sinusi%is. !he mos% (ommon %+,es o'
rhinosinusi%is are o' allergi( an$ .iral e%iolog+. 0e(ause o' (om,leAi%+ o' 'a(%ors
asso(ia%e$ wi%h rhino sinusi%is) %he (lassi'i(a%ion 6 E or $e'ini%ions o' "S is signi'i(an%l+
$eba%able %o,i(. / wi$el+ a((e,%e$ (lassi'i(a%ion 6 $e'ini%ion was $e.elo,e$ b+
"hinosinusi%is !as- For(e o' %he /meri(an /(a$em+ o' &%olar+ngolog+ 7 Gea$ 6 Ne(-
Surger+ ;H< an$ re,or%e$ b+ >anBa 6 Kenne$+;8< ;%able1<. !hese (ri%eria are base$ on
%em,oral %ime 'rames. !he $is%in(%ions be%ween /"S) "/"S) S"S) 1"S 6 /@1"S are
base$ on %he %em,oral $i''eren(es in %he ,resen%a%ion 6 in some (ases) on (lini(al
,resen%a%ions. 0eing a (ommon 6 .eAing (lini(al en%i%+) mos% o' %he $is(ussion here will
be 'o(use$ on (ommuni%+ 7 a(*uire$ a(u%e ba(%erial rhino sinusi%is. Viral rhinosinusi%is
has been i$en%i'ie$ b+ 1! s(an in a,,roAima%el+ 909 o' ,a%ien%s wi%h a .iral u,,er
res,ira%or+ in'e(%ion. / small ,er(en%age o' %hese ,a%ien%s ma+ $e.elo, se(on$ar+
ba(%erial in'e(%ion.
Sin(e 3"!I s+m,%oms ma+ mimi( %hose o' an e,iso$e o' rhinosinusi%is ) a minimal
$ura%ion o' s+m,%oms is re(ommen$e$ ,rior %o $e%ermina%ion o' an a(u%e ba(%erial
rhinosinusi%is) %+,i(all+ 5-8 $a+s 410$a+s %o 4wee-s5. / %+,i(al .iral 3"!I im,ro.es
wi%hin 5-8 $a+s 6 usuall+ largel+ resol.es b+ 10 %o 14 $a+s. 0a(%erial su,er in'e(%ion or
/0"S (an be (onsi$ere$ when s+m,%oms ,ersis% be+on$ 10 $a+s or worsen a'%er 5-8
$a+s. "e(urren% a(u%e in'e(%ions are $e'ine$ b+ 4 or more e,iso$es ,er +ear ) wi%h ea(h
las%ing grea%er %han 8-10 $a+s 6 absen(e o' signs 6 s+m,%oms %ha% woul$ sugges%
(hroni( rhinosinusi%is. Suba(u%e 0a(%erial "S is $e'ine$ when $ura%ion o' s+m,%oms
range be%ween 4 wee-s %o 12 wee-s 6 %hose o' grea%er %han 12 wee-s are (onsi$ere$ as
1"S. !able 1;8<.
Table :1
!I2@ J3"/!I&N
/"S 4/(u%e "S5 8 Ja+s K 4 wee-s
"/"S 4"e(urren% /(u%e "S5 L 4 e,iso$es o' /"S ,er +ear
S/0"S 4Sub /(u%e 0a(%erial "S5 4 7 12wee-s
1"S 41hroni( "S5 L12w-s
/@1"S 4/(u%e @Aa(erba%ion o' 1hroni(
"S5
Su$$en worsening o' 1"S wi%h re%urn %o
baseline a'%er %rea%men%.
@.en %hough in'lamma%ion o' mu(osal linings is ,resen% in all (ases o' "S) %he 'o(us is on
%hose ,a%ien%s who $e.elo, %he s+m,%oms o' in'lamma%ion. !able No.2. $e,i(%s grou, o'
s+m,%oms %o be a,,lie$ 'or (lini(al $iagnosis;H<.
Table : "hino sinusi%is s+m,%oms an$ signs 4re*uires %wo ma#or 'a(%ors or one ma#or
an$ %wo minor5.
a#or inor
1. Fa(ial 2ain E ,ressure Gea$a(heE'a%igue
2. Fa(ial (onges%ion Fe.er 4non a(u%e5
3. Nasal blo(-ageEobs%ru(%ion Gali%osis
4. Nasal Jis(hargeE ,urulen(eE $is(olore$ ,os% nasal $ri, Jen%al 2ain
5. G+,osmia E anosmia 1ough
H. Fe.er 4/(u%e "S onl+5 @ar ,ain E Fullness

DI!!"R"NTIA# DIA$NOSIS O! RHINO SINUSITIS:
In'e(%ious "hini%is
1. Viral 3"!I.
2. 0a(%erial "S.
/llergi( rhini%is 4seasonal or ,erennial5
Nonallergi( rhini%is 4i$io,a%hi( rhini%is5 whi(h in(lu$es
1. Vasomo%or rhini%is.
2. @osino,hili( nonallergi( rhini%is4N/"@S5.
3. @n$o(rine rhini%is i:e hormonal) ,regnan(+ an$ h+,o%h+roi$ s%a%es.
4. ?ranuloma%ous rhini%is 4MegnerDs5.
"hini%is me$i(amen%osa.
/na%omi( $e'ormi%ies.
Nasal se,%al obs%ru(%ion.
Nasal %urbina%e h+,er%ro,h+.
1hon(ha bullosa.
!umors.
ANATO%& ' (ATHO(H&SIO#O$& O! RHINOSINUSITIS: -
!he sinuses $e.elo, 'rom nasal (hambers. &nl+ maAillar+ an$ e%hmoi$ sinuses
(an be i$en%i'ie$ a% bir%h. For %he 'irs% H +ears o' li'e %he grow%h o' sinuses is slow
6 %he os%ium o' sinuses is small. !he sha,es o' sinuses be(ome irregular a'%er age
o' H-8 +ears be(ause o' $is%or%ing e''e(% b+ $e.elo,ing a$#a(en% s%ru(%ures)
in(lu$ing o%her sinuses. !he a$ul% siBe an$ sha,e o' sinuses is a(hie.e$ b+ 12 7 14
+ears o' age. !he maAillar+) 'ron%al 6 s,henoi$al sinuses are larger 6 ,aire$ bon+
(hambers) while an%erior 6 ,os%erior e%hmoi$ sinuses (onsis% o' lab+rin%h o' small
bon+ (ells.
aAillar+ an$ Fron%al sinuses 6 an%erior e%hmoi$ air (ells $rain in%o mi$$le
mea%us. !he ,os%erior e%hmoi$ air (ells 6 s,henoi$ sinus o,enE$rain in%o su,erior mea%us
6 s,henoe%hmoi$al re(ess.
Normall+ %he sinuses ha.e s%erile en.ironmen%. New resear(hes show %ha% %he 2ara
Nasal Sinuses 42NS5 are a large reser.oir 'or Ni%ri( &Ai$e4N&5 whi(h im,ro.es
mu(o(illiar+ 'un(%ion. N& is also su,,ose$ %o ha.e ba(%erios%a%i( 'un(%ion as well as
an%i.iral 'un(%ion. N& ,ro$u(%ion in(rease$ in a(u%e 6 (hroni( in'lamma%ion o' nose 6
2NS.
!+,i(all+ /0"S $e.elo,s 'ollowing a(u%e .iral 3"!I. In'lamma%or+ res,onse is
eA,e(%e$ se*uel o' %his in'e(%ions ,ro(ess. !his in'lamma%or+ res,onse lea$s %o mu(osal
swelling wi%h o((lusion or obs%ru(%ion o' sinus os%ia. / re$u(%ion in oA+gen %ension
o((urs whi(h re$u(es mu(o(iliar+ %rans,or% 6 %rans$u(%ion o' 'lui$ in%o sinuses;:<. !hese
(hanges in %he nasal 7 sinus en.ironmen% lea$ %o mu(os%asis 6 ba(%erial (oloniBa%ion) an$
hen(e in'e(%ion ;9<. !he role o' allergies has been s%rongl+ sugges%e$ bu% no% ,ro.en.
an+ (ells 6 ,ro%eins %ha% are in.ol.e$ wi%h in'lamma%or+ res,onse ha.e been
im,li(a%e$ an$ are being in.es%iga%e$ %o %heir roles in rhinosinusi%is. !hese in(lue$
eosino,hils) neu%ro,hils) mas% (ells) ! 6 0 (ells) immunoglobulins) in%erleu-ins) !NF)
a#or 0asi( 2ro%iens 6 number o' o%her me$ia%ors. 2resen(e o' s,e(i'i( in'lamma%or+
me$ia%ors .er+ base$ on in(i%ing 'a(%or in in'lamma%ion;:)10)11 <.
Gis%o,a%hologi(all+ /"S shows ,re$ominan(e o' neu%ro,hils) along wi%h
eAu$a%i.e ,ro(ess) .isible areas o' ne(rosis) ul(era%ion 6 hemorrhage are seen;8)12<. In
1"S) a ,roli'era%i.e ,ro(ess is ,resen% wi%h l+m,ho(+%es) ,lasma (ells 6 eosino,hils
being ,resen%. @.i$en(es o' 'ibrosis o' lamina ,ro,ria are also seen ;8):)10)11)31 <.
os% (ommon ba(%eria asso(ia%e$ wi%h /0"S in a$ul%s are S%re,%o(o((us
2neumoniae 4209-4595 6 G in'luenBae 4229-3595 6 . (a%arrhalis 439-1095. In
(hil$ren S%re,%. 2neumoniae 4309-4395) G In'luenBae 4209-2:95. 6 (a%arrhalis
4209-2:95 are mos% (ommonl+ asso(ia%e$ ba(%eria. &u% o' %hese (a%arrhalis is largel+
a sel' limi%e$ ,a%hogen;8)13)14 <.
/s 'ar as 2a%hogenesis o' 1"S is (on(erne$ i% is %hough% %o be an in'lamma%or+
$isease 6 i% ma+ or ma+ no% in.ol.e ,a%hogeni( mi(robes. In %hose ,a%ien%s wi%h 1"S)
who $o ha.e ,o%en%ial ,a%hogeni( ba(%eria) %he mos% (ommon organisms are s%a,h s,e(ies
45595) s%a,h aureus 42095;8)14<. 2re.alen(e o' @n%eroba(%eria(eae organisms ;15)1H<.
/naerobes ;18< 6 'ungi ;11< also been seen.
!I$UR" ) 7 "anges o' 2re.alen(e o' %he a#or 2a%hogens /sso(ia%e$ Mi%h /(u%e
0a(%erial "hinosinusi%is in /$ul%s
S%re,%o(o((us Series 439-995
/naeribes 409-395
oraAella (a%arrhalls 429-1095
S%ao,h+lo(o((us aureus 409-:9
&%her4495
Gaemo,hilus in'luenBae 4229-3595
S%re,%o(o((us ,neumoniae 4209-4395
!I$UR" 7 i(robiolog+ o' /(u%e 0a(%erial "hinosinusi%is in 1hil$ren
oraAella (a%arrhalis 4219-2:95
S%a,h+lo(o((us 2+ogenes 439-895
/naerobes 439-895
Gaemo,hilus in'luenBae 4 219-2:95
S%re,%o(o((us 4359-4295
DIA$NOSIS: - !he bes% o' $iagnosis o' /0"S (an be ma$e on (lini(al groun$ 6
(ri%eria 4 %able 25. !he mos% (os% e''e(%i.e me%ho$s o' $iagnosis $i''er a% $i''eren%
,re.alen(e ra%es. !he $iagnosis (an be ma$e on em,iri( basis 6 s+m,%oms i' ,re.alen(e
ra%es are high su(h as in s,e(ial%+ ,ra(%i(es. In low ,re.alen(e areas (lini(al (ri%eria
in(lu$ing s+m,%oms 6 ,h+si(al 'in$ings are ,re'erre$ ;1)2<. !he $iagnosis 'or resear(h
usuall+ nee$s more ob#e(%i.e in'orma%ion. !o i$en%i'+ s,e(i'i( 2a%hogen 'or resear(h a
maAillar+ sinus %a, wi%h (ul%ure is re(ommen$e$4GOLD standard for diagnosis of ABRS5
;15)1:<. !he role o' en$os(o,i( gui$e$ mi$$le mea%us (ul%ure is un$er resear(h. I' one
has %o ma-e $iagnosis o' ba(%erial rhino sinusi%is) %he (urren% a((e,%e$ re'eren(e s%an$ar$
'or (ul%ure is more %han 1N 10
4
1F3E ml in sinus as,ira%e;19<. >ower (oun%s ,o%en%iall+
re,resen% earl+ in'e(%ion.
In 1"S 6 S"S $e'ini%i.e me%ho$s 'or $iagnosis has +e% no% been $e%ermine$. !he
re(ommen$e$ %ime 'rame 'or grea%er %han 12wee- 'or 1"S 6 be%ween 4-12 wee-s 'or
S"S ha.e been (ommonl+ a$o,%e$. !hus a,,ro,ria%e his%or+) ,ro,er ,h+si(al
eAamina%ion 6 %es%ing will (on'irm %he $iagnosis. / number o' %es%s (an be use$ %o
es%ablish %he $iagnosis o' rhinosinusi%is bu% %hese are more im,or%an% in (hroni( ra%her
%han a(u%e rhinosinusi%is Nasal en$os(o,+ is an im,or%an% %ool %o assess %he nasal
ana%om+) (on'irm $rainage 6 e.alua%e %rea%men% res,onse. N-ra+s ha.e been use$ 'or all
%+,es o' rhinosinusi%is bu% are no% (os% e''e(%i.e in $iagnosis o' /0"S;1)2<. /% ,resen%
%ime %he ,re'erre$ ra$iologi(al %es% is sinus 1! s(an bu% i% (anno% $is%inguish be%ween
in'lamma%ion 6 in'e(%ion .1! s(an are no% re(ommen$e$ in /0"S as %he+ are no% (os%
e''e(%i.e 'or %his in$i(a%ion;1)2)20<. 0u% are goo$ 'or e.alua%ion o' sus,e(%e$ im,en$ing
(om,li(a%ions su(h as orbi%al or in%ra(ranial in.ol.emen%. 1! s(an is goo$ 'or assessing
%he se.eri%+ o' $isease or res,onse %o %rea%men% in 1"S. >un$ 6 a(-a+ gra$ing 419935
o' 1! s(an 2NS is mos% (ommonl+ re(ommen$e$ as s%aging s+s%em %o asses se.eri%+ o'
rhino sinusi%is;21<. I% has been re(en%l+ re(ommen$e$ %ha% ei%her a 1! s(an or en$os(o,i(
e.alua%ion o' nose ,re'erabl+ wi%h ,ho%o or .i$eo $o(umen%a%ion shoul$ be ,ar% o' an+
,ros,e(%i.e (lini(al %rial in 1"S;10<.
TR"AT%"NT*
e$i(al managemen% o' "S (an be sim,li'ie$ in%o %hree grou,s-an%imi(robial)
an%i-in'lamma%or+ an$ me(hani(al. I% is brea-$own %rea%men% 'rom ea(h grou, an$
(ombine %hem when a,,ro,ria%e in%o a (om,rehensi.e %rea%men% ,lan. /lso) i% is
im,or%an% %o (onsi$er %he si$e e''e(% o' ea(h %hera,+) an$ weigh %hem wi%h %he ,a%ien%Ds
s+m,%oms se.eri%+ an$ o%her me$i(al (on$i%ions. In general) me$i(al managemen% o' "S
shoul$ in(lu$e (ul%ure $ire(%e$4or broa$ s,e(%rum5 an%ibio%i(s) a nasal s%eroi$ s,ra+)
saline irriga%ion an$ $e(onges%an%. S%rong (onsi$era%ion shoul$ also be gi.en 'or s%eam
inhala%ion.
Table +,- . (re/alence of Cross . Resistance 0etween (enicillin and 1arious
Antibiotic Classes A2on3 Strains of (enicillin . Nonsusceptible Strains of
Streptococcus pneu2onia
Class 4 A3ent
9 o' S%rains "esis%an%
(en . S (en . I (en . R All
a(roli$es H 49 8H 32
1lin$am+(in 1 14 2: 10
!2ESN 14 58 91 43
JoA+(+(line 4 25 55 22
/bbre.ia%ions: I1) minimum inhibi%or+ (on(en%ra%ion O 2en 7 I) ,eni(illin 7 in%erme$ia%e
4,eni(illin I1 0.12 mgE m> %o 1 mgEm>5O 2en 7 ") 2eni(illin 7 resis%an% 4,eni(illin I1
L2 mgE m> 5O 2en 7 S) ,eni(illin 7 sus(e,%ible 4,eni(illin I1 K0.0H mgEm>5O !2ESN)
%rime%ho,rim E sul'ame%hoAaBole.
TA0#" 5,+- . Anti2icrobial A3ents Stratified by (har2acodyna2ic (rofile A3ainst
Streptococcus pneu2oniae and Hae2ophilus influen6a
/n%imi(robial /gne%
/(hie.es 2harma(o$+nami( !arge%*
S ,neumoniae G in'luenBa
2eni(illin-
Sus(e,%ible
2eni(illin-
In%erme$ia%e
2eni(illin-
resis%an%
P->a(%amase
- nega%i(
P->a(%ama
se 7
,osi%i.e
P 7 >a(%ams
/moAi(illin
Q

/moAi(illin E (la.ulana%e*
1e'$inir R
1e',o$oAime
1e'%riBAone
1e'uroAime
Fola%e Inhibi%ors
!2ESN R
Ke%oli$es
!eli%hrom+(in R R
a(roli$es
/Bi%hrom+(in R R R
1lari%hrom+(in R R R
@r+%hrom+(in R
Fluoro*uinolones
?a%i'loAa(in
?emi'loAa(in
>e.o'loAa(in
aAi'loAa(in
!e%ra(+(lines
JoA+(+(line R
/bbre.ia%ions: /31) area un$er %he (ur.eO I1) minimum inhibi%or+ (on(en%ra%ionO !2ESN)
%rime%ho,rimE sul'ame%hoAaBole.
Ke+: ) /$e*ua%e ,harma(o$+nami( ,ro'ile using (on.en%ional $osing in ,a%ien%s wi%h normal renal
an$ he,a%i( 'un(%ionO
R) bor$erline ,harma(o$+nami( ,ro'ile using (on.en%ional $osing in ,a%ien%s wi%h normal renal an$
he,a%i( 'un(%ion.
* P 7 >a(%ams an$ ma(roli$es: ! L I1 L 409 o' %he $osing in%er.al. Fluoro*uinolones: 24 7 h
/31EI1 ra%io L 100 7 125 'or G in'luenBae an$ L 30 7 50 'or S ,neumoniae.
Q Gigh 7 $ose amoAi(illin
TA0#" 7,- . %echanis2s of Action of Co22only Used Anti2icrobials for
Co22unity . Ac8uired Respiratory Tract Infections
!arge% @Aam,les
1ell 7 wall 7 a(%i.e agen%s P 7 >a(%ams 4,eni(illins) (e,halos,orins5
2ro%ein s+n%hesis inhibi%ors 4ribosome5
a(roli$es) >in(osami$es 4eg)
(lin$am+(in5) %e%ra(+(lines) 4eg)
%e%ra(+(line) $oA+(+(line5) -e%oli$es.
JN/ re,li(a%ion inhibi%ors Fluoro*uinolones
Foli( a(i$ me%abolism inhibi%ors !rime%ho,rim E sul'ame%hoAaBole
TA0#" 9 . Anti2icrobial A3ents for Acute 0acterial Rhino sinusitis
?eneri( Name !ra$e Name !+,i(al /$ul% Josage
"egimen
!+,i(al 2e$ia%ri(
Josage "egimen
/.ailable
Josage4mg5
P 7 >a(%ams
/moAi(illin /moAil
?eneri(s
:85 mg bi$ A 10 $ L 3 mo: 45 mgE-gE$
gi.en *12h A10 $
250)500):85*
/moAi(illin E
1la.ulana%e
/ugmen%in 500-2000mg bi$ A 10 $ L 12 w-s: 45mgE-g
gi.en * 12h A 10 $
250E125)500E125)
:85E125*
/ugmen%in
@S 7 H00
NE/ 90 mgE-gE$ $i.i$e$
* 12h A 10 $
H00 mgE5m>
/ugmen%in
N"
2000E125 mg bi$ A 10 $ NE/ 1000 E H2.5
1e'$inir &mni(e' 300 mg bi$ A 10 $ or H00
mg *$ A 10 $
H mo 7 12 +rs: 8
mgE-g *12h or 14
mgE-g *24h A 10 $
125)250)300*
1e',o$oAime Van%in 200 mg bi$ A 10 $ 2D mo 7 11 +rs: 5
mgE-gE$ gi.en *12h
A 10 $
100) 200*
1e'%in 1e'uroAime 250 mg bi$ A 10 $ 3 mo 7 12 +rsO 15
mgE-g bi$ A 10 $
125)250)500*
1e'%riaAone "o(e,hin 1-2 g 1 *$ A 3-10 $ 50 mgE-g I A 3 $
4minimum5
500)1 g) 2 g
Fola%e Inhibi%ors
!2ESN 0a(%rim)
Se,%ra
1H0E:00 bi$ A 10 $ L mo: 4 mgE-g !2
an$ 20 mgE-g SN
gi.en *12h A 10 $
:0E400) 1H0E:00
4JS5*
a(roli$es E
/Bali$esE
Ke%oli$es
/Bi%hrom+(in Si%hromaA 500mg *$ A 3 $ L H mo: 10 mgE-g *$
A 3 $
250)500*
1lari%hrom+(in 0iaAin 500 mg *12h A 14 $ L mo: 8.5 mgE-g
gi.en *12 A 10 $
250)500*
0iaAin N> 1000 mg *$ A 14 $ NE/ 500
1lin$am+(in 1leo(in 150 7 300 mg * Hh A 10 $ 0ir%h 7 1H +rs: : 7
1H mgE-gE$A 10 $
85)150)300*
!eli%hrom+(in Ke%e- :00 *$ A 5 $ NE/ 400
"es,ira%or+
=uinolones
?a%i'loAa(in !e*uin 400mg *$ A 10 $ NE/ 200) 400
?emi'loAa(in Fa(%i.e 320 mg *$ A 10 $ NE/ 320
>e.o'loAa(in >e.a*uin 500-850 mg *$ A 10 $ NE/ 500) 850
oAi'loAa(in /.eloA 400 mg *$ A 10 $ NE/ 400
!e%ra(+(lines
JoA+(+(line Vibram+(in)
o%hers
100 mg *$ gi.en *12h A
10 $
L: +rsO K 100 lbsO 1
mgE lb bi$ on $a+ 1)
%hen 1 mgElb or 0.5
mgElb bi$ A 10 $
50)85)100*
/bbre.ia%ions JS) $ouble s%reng%hO NE/) no% a,,ro.e$ 'or useO !2 E SN) %rime%ho,rimE
sul'ame%hoAaBole.
!his %able ,ro.i$es %+,i(al $osage regimen.
* Some $osages are also a.ailable in sus,ension 'orm.
TA0#" : . Reco22ended Antibiotic Therapy for Adults ;ith A0RS
Initial Therapy Calculated
Clinical
"fficacy <=>?
Calculated
0acteriolo3ic
"fficacy <=>?
Switch . Therapy Options
<No I2pro/e2ent or ;orsenin3
After : Hours>
@
%ild disease
@
with no recent anti2icrobioal use <past 5A9 weeBs>
C
/moAi(illin E 1la.ulana%e
41.85 - 4 gE250 mgE$5
TII
90 7 91 98 - 99 ?a%i'loAa(in) le.o'loAa(in)
oAi'loAa(in
/moAi(illi E(la.ulana%e4gE250 mg
1e'%riaAone
1ombina%ion !hera,+
T
/moAi(illin 41.5-4 gE$5
II
:8 7 :: 91 7 92
1e',o$oAime ,roAe%il :8 91
1e'uroAime aAe%il :5 :8
1e'$inir :3 :5
P 7 >a(%am allergi(
U
!2 E SN :3 :4
?a%i'loAa(in) le.o'loAa(in)
oAi'loAa(in
"i'am,in ,lus (lin$am+(in
JoA+(+(line :1 :0
/Bi%hrom+(in)
1lari%hrom+(in)
er+%hrom+(in
88 83
!eli%hrom+(in See 'oo%no%e. ** 83
il$ $isease
U
wi%h re(en% an%imi(robial use 4 ,as% 4-H wee-s5 or mo$era%e $isease
T
?a%i'loAa(in) >e.o'loAa(in)
moAi'loAa(in
92 100
"ee.alua%e ,a%ien%
TT
/moAi(illi E(la.ulana%e
4E250 mg5
91 99
1e'%riaAone 91 99
41ombina%ion %hera,+5
T
NE/ NE/
P 7 >a(%am allergi(
U
?a%i'loAa(in) le.o'loAa(in)
moAi'loAa(in
92 100
"ee.alua%e ,a%ien%
TT
1lin$am+(in an$ ri'am,in
QQ
NE/ NE/
/bbre.ia%ions : /0"S) a(u%e ba(%erial rhinosinusi%isO 1!) (om,u%e$ %omogra,h+O NE/) no% a.ailableO
!2ESN) %rime%ho,rim E sul'ame%hoAaBole.
1lini(al an$ ba(%erial e''i(a(+ 4ie) lini(al an$ mi(robiologi( a$e*ua(+5 is re,resen%e$ b+ %he
(al(ula%ion 'rom %he ,oole !hera,eu%i( &u%(ome o$el using %he mean .alues o' %wo
sur.eillan(e $a%a se%s: %he 3S (om,onen% o' %he /leAan$er ,ro#e(% 4199: %o 20015 an$
S@N!"I sur.eillan(e $a%a. !hese .alues %o no% guaran%ee (lini(al su((ess or 'ailure. !he
2oole !hera,eu%i( ou%(ome mo$el has no% been (lini(all+ .ali$a%e$.
Q Mhen a (hange in an%ibio%i( %hera,+ is ma$e) %he (lini(ian shoul$ (onsi$er %he limi%a%ions in
(o.erage o' %he in%i%ial an%ibio%i(. !he res,ira%or+ 'luoro*uinolones 4 ga%i'loAa(in)
>e.o'loAa(in) an$ moAi'loAa(in5) (e'%riaAone) an$ amoAi(illinE (la.ulana%e 44 gE250 mg5
(urren%l+ ha.e %he bes% (o.erage 'or bo%h S%re,%o(o((us ,neumoniae an$ Gaemo,hilus
in'luenBae. !he %erms mil$ an$ mo$era%e are $esigne$ %o ai$ in sele(%ing an%ibio%i( %hera,+.
V !he $i''eren(e in se.eri%+ o' $isease $oes no% im,l+ %he ,resen(e or absen(e o' an%imi(robial
resis%an(e. "a%her) %his %erminolog+ in$i(a%es %he rela%i.e $egree o' a((e,%an(e o' ,ossible
%hera,eu%i( 'ailure an$ %he li-elihoo$ o' a(hie.ing s,on%aneous resolu%ion o' s+m,%oms. !he
$e%ermina%ion o' $isease se.eri%+ lies wi%h %he (lini(ianDs e.alua%ion o' %he ,a%ien%Ds his%or+
an$ (lini(al ,resen%a%ion. Se.ere) li'e-%hrea%ening in'e(%ion) wi%h or wi%hou% (om,li(a%ions) is
no% a$$resse$ in %hese gui$elines.
T 2rior an%ibio%i( %hera,+ wi%hin 4 %o H wee-s is a ris- 'a(%or 'or in'e(%ion wi%h resis%an%
organisms. /n%ibio%i( (hoi(es shoul$ be base$ on %his an$ o%her ris- 'a(%ors.
II !he %o%al $ail+ $ose o' amoAi(illin an$ %he amoAi(illin (om,onen% o' amoAi(illin E (la.ulana%e
(an .ar+ 'rom 1.5 %o 4 gE$a+. >ower $ail+ $oses 41.5 gE$a+5 are more a,,ro,ria%e in mil$
$isease in ,a%ien%s wi%h no ris- 'a(%ors 'or in'e(%ion wi%h a resis%an% ,a%hogen 4in(lu$ing re(en%
an%ibio%i( use5. Gigher $ail+ $oses 44 gE$a+5 ma+ be a$.an%ageous in areas wi%h a high
,re.alen(e o' ,eni(illin 7 resis%an% S ,neumoniae or $rug 7 resis%an% S ,neumoniae) 'or
,a%ien%s wi%h mo$era%e $isease) 'or ,a%ien%s who ma+ nee$ be%%er G in'luenBae (o.erage or 'or
,a%ien%s wi%h ris- 'a(%ors 'or in'e(%ion wi%h a resis%an% ,a%hogen. !here is a grea%er ,o%en%ial
'or %rea%men% 'ailure or resis%an% ,a%hogens is %hese ,a%ien% grou,s.
II 0ase$ on in .i%ro s,e(%rum o' a(%i.i%+O (ombina%ion %hera,+ using a,,ro,ria%e gram 7 ,osi%i.e
an$ gram 7 nega%i.e (o.erage ma+ be a,,ro,ria%e. @Aam,les o' (ombina%ion %hera,+
regimens in(lu$e high 7 $ose amoAi(illin 4 4 gE$a+5 or (lin$am+(in ,lus (e'iAime) or high 7
$ose amoAi(illin 44 gE$a+5 or (lin$am+(in) ,lus ri'am,in. !here is no (lini(al e.i$en(e a% %his
%ime) howe.er) o' %he sa'e%+ or e''i(a(+ o' %hese (ombina%ions.
U 1e,halos,orins shoul$ be (onsi$ere$ ini%iall+ 'or ,a%ien%s wi%h ,eni(illin in%oleran(e E non
7!+,e I h+,ersensi%i.i%+ rea(%ions 4eg) rash5. !2ESN) $oA+(+(line) ma(roli$es) aBali$es)
an$ -e%oli$es are no% re(ommen$e$ unless %he ,a%ien% is P 7 la(%am allergi(. !heir
e''e(%i.eness agains% %he ma#or ,a%hogens o' /0"S is limi%e$) an$ ba(%erial 'ailure o' 209 %o
259 is ,ossible. / res,ira%or+ 'luoro*uinolone 4eg) ga%i'loAa(in) lo.o'loAa(in) moAi'loAa(in5
is re(ommen$e$ 'or ,a%ien%s who ha.e allergies %o P 7 la(%ams or who ha.e re(en%l+ 'aile$
o%her regimens.
** Fur%her 2harma(o-ine%i(E ,harma(o$+nami( $a%a on %his (om,oun$ is nee$e$.
QQ "i'am,in is a well 7 -nown in$u(er o' se.eral (+%o(hrome 2450 isoenB+mes an$ %here'ore has
a high ,o%en%ial 'or $rug in%era(%ions.
VV "ee.alua%ion is ne(essar+ be(ause %he an%ibio%i(s re(ommen$e$ 'or ini%ial %hera,+ ,ro.i$e
eA(ellen% a(%i.i%+ agains% %he ,re$ominan% /0"S ,a%hogens) in(lu$ing S ,neumoniae or G
in'luenBae. /$$i%ional his%or+) ,h+si(al eAamina%ion) (ul%ures) an$ E or 1! s(an ma+ be
in$i(a%e$) an$ %he ,ossibili%+ o' o%her less (ommon ,a%hogens (onsi$ere$.
Chronic Rhinosinusitis
1hroni( rhinosinusi%is 41"S5 is an umbrella %erm 'or a number o' ,a%hologi(
(on$i%ions in whi(h in'lamma%ion o' %he nose an$ ,aranasal sinuses is %he 'inal (ommon
,a%hwa+. !hese in(lu$e:
/llerg+
Immuno$e'i(ien(+ s%a%es
Neo,lasmDs
Virus
0a(%eria
Fungi
?ene%i( E (ongeni%al abnormali%ies
u(o(iliar+ $+s'un(%ion
NoAious (hemi(als
2ollu%an%s
Smo-ing.
Subgrou,s o' %hese (a%egories) su(h as su,er an%igen 'orma%ion) ba(%erial bio'ilms) an$
allergi( 'ungal $isease) ha.e been i$en%i'ie$.
!he $iagnosis o' 1"S has been $e'ine$ b+ (onsensus in or$er %o $e.elo, a
'ramewor- o' %erminolog+ %ha% (lini(ians an$ resear(hers (an u%iliBe 'or s%an$ar$iBe$
(ommuni(a%ion 4!able 5. 1"S is when s+m,%oms ha.e been ,resen% 'or 12 wee-s an$
%here is ,h+si(al e.i$en(e 4usuall+ b+ nasal en$os(o,+5 o' mu(osal swelling) nasal
$is(harge) or ,ol+,s. u(osal abnormali%ies o' %he mi$$le mea%us or bulla are also
(on(re%e signs o' in'lamma%or+ $isease. ?eneraliBe$ or lo(aliBe$ e$ema) er+%hema) or
granula%ion %issue (an be (ause$ b+ o%her rhinologi( $iseases) su(h as allergi( rhini%is) an$
%here'ore re*uires imaging (on'irma%ion.
TA0#" D . %easures for Dia3nosin3 Chronic Rhinosinusitis for Adult Clinical Care
Jura%ion o' $isease is *uali'ie$ b+ (on%inuous s+m,%oms 'or L 12 (onse(u%i.e
wee-s or L 12 wee-s o' ,h+si(al 'in$ings.*
&ne o' %hese signs o' in'lamma%ion mus% be ,resen% an$ i$en%i'ie$ in asso(ia%ion
wi%h ongoing s+m,%oms (onsis%en% wi%h 1"S.
- Jis(olore$ nasal $rainage arising 'rom %he nasal ,assage) nasal ,ol+,s) or
,ol+,oi$ swelling as i$en%i'ie$ on ,h+si(al eAamina%ion wi%h an%erior
rhinos(o,+ or nasal en$os(o,+. /n%erior rhinos(o,+ shoul$ be ,er'orme$
in %he $e(onges%e$ s%a%e.
- @$ema or er+%hema o' %he mi$$le mea%us or e%hmoi$ bulla as i$en%i'ie$ b+
nasal en$os(o,+.
- ?eneraliBe$ or lo(aliBe$ er+%hema) e$ema) or granula%ion %issue. I' i% $oes
no% in.ol.e %he mi$$le mea%us or e%hmoi$ bulla) ra$iologi( imaging is
re*uire$ %o (on'irm $iagnosis U.
Imaging mo$ali%ies 'or (on'irming %he $iagnosis:
- 1! s(an: $emons%ra%ing isola%e$ or $i''use mu(osal %hi(-ening) bone
(hanges) air-'lui$ le.el.
- 2lain sinus ra$iogra,h: Ma%erDs .iew re.ealing mu(ous membrane
%hi(-ening o' L5 mm or (om,le%e o,a(i'i(a%ion o' one or more sinuses. /n
air 7 'lui$ le.el is more ,re$i(%i.e o' a(u%e rhino sinusi%is bu% ma+ also be
seen in 1"S**.
- "I is no% re(ommen$e$ as an al%era%i.e %o 1! 'or rou%ine $iagnosis o'
1"S be(ause o' i%s eA(essi.el+ high sensi%i.i%+ an$ la(- o' s,e(i'i(i%+.
/bbre.ia%ions: 1"S) (hroni( rhino sinusi%isO 1!) (om,u%e$ %omogra,h+O "I) magne%i(
resonan(e imaging.
*Signs (onsis%en% wi%h 1"S will su,,or% %he s+m,%om %ime $ura%ion
U&%her (hroni( rhinologi( (on$i%ions su(h as allergi( rhini%is (an resul% in su(h 'in$ings) an$
%here'ore %he+ ma+ no% be asso(ia%e$ wi%h rhino sinusi%is. I% is re(ommen$e$ %ha% a $iagnosis
o' rhino sinusi%is re*uire ra$iologi( (on'irma%ion un$er %hese (ir(ums%an(es
**/ ,lain sinus ra$iogra,h wi%hou% %he e*ui.o(al signs lis%e$ here is no% (onsi$ere$
$iagnos%i(. /si$e 'rom an air-'lui$ le.el) ,lain sinus ra$iogra,hs ha.e low sensi%i.i%+ an$
s,e(i'i(i%+.
!he bes% ra$iologi( s%u$+ 'or %he e.alua%ion o' %he sinuses is a (om,u%e$
%omogra,h+ 41!5 s(an. 2lain 'ilm sinus ra$iogra,hs ma+ be hel,'ul in some ins%an(es 'or
(on'irming %he $iagnosis o' s+m,%oma%i( ,a%ien%s wi%h e*ui.o(al ,h+si(al 'in$ings.
agne%i( resonan(e imaging 4"I5 s(ans ma+ be %oo sensi%i.e. ?i.en %he role o' 1!
S(anning in i$en%i'+ing mu(osal abnormali%ies in %he sinuses) "I s(ans are no% (urren%l+
re(ommen$e$.
/ %rea%men% ,ara$igm 'or 1"S is $i''i(ul%) sin(e %here are numerous un$erl+ing
e%iologies) sin(e in'lamma%ion is ,resen%) an%i 7 in'lamma%or+ %hera,+ is -e+ in %he
(lini(ianDs arsenal. Fre*uen%l+) a WSho%-gunX a,,roa(h is un$er%a-en. &ne regimen migh%
in(lu$e an%ibio%i( %hera,+ 'or 10 %o 21 $a+s) s+s%emi( s%eroi$s) leu-o%riene mo$i'iers)
nasal irriga%ions 4su(h as saline wi%h an%i'ungal) an%iba(%erial5) an$ nasal s%eroi$s. "e,ea%
e.alua%ion o' %he ,a%ien% wi%h or wi%hou% 1! s(an is ,er'orme$ a number o' wee-s a'%er
%his WmaAimalX %hera,+.
SUR$ICA# %ANA$"%"NT*
Surger+ is a las% resor% an$ is reser.e$ 'or ,a%ien%s who ha.e no% res,on$e$ %o
%hera,+. &b.iousl+) neo,lasmDs an$ (er%ain o%her ,a%hologies are absolu%e in$i(a%ions 'or
surgi(al in%er.en%ion. Surger+ is usuall+ ,er'orme$ .ia a minimall+ in.asi.e en$os(o,i(
a,,roa(h. !he use o' (om,u%er 7 ai$e$ surgi(al $e.i(es has re.olu%ioniBe$ %he manner in
whi(h en$os(o,i( surger+ is ,er'orme$.
Jes,i%e %he 'a(% %ha% maAimal me$i(al %hera,+ is in$i(a%e$ in all (ases o' "S an$ man+
(ases $o res,on$ %o i%) %here s%ill eAis%s a number o' ,a%ien%s who im,ro.e onl+ a'%er
surgi(al managemen%;25)2H)28<.
From surgi(al $rainage o' sinuses) being ,ra(%i(e$ e.en in ,rean%ibio%i( era) an$
(on.en%ional o,en sinus surgeries %o %he ,resen%l+ ,ra(%i(e$ minimall+ in.asi.e
en$os(o,i( sinus surgeries) sinus surger+ has e.ol.e$ a long wa+. 0eing a highl+
,re.alen% $isease worl$wi$e ;2:)29< %ha% resul% in a huge 'inan(ial an$ $isease bur$en
globall+;2:)30<. /ll o.er %he worl$ a,,roAima%el+ 5 la-hs o' surgi(al ,ro(e$ures are
,er'orme$ annuall+ on "S ,a%ien%s ;28<.

TA0#" E* (rocedures for CRSF
SINUS CONSERVATIVE RADICAL
%aGillary /n%ral washou% 1al$well->u(
In%ranasal an%ros%om+
i$$le
mea%al4en$os(o,i(5
In'erior mea%al
!rontoeth2osphenoid Jra' 1-3 en$onasal
$rainage
@A%ernal
'ron%oe%hmos,henoi$e(%om+4>+n(h-
Gowra%h) 2a%%erson5 !re,hina%ion o' 'ron%al
sinus or s,henoi$
washou%
i$line se,%e(%om+ 4>o%hro,O
rhino'ron%al sinuse,%o%om+5.
In%ranasal
e%hmoi$e(%om+
&s%eo,las%i( 'la,4wi%h or wi%hou%
obli%era%ion5.
F@SS 1ranialisa%ion o' 'ron%al sinus.
!ransan%ral
e%hmoi$e(%om+4Yansen-
Gorgan5
Table* )H* Indication for sur3ical 2ana3e2ent*
)F 1"S no% res,on$ing %o o,%imum me$i(al managemen%.
F "e(urren% a(u%e "S.
+F /llergi( 'ungal "S.
5F Sinonasal ,ol+,osis.
7F /(u%e "S wi%h (om,li(a%ions.
9F Sinus mu(o(eles.
:F /n%ro(hoanal ,ol+,.
Table ))*
Contraindications for sur3ical treat2ent*
)F 2a%ien%s wi%h @A%ensi.e ,ol+,osis or allergi( 'ungal sinusi%is who are no%
li-el+ %o a$here %o ,os% o,era%i.e ,rolonge$ me$i(al %rea%men%.
F 2a%ien%s (hie' (om,lains o' hea$a(he or mi$'a(ial ,ain whi(h is unli-el+ %o be
o' sinus origin e.en %hough 1! s(an shows sinus o,a(i%+.
+F Frail ,a%ien% or o%her me$i(al (on$i%ion ma-ing surger+ highl+ ris-+
,ro,osi%ion.
5F ?rossl+ h+,o,las%i( sinuses an$Eor %hi(- bones.4rela%i.e5.
Conclusion* "hinosinusi%is is a (om,leA (on$i%ion wi%h ,ro'oun$ e''e(% on ,a%ien%s
*uali%+ o' li'e an$ heal%h (are eA,en$i%ure. !he (om,leAi%+ o' i%s e%io,a%hogenesis
,resen%s a (hallenge 'or i%s managemen%. Mhile %he an%imi(robials an$ s%eroi$s 'rom %he
mains%a+ o' %rea%men%) %o,i(al %hera,+ in 'orm o' im,ro.e$ $eli.er+ s+s%em is being
,re'erre$ as o' now. 2o%en%ial $e.elo,men% o' mi(robial resis%an(e remains a salu%ar+
(on(ern in %hese ,a%ien%s $ue %o re,ea%e$ an$ ,rolonge$ use o' an%ibio%i(s. Surger+
(on%inues %o ,la+ an im,or%an% role in managemen% o' re(al(i%ran% $isease) resul%ing in
im,ro.e$ *uali%+ o' li'e. Immune mo$ula%ors) su(h as an%i-Ig@ an$ an%i-I>5 an%ibo$ies)
are ,romising newer agen%s %o$a+. Surgi(al mo$ali%ies li-e balloon sinu,las%+ an$
s%en%ing are un$er resear(h. !he (om,leA an$ $i.erse na%ure o' rhinosinusi%is re*uires an
in$i.i$ualiBe$ a,,roa(h %o bo%h me$i(al an$ surgi(al managemen% in a mul%i$is(i,linar+
se%%ing.

References*
1. /gen(+ on Geal%h 1are 2oli(+ an$ "esear(h. Jiagnosis an$ !rea%men% o'
/(u%e 0a(%erial "hinosinusi%is. /G12" 2ubli(a%ions 1learinghouse)
2ubli(a%ion No. 997@01H) 1999.
2. 0enninger S) GolBer S@) >au Y. Jiagnosis an$ %rea%men% o' un(om,li(a%e$
a(u%e ba(%erial rhinosinusi%is : Summar+ o' %he /gen(+ on Geal%h 1are 2oli(+
an$ "esear(h @.i$en(e 0ase$ "e,or%. &%olar+ngolog+ an$ Gea$ an$ Ne(-
Surger+. 2000O 122: 1-8.
3. ?li(-li(h "@) e%son ". !he heal%h imn,a(% o' (hroni( sinusi%is in ,a%ien%s
see-ing o%ola+ngologi( (are. &%olar+ngolog+ an$ Gea$ an$ Ne(- Surger+.
1995O 113: 104-9.
4. 0enninger S. Senior 0/. !he $e.elo,men% o' %he rhinosinusi%is $isabili%+
in$eA. /r(hi.es o' &%olar+ngolog+ an$ Gea$ an$ Ne(- Surger+. 1998O 123:
1185-9.
5. Senior 0/) 0enninger S) ?laBe 1. !he use o' %he "hinosinusi%is Jisabili%+
In$eA 4"SJI5 in rhinologi( $isease. /meri(an Yournal o' "hinolog+. 2001O 15:
21-5.
H. "e,or% o' %he "hinosinusi%is !as- For(e 1ommi%%ee ee%ing. &%olar+ngolog+
an$ Gea$ an$ Ne(- Surger+. 1998O 118: S1-H:.
8. >anBa J1) Kenne$+ Jw. /$ul% rhinosinusi%is $e'ine$. &%olar+ngolog+ an$
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