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Treatment of Acute Rhinosinusitis Diagnosed by Cli PDF
Treatment of Acute Rhinosinusitis Diagnosed by Cli PDF
Treatment of Acute Rhinosinusitis Diagnosed by Cli PDF
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Scand J Prim Health Care 2003;21:121–126. ISSN 0281-3432 Results – A total of 146 patients completed the 2-week follow-up.
Patients receiving antibiotics achieved a slightly higher rate of
Objecti7es – To compare antibiotics and placebo in patients with clinical success than patients receiving placebo (80% vs 66%; p =
clinically diagnosed acute maxillary sinusitis (AMS). To study 0.068).
whether sinus ultrasound examination would help to detect those Conclusions – Antibiotics hasten symptom relief in AMS. Yet many
patients who benefit from antibiotic therapy. patients recover in 2 weeks without antimicrobial treatment. Only
Design – A double-blind, randomised, placebo-controlled multicentre half of patients with a clinical diagnosis of AMS have sinusitis in
trial. ultrasound examination.
Setting – Nine primary care sites in Finland.
Subjects – 150 adult patients (mean age 39.7 years) with a clinical Key words: maxillary sinusitis, randomised controlled trial, sinusitis,
diagnosis of sinusitis. ultrasound.
For personal use only.
Acute maxillary sinusitis (AMS) is a common infec- we compared the effect of antibiotics to that of
tious disease and by no means a settled question. In placebo in clinically diagnosed AMS in adults, and
a Finnish survey, 12% of patients consulting for studied whether sinus ultrasound examination would
infectious diseases were diagnosed as having sinusitis help to detect patients who would benefit from antibi-
(1). Rhinoviruses are common in the sinus epithelium otic therapy.
of AMS patients (2,3), and may cause AMS in up to
50% of cases (4). Symptoms and signs are unspecific
(5 –7), and if AMS is diagnosed solely by clinical PATIENTS AND METHODS
criteria, antibiotics are prescribed unnecessarily to Setting and patients
many patients with viral infections (8). In a previous The study took place in nine health centres in Fin-
primary care study, antibiotic treatment did not im- land from November 1998 to October 1999
prove the clinical course of AMS (9). Despite limited
research evidence on the effectiveness of antibiotics
for AMS, this disease nevertheless is most often Although antibiotics are widely used for maxillary
treated with antibiotics (10,11). sinusitis, research evidence on their effectiveness is
Fluid retention is usually regarded as indicating still limited.
bacterial infection in sinusitis (12). In studies of AMS Antibiotics hasten symptom relief in acute max-
therapy, the diagnosis is most often based on radiog- illary sinusitis.
raphy or aspiration (13). However, these diagnostic However, many patients recover in two weeks
methods are impractical in the primary care setting without antimicrobial treatment.
and not recommended in recent guidelines (8,14). Only about 50% of patients with a clinical diag-
Ultrasound examination has been suggested as a nosis of acute maxillary sinusitis have sinusitis
means to detect fluid in sinuses and to improve AMS confirmed by ultrasound.
diagnosis (15,16). In this diagnostic – therapeutic trial
(Karstula, Saarijärvi, Halikko, Salo, Katriina, Simo, the result was not disclosed to the patient because the
Kuivaniemi, Heinävesi and Tikkurila). Ear, nose and ultrasound-negative cases also received treatment.
throat (ENT) specialists (SS and MR) gave a small To control the severity of AMS at the Karstula
group tutorial of 1.5 h on sinus ultrasound to 60 health centre, also nasal samples for bacteriological
physicians in participating health centres. culture were taken and sinus radiography (occipito-
Our inclusion criteria covered adult patients (over mental, Waters’ view) was examined between 15 min
18 years of age) with a clinical diagnosis of AMS. and 1 h after the ultrasound examination. Criteria for
Reasons for exclusion were AMS symptoms lasting AMS were total opacification or an air–fluid level or
over 30 days, antibiotics during the previous month, mucosal thickening of 6 mm or more. Bacterial culture
allergy to study medications, pregnancy or breastfeed- was performed according to common bacteriological
ing, exacerbation of a diagnosed chronic maxillary methods.
sinusitis, previous paranasal sinus surgery, and clinical
suspicion of dental or frontal sinusitis or pansinusitis Randomisation and treatments
or suspicion of a severe complication, and previous The patients were randomised to 1 of 4 treatment
sinus surgery. options, all for 7 days: amoxicillin 750 mg× 2, peni-
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unilateral facial pain, maxillary toothache, hyposmia, kept the code and was the primary contact in the case
anosmia, malaise and fever), and three clinical signs of adverse effects or severe complications. All study
(purulent secretion in the nasal cavity, discharge in the centres also had the code in a closed envelope to be
pharynx and tenderness in sinus tapping). Patients opened only if SS could not be reached.
assessed the symptoms on a 3-step scale (1= no, Symptomatic treatments with xylometazoline,
2= little, 3= much). A symptom score of the 12 paracetamol or anti-inflammatory agents were possi-
symptoms was counted by giving 2 points for ‘‘much’’ ble if the physician considered them necessary, and
answers and 1 point for ‘‘little’’ answers. The points their use was recorded.
for the three most important symptoms (maxillary
pain, postnasal drip and cough) were doubled. The Follow-up
maximum symptom score was thus 30. The patients received diaries for recording their symp-
We also asked the patients whether they had had toms daily over 2 weeks. The same list of 12 symptoms
symptoms for more than 5 days before the visit and with a 3-step scale as in the initial patient form was
whether they had experienced 2 phases in the disease used. Possible self-medication and side effects were
(double sickening). recorded daily in the diary as well as the patients’
The physicians discussed the study with the patients, overall estimate of whether they thought they contin-
recorded history and clinical findings, and delivered ued to have sinusitis.
the study medication if the patient had AMS on Two weeks (14 –16 days) after the initial consulta-
clinical grounds. The minimum criterion for clinical tion, the researcher (HV) interviewed the patients by
diagnosis of AMS was the presence of at least three telephone, asking about subjective symptoms, their
symptoms and one clinical sign. After the treatment severity, possible side effects and the patient’s estimate
decision was made, the ultrasound examination was of recovery or recurrence. The interviewer did not
performed by using a technique described in detail know the patient’s history, treatment or the result of
earlier (12,15). The ultrasound device used was Sinus- the ultrasound examination.
can 102 (Oriola, Espoo, Finland) with a frequency of After 1 year the researcher (HV) checked the patient
3 MHz and a transducer with an 8-mm diameter. The records to register recurrent or chronic sinusitis in the
criterion for AMS was a back wall echo on the screen study patients. Recurrent sinusitis was defined as
of the device at a distance of 3.5 cm or more, another episode of sinusitis diagnosed by a primary
indicating fluid in the maxillary sinus. None of the care physician. Chronic sinusitis was defined as sinusi-
other findings were considered sinusitis. To avoid bias, tis with symptoms lasting for more than 3 months.
Outcome measures ble and randomised; 105 females (70%) and 45 males
Our main outcome measure was frequency of recov- (30%). Reasons for exclusion are presented in Fig. 1.
ery at the 2-week follow-up (according to the tele- Patients were aged between 18 and 75 years (mean
phone interview). Other outcome measures included 39.7 years). The baseline characteristics of the study
subjective symptom scores on days 3 and 10 in pa- patients are presented in Table I.
tient diaries, frequency of side effects, duration of Ultrasound examination was performed on 148
sinusitis, use of additional medication and the fre- patients, and 74 (50%) tested positive for AMS. At
quency of chronic or recurrent sinusitis and number Karstula health centre, 32 patients had sinus radio-
of physician consultations during the 1-year follow- graphies taken, and 13 (41%) had a radiologically
up. diagnosed AMS. Nasal bacterial cultures were ob-
tained from 28 patients in Karstula, and in the cul-
Study size and statistical analysis ture of 8 cases (29%) grew pathogens for acute
Previous studies have shown that approximately 75– maxillary sinusitis.
80% of patients with AMS treated with placebo
recover in 2 weeks (9,17). To find a 15% treatment Main outcome
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difference from 75% to 90% at the significance level The main outcome, recovery at the 2-week follow-up,
of a =0.05 and b =0.20 (power=0.80), a sample size was slightly better in patients receiving active treat-
of 98 patients in each treatment arm was needed. ment, antibiotics (70/88, 80%), than in the placebo
We analysed the data by intention-to-treat in main group (39/59 patients, 66%, chi-squared= 3.33,
outcomes. Differences in proportions in study groups d.f.= 1, p= 0.068). There were no differences be-
were tested with the chi-squared or Fisher exact test. tween antibiotics (clinical success rates 18/23, 78% for
Duration of sinusitis was analysed only in patients amoxicillin, 26/33, 79% for doxycycline and 26/32,
who recovered fully during the 2-week follow-up. We 81% for penicillin V).
investigated differences in symptom scores between
the group using descriptive statistics, unpaired t-tests Other outcomes
For personal use only.
and the Mann-Whitney U-test. All reported p-values Patients receiving antibiotics recovered faster than
are two-sided. We analysed all data with StatView those receiving placebo. On day 3, the difference in
5.0.1 software (SAS Institute Inc.). symptom scores was 2.1 (p= 0.048, Table II). By day
10, the difference had disappeared. Mean disease
Ethical aspects duration of AMS was 6.4 days in the placebo group
The ethics committee of the National Research and and 6.0 days in the antibiotics group (Table II).
Development Centre for Welfare and Health and the Patients receiving placebo used additional medica-
local ethics committees at study centres accepted the tion, especially analgesics, more often than those
study protocol. The patients received written infor- receiving antibiotics (Table II). Patients in the
mation on the study and its possible harmful effects. placebo group started other antibiotics more often
Because the study was placebo-controlled, study cen- (10/58, 17%) than patients in the active treatment
tres were provided with a second medication, doxycy- group (6/88, 7%, p= 0.09 Table II).
cline for the amoxicillin group and amoxicillin for the
others. The second medication was given if the pa- Subgroups of ultrasound positi6e and negati6e
tient reconsulted with worsened symptoms and the patients
physician considered antibiotics necessary. Patients Ultrasound positive and negative patients had similar
and physicians stayed blind also to the second medi- symptom scores at the beginning of study (15.3, SD
cation, knowing only that it contained an active 4.3 and 15.4, SD 4.3, respectively). At the 2-week
agent. Physicians ensured that the patients had suffi- follow-up, patients with sinusitis on ultrasound exam-
cient information and understood the process of the ination had recovered better (symptom score 2.8, SD
study. The patients gave their written informed 3.2) than those without findings (symptom score 4.1,
consent. SD 3.8, p= 0.03). In the placebo group, patients who
had sinusitis on ultrasound started other antibiotics
and withdrew from the study more often than those
RESULTS with no sinusitis on ultrasound (7/32, 22% versus
Patients 3/25, 12%, p= 0.33).
The trial profile is presented in Fig. 1. Thirty-five
primary care physicians in nine health centres partici- Side effects
pated in patient recruitment. Of 187 patients with We analysed side effects in the 130 patients who
suspected AMS considered for study, 150 were eligi- completed the 2-week follow-up in the initial treat-
Table I. Baseline characteristics of study patients (n = 148). ment arm. In the telephone interview at 2 weeks, 13
out of 48 (27%) patients in the placebo group and
Antibiotic Placebo 32 out of the 82 (39%) receiving antibiotics re-
(n=88) (n = 60)
ported side effects (Table III). Stomach pain, di-
Patient characteristics arrhoea and fatigue were the most common side
Mean age (SD) in years 40.6 (14.1) 38.1 (12.3) effects (Table III). Two patients receiving penicillin
Male/female 24 (27%)/ 20 (33%)/ V withdrew: one got nausea and the other stomach
64 (73%) 40(67%) pain and skin rash. One patient receiving amoxi-
History cillin stopped treatment because of diarrhoea, and
Previous sinusitis 74 (84%) 49 (82%) one in the placebo group discontinued treatment
Allergic rhinitis 24 (28%) 10 (17%) because of stomach pain and headache.
Vasomotor rhinitis 6 (7%) 5 (8%)
Asthma 8 (9%) 2 (3%)
Follow-up
Symptoms and signs One-year follow-up data were available for 144 pa-
Mean initial symptom score (SD) 15.3 (4.6) 15.3 (4.1)
Symptoms for more than 5 days 63 (72%) 45 (75%) tients (60 in the placebo arm and 84 in the antibi-
Double sickening 45 (51%) 35 (58%) otics group). Two patients in the placebo group
developed chronic sinusitis in follow-up, and both
Mean symptom score (SD) on day 3 9.4 (4.7) 11.5 (5.2) 2.1 0.0481
Mean symptom score (SD) on day 10 5.2 (4.9) 5.4 (4.7) 0.2 0.601
Mean duration of sinusitis (days) 6.0 6.4 0.4 0.662
Percentage of patients using additional medication 37/88 (42%) 32/58 (55%) 13% (−3% to 29%) 0.123
Analgesics 26% 43% 17% (1% to 32%) 0.033
Vasoconstrictors and antihistamines 10% 12% 2% (−8% to 14%) 0.683
Antibiotics 7% 17% 10% (−1% to 21%) 0.093
Mean number (SD) of physician consultations during 3.9 (3.5) 5.1 (6.1) 1.2 0.141
1-year follow-up
Percentage of patients having recurrent sinusitis during 26% 24% −2% (−16% to 13%) 0.763
1-year follow-up
Percentage of patients consulting because of respiratory 32% 26% −6% (−21% to 9%) 0.423
tract infections during 1-year follow-up
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1
Mann-Whitney U-test.
2
T-test.
3
Chi-squared test.
had AMS in ultrasound examination. There were no lem is that our study lacks power and the ultrasound
differences in the number of cases with recurrent subgroups are too small for definite conclusions to be
sinusitis in the study groups, but the patients who drawn. For the same reason, we cannot draw conclu-
received antibiotics consulted slightly more often be- sions about the different antibiotics in the study.
cause of respiratory tract infections during the fol- This randomised study in primary care has several
low-up year (32% vs 26%, p= 0.42). strengths: we combined diagnosis and treatment, the
study was conducted in a real-life situation and the
For personal use only.
based study found no benefit in antibiotic therapy for 4. Pitkaranta A, Arruda E, Malmberg H, Hayden FG. Detec-
AMS diagnosed by radiography. At that point, we tion of rhinovirus in sinus brushings of patients with acute
community-acquired sinusitis by reverse transcription
considered that another placebo-controlled study PCR. J Clin Microbiol 1997;35:1791 – 3.
comparing the first-line antibiotics would be ethical 5. Hansen JG, Schmidt H, Rosborg J, Lund E. Predicting
and justified. Concentrating on one active treatment acute maxillary sinusitis in general practice population.
instead of three might have been a better strategy. A BMJ 1995;311:233 – 6.
6. Williams Jr JW, Simel DL, Roberts L, Samsa GP. Clinical
Cochrane review (13) and another meta-analysis (18) evaluation for sinusitis. Making the diagnosis by history
on the therapy of AMS have later shown that there is and physical examination. Ann Intern Med 1992;117:705 –
a small treatment effect and that different antibiotics 10.
have similar efficacy. 7. Varonen H, Makela M, Savolainen S, Laara E, Hilden J.
Comparison of ultrasound, radiography, and clinical ex-
More research is needed to compare feasible strate- amination in the diagnosis of acute maxillary sinusitis: a
gies of AMS diagnosis in primary care to bridge the systematic review. J Clin Epidemiol 2000;53:940 – 8.
gap between current practice and the evidence. Ultra- 8. Hickner JM, Bartlett JG, Besser RE, Gonzales R, Hoff-
sound seems accurate and practical and has no ad- man JR, Sande MA. Principles of appropriate antibiotic
use for acute rhinosinusitis in adults: background. Ann
verse effects. Its use warrants further studies in
Emerg Med 2001;37:703 – 10.
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