Høsøien et al: Therapeutic ultrasound and sinusitis

Similar effect of therapeutic ultrasound

and antibiotics for acute bacterial rhinosinusitis:
a randomised trial
Eli Høsøien1, Anne B Lund2 and Ottar Vasseljen3
1
Physiotherapy Private Practice, Røros, 2Røros Medical Centre, 3Norwegian University of Science and Technology
Norway

Question: Is there any difference between the effect of therapeutic ultrasound and antibiotics (amoxicillin) on pain and
congestion for acute bacterial rhinosinusitis in the short-term? Is there any difference in patient satisfaction, preferred future
intervention, side-effects and relapses in the long-term? Design: A randomised trial with concealed allocation and intention-
to-treat analysis. Participants: 48 patients (6 dropouts) with clinically diagnosed acute bacterial rhinosinusitis in primary care.
Intervention: The experimental group received 4 consecutive days of ultrasound and the control group received a 10-day
course of antibiotics. Outcome measures: Pain and congestion around the nose and in the forehead and teeth were measured
on a 0–10 numeric rating scale at baseline, Day 4, and Day 21. Satisfaction, preferred future intervention, side-effects, and
relapses were measured one year later. Results: By Day 4, pain around the nose had decreased by 1.5 points out of 10 (95%
CI 0.6 to 2.5) more in the experimental group than the control group. There were no other differences in decrease in pain
and congestion between the groups at Day 4 or 21. At one year follow-up, the experimental group were more likely to prefer
ultrasound than the control group were to prefer antibiotics to manage a future episode (RR 2.75, 95% CI 1.19 to 7.91). There
were no other differences between the groups in terms of satisfaction with intervention, number of side-effects, or number of
relapses. Conclusion: The results of this study suggest that therapeutic ultrasound is a viable alternative to antibiotics in the
management of acute bacterial rhinosinusitis. Trial registration: NCT00934830. [Høsøien E, Lund AB, Vasseljen O (2010)
Similar effect of therapeutic ultrasound and antibiotics for acute bacterial rhinosinusitis: a randomised trial. Journal
of Physiotherapy 56: 27–32]
Key words: Acute sinusitis, Rhinosinusitis, Therapeutic ultrasound, Antibiotics, Intervention, Physiotherapy,
Randomized trial

Introduction for antibiotic prescription for acute bacterial rhinosinusitis

Sinusitis is frequently encountered in general practice. The
one-year incidence in primary care in Norway has been
reported to be approximately 3.5 per 100 adults (Lindbaek
2004). In the United States, sinusitis is reported to affect 1
in 7 adults each year (Rosenfeld et al 2007a), and sinusitis
accounts for 15–21% of antibiotic prescriptions for adult
outpatients (Ahovuo-Saloranta et al 2008). The term
rhinosinusitis is often used and acute rhinosinusitis may be
classified further into acute bacterial rhinosinusitis and viral
rhinosinusitis based on symptoms (Rosenfeld et al 2007a).
Antibiotics should only be prescribed for acute bacterial
rhinosinusitis.
Distinguishing viral from bacterial infections is particularly
challenging in the acute stages (Lindbaek 2007). Diagnosis
in primary care is normally based on symptoms such as
facial and tooth pain, pain when bending forward, and
purulent nasal discharge (Lindbaek and Hjortdahl 2002,
Meltzer et al 2004). Antibiotics have been the most common
intervention for both acute and chronic sinusitis, and when
antibiotics are prescribed for acute bacterial rhinosinusitis,
amoxicillin has been recommended as the first choice
(Rosenfeld et al 2007a). Frequent prescription of antibiotics
can lead to an increase in antibiotic resistance (Ahovuo-
Saloranta et al 2008, Ferech et al 2006) and current
guidelines provide more conservative recommendations
(Ahovuo-Saloranta et al 2008, Lindbaek 2004, Rosenfeld
et al 2007a). Current guidelines recommend delaying
antibiotic prescription for up to 7 days in patients without
severe illness (Rosenfeld et al 2007a). Although reviews
report superior effect of antibiotics compared with placebo
after seven days (Lindbaek 2004, Rosenfeld et al 2007a),
others claim that antibiotics are not justified even after 7–10
days (Williamson et al 2007, Young et al 2008). However,
physicians often feel pressured by patients to prescribe
antibiotics (Varonen et al 2004). Perhaps it is not surprising
therefore that the practice of prescribing antibiotics for
common infectious diseases, including sinusitis, has not
changed significantly in spite of new recommendations and
efforts to implement them (Ferech et al 2006, Neumark et
al 2009, Varonen et al 2007).
The continuing debate and controversy about prescribing
antibiotics for acute bacterial rhinosinusitis, and the
resistance to change in practice, motivate a search for
alternative interventions. Rapid reduction of the symptoms
of acute bacterial rhinosinusitis with therapeutic ultrasound
has been observed in the clinic. However, no controlled
studies have been conducted. The purpose of this study
was to compare the effect of antibiotics with therapeutic
ultrasound in patients with clinically diagnosed acute
bacterial rhinosinusitis in primary care. The specific
research questions were:

Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010 27

Research

1. Is there any difference in the effect of therapeutic

ultrasound and antibiotics (amoxicillin) on pain and
congestion for acute bacterial rhinosinusitis in the
short-term?
2. Is there any difference in patient satisfaction, preferred
future intervention, side-effects and relapses in the
long-term?
If therapeutic ultrasound gives symptomatic relief
equivalent to amoxicillin, it may serve as an alternative to
antibiotics.

Method
Design
A randomised trial was conducted in a primary care setting
in Norway. Participants were recruited from consecutive
patients coming to a single general practice with sinusitis-
like symptoms, where they were diagnosed by a physician
(AL). After collection of baseline measures, the participants
were randomly allocated to an experimental or a control
group. The allocation sequence was computer generated
in random permutated blocks of 6 or 8 and was concealed
from the recruiter and participants in sealed envelopes
which were opened by a nurse. The experimental group
received four consecutive days of ultrasound and the control
Figure 1. Ultrasound was applied to the shaded areas of
the sinuses with small, circular movements continuously
for 10 minutes.
group received a 10-day course of antibiotics. The outcomes
were all self-reports by the participants who along with the
therapists were not blind to group allocation. However, the
person analysing the data was blind to group allocation.
Pain and congestion were measured at baseline, Day 4, and
Day 21. Day 4 coincided with the last day of ultrasound,

Eligible patients with acute bacterial

rhinosinusitis (n = 48)

Measured pain and congestion

Day 1 Randomised (n = 48)
(n = 24) (n = 24)

Lost to follow-up
Experimental group Control group
• pneumonia Lost to follow-up
• 10 min ultrasound • Antibiotics
(n = 1) • none
• 1/day x 4 days • 3/day x 10 days

Measured pain and congestion

Day 4
(n = 23) (n = 24)

Lost to follow-up
Control group Lost to follow-up
• did not return
• Antibiotics • none
questionnaire (n = 2)
• 3/day x 10 days

Measured pain and congestion

Day 21
(n = 21) (n = 24)

Lost to follow-up
Lost to follow-up
• did not return
• none
questionnaire (n = 3)

Measured satisfaction, side-effects, relapses, preferred future intervention

One year
(n = 21) (n = 21)

Figure 2. Design and flow of participants through the trial.

28 Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010

 Høsøien et al: Therapeutic ultrasound and sinusitis

Table 1. Baseline characteristics of participants, therapists and centres.

Characteristic Randomised Lost to follow-up

(n = 48) (n = 6)
Exp Con Exp Con
(n = 24) (n = 24) (n = 3) (n = 3)
Participants
Age (yr), mean (SD) 42 (15) 47 (14) 36 (6) 60 (15)
Gender, n females (%) 17 (71) 17 (71) 3 (100) 2 (67)
Smokers, n (%) 5 (21) 7/23 (30) 1 (33) 2 (67)
Duration of current symptoms, n (%)
> 7 days 20 (83) 17 (71) 2 (67) 3 (100)
> 30 days 4 (17) 2/23 (9) 1 (33) 1 (33)
First episode of sinusitis, n (%) 3 (13) 4 (17) 0 (0) 0 (0)
More than one episode per year, n (%) 7 (29) 9/23 (39) 1 (33) 1 (33)
Previous intervention, n (%)
Antibiotics 21 (88) 20 (87) 3 (100) 3 (100)
Acupuncture 4 (18) 2 (13) 2 (67) 0 (0)
Homeopathy 3 (14) 5 (29) 1 (33) 0 (0)
Nasal spray 20 (87) 15 (79) 3 (100) 2 (67)
Saline nasal irrigation 14 (67) 6 (33) 1 (33) 1 (33)
WBC count (%), mean (range)
Lymphocytes* 25 (14-34) 23 (9–37) 30 (25–33) 19 (9–25)
Granulocytes (neutrophils)** 70 (59-83) 72 (58–88) 65 (60–72) 76 (68–88)
Therapists, n participants (%)
Physiotherapist 24 (100) 0 (0) 3 (100) 0 (0)
General practitioner 0 (0) 24 (100) 0 (0) 3 (100)
Centres, n participants (%)
Physiotherapy private practice 24 (100) 0 (0) 3 (100) 0 (0)
General medical practice 0 (0) 24 (100) 0 (0) 3 (100)
Exp = experimental group (ultrasound), Con = control group (antibiotics), WBC = White blood cell, * = High values suggest viral infection
(normal reference range for adults is 21–43), ** = High values suggest bacterial infection (normal reference range for adults is 47–75)

while Day 21 was 11 days after the end of the course of
antibiotics. Satisfaction with the intervention, preferred
future intervention, side-effects and relapses were measured
one year later.
Participants
Patients with sinusitis-like symptoms were included if they
were over 15 years old and had one of the following: pain
when bending forward, headache, or pain in the teeth.
They must also have had purulent nasal secretion; ‘double
worsening’, ie, worsening of symptoms within 10 days after
initial improvement (Lindbaek and Hjortdahl 2002, Meltzer
et al 2004, Rosenfeld et al 2007a); and a bacterial infection
as indicated by an increased number of granulocytes
(neutrophils) relative to lymphocytes on white blood cell
count. They were excluded if they had had antibiotics or
allergy medication within the last three weeks, were allergic
to antibiotics, or were pregnant.
Intervention
The experimental group received therapeutic ultrasounda at
1.0 W/cm2 in continuous mode for 10 minutes each day for
four days. The transducer was moved constantly in small
circular movements on both sides of the nose and over the
forehead, ie, over the sinuses (Figure 1). The same machine
was used to deliver all ultrasound.
The control group was prescribed antibiotics – 500 mg of
amoxicillin three times a day for 10 days.
Outcome measures
Pain and congestion around the nose and in the forehead
and teeth were measured on a numeric rating scale, where
0 represented no pain/congestion and 10 represented the
worst pain/congestion possible. Pain around the nose was
considered the primary outcome.
Satisfaction with intervention (Y/N), preferred intervention
to manage a future episode (same as allocated/opposite of
allocated), number of side-effects, and number of relapses
were measured using a postal questionnaire.
Data analysis
A change in pain of 2 points on an 11-point numeric rating
scale has been shown to represent a clinically important
difference (Farrar et al 2003). To have 80% power to detect
a between-group difference in pain around the forehead of
2 points on an 11-point numeric rating scale, with alpha at
0.05 and assuming a SD of 2 points, 17 participants were
needed in each group. Considering the uncertainty of the
SD, to increase the likelihood of normally distributed data,
and to account for drop-outs, it was decided to recruit 48
participants.
All participants with follow-up data were analysed
according to their group allocation, ie, using an intention-
to-treat principle. Due to a low drop-out rate of 6% in the
short-term and 12% in the long-term, no attempt was made
to impute missing data. Between-group effects for pain

Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010 29

 Research

and congestion by Days 4 and 21 were reported as mean

Day 21 minus Day 1 (95% CI) difference while satisfaction with intervention,
Exp minus Con preferred future intervention, side-effects and relapses at

(–0.4 to 2.0)

(–0.4 to 2.0)
(–1.7 to 0.7)

(–1.5 to 1.0)
(–2.4 to 1.1)
one year follow-up were reported as relative risk (95% CI).

–0.5

–0.3
–0.6
Difference between groups

0.8

0.8
Results
Flow of participants, therapists, and centres
through the trial
Forty-eight patients with acute bacterial rhinosinusitis
Day 4 minus Day 1

participated in the trial; 24 were allocated to the experimental

Exp minus Con

(–2.5 to–0.6)

(–3.3 to 0.3)
(–1.3 to 0.9)

(–1.9 to 0.4)

(–1.6 to 1.0)
group to receive ultrasound and 24 to the control group to
receive antibiotics. In the short-term, there were 3 dropouts
–0.2

–0.3
–0.7
–1.5

–1.5

so that 94% of data was collected and in the long-term

there were 6 dropouts so that 88% of data was collected.
Figure 2 shows the flow of participants through the trial
and reasons for dropping out. The baseline characteristics
of the participants are presented in Table 1. The groups
Day 21 minus Day 1

were similar in age, gender, smoking habits, duration of

(2.0)

(2.7)

–4.3
–4.4
–3.4

–2.8

–4.7
(1.8)

(1.9)

(1.4)
Con

current symptoms, previous episodes of sinusitis, and

previous intervention except that the experimental group
had more experience with nasal irrigation than the control
Difference within groups

group. Three out of four participants (77%) reported having

(3.2)

(2.3)
–3.9

–3.9
(2.4)
–3.6

–4.6
–3.4
(2.1)

(2.1)
Exp

symptoms for more than 7 days and 41 participants (85%)

Exp = experimental group (ultrasound), Con = control group (antibiotic), shaded row = primary outcome, NRS = numeric rating scale

had had sinusitis previously. White blood cell counts at

Table 2. Mean (SD) of groups, mean (SD) difference within groups, and mean (95% CI) difference between groups.

baseline showed an increase in granulocytes indicative of

bacterial infection.
Day 4 minus Day 1

(3.3)
–2.5

–3.0
–2.8
(1.5)
(1.6)

(1.7)

(1.7)
–1.5
–1.8
Con

One general practitioner in general practice recruited all the

participants and prescribed the antibiotics for the control
group. One physiotherapist in a private physiotherapy
practice delivered all ultrasound interventions (Table 1).
(2.2)

(2.5)
(2.3)
(2.7)
–3.3

–3.5

–3.3
–2.8

–3.0
(1.6)
Exp

Compliance with trial method

All participants in the experimental group completed the
four sessions of ultrasound. Compliance with taking the
(n = 21) (n = 24)

(0.5)
(0.9)
(0.9)

(0.8)
(1.0)

antibiotics was not formally assessed, but there were no

Con

0.2
0.5
0.8

0.5
1.5

reports of interruption. The side-effects reported by the

Day 21

experimental group were nausea/stomach pain (n= 1) and

headache (n = 2), and by the control group were nausea/
(2.0)
(1.8)

(1.3)
(1.6)

(1.7)
Exp

stomach pain (n = 1), fungal infection (n = 1), headache (n =

0.8
0.6
1.2

1.6
1.1

1) and allergy (n = 1).

Effect of intervention
(n = 23) (n = 24)

Group data for pain and congestion in the short-term is

(1.9)

(1.8)

(1.9)
(1.7)
(2.1)
Con

2.3

2.3
3.0
2.4

1.5

presented in Table 2 and satisfaction, preferred future

Groups
Day 4

intervention, side-effects, and relapses in the long-term are

presented in Table 3.
(2.0)
(1.5)

(1.2)
(1.3)

(1.7)
Exp

2.6
1.9

1.0
1.7

1.7

By Day 4, pain and congestion had decreased markedly in

both groups. Pain around the nose had decreased by 1.5
points out of 10 (95% CI 0.6 to 2.5) more in the experimental
group than in the control group. There was also a trend for
(n = 24)

pain in the teeth to decrease more in the experimental group

(2.3)

(2.0)

(3.0)

(1.5)
(1.7)
Con

4.2

5.8
4.9

3.0

5.1

than the control group (mean difference –1.5 points out of

Day 1

10, 95% CI –3.3 to 0.3). There were no other differences in

decrease in pain and congestion between the groups.
(n = 24)

(2.2)

(2.3)

(2.5)
(3.4)

(2.1)
Exp

5.2
4.2

6.3
4.8
5.0

By Day 21, pain and congestion had decreased to low

levels in both groups. However, there were no differences
in decrease in pain and congestion between the groups in
any area.
NRS (0 to 10)

NRS (0 to 10)
Forehead

Forehead
Congestion

At one year follow-up, there were no differences between

Outcome

the groups in terms of satisfaction with intervention (RR

Teeth
Nose

Nose

0.77, 95% CI 0.50 to 1.04), number of side-effects (RR 0.71,

Pain

95% CI 0.20 to 2.56), or number of relapses (RR 1.83, 95%

30 Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010


Table 3. Number of participants (%) in each group* for satisfaction, side-effects, relapse, and preferred future intervention,
and relative risk (95 % CI) between groups at one year.
Outcome
Satisfaction with intervention, n yes (%)
Preferred future intervention, n same as allocated (%)
Side-effects of intervention, n (%)
Relapse, n (%)
* = excluding participants who answered ‘uncertain’, Exp = experimental group (ultrasound), Con = control group (antibiotics)
CI 0.87 to 4.12). However, the experimental group were
more likely to prefer ultrasound than the control group were
to prefer antibiotics for a future episode (RR 2.75, 95% CI
1.19 to 7.91).
Discussion
Despite rapid and clinically significant reductions in facial
pain and congestion in both groups, there was little or no
difference between the effect of therapeutic ultrasound
and antibiotics on pain and congestion in acute bacterial
rhinosinusitis in the short-term, although a trend for a faster
effect for ultrasound was indicated by a larger decrease in
pain around the nose by Day 4. The experimental group
were more likely to prefer ultrasound than the control
group were to prefer antibiotics as an intervention for a
future episode of sinusitis, possibly reflecting a concern for
antibiotic resistance. Few side-effects were reported. Four
days were required to administer the ultrasound as opposed
to 10 days for the course of antibiotics. Delivery of the
ultrasound necessitated four visits to a professional whereas
prescription of the antibiotics only needed one attendance.
The direct costs are probably only marginally different.
There are a number of potential causes of sinusitis (such
as bacteria, viruses, fungi, parasites, allergies) and there is
lack of consensus on diagnostic criteria and classification
(Benninger et al 2003). Distinguishing between viral and
bacterial infection in the clinic is difficult (Hickner et
al 2001, Young et al 2008) and we cannot rule out that
participants with viral infections or other causes of sinusitis
were included in our sample. However, symptom duration
for most participants of above seven days suggests a
bacterial infection (Rosenfeld et al 2007a) and an increase of
granulocytes (neutrophils) rather than lymphocytes favours
a bacterial rather than a viral infection (Table 1). This is,
however, only an indication and not conclusive evidence of
a bacterial origin for acute bacterial rhinosinusitis. Imaging,
laboratory tests or bacterial culture are not recommended for
routine use in primary care (Hickner et al 2001, Rosenfeld
et al 2007a). The primary care clinician is thus left to base
the diagnosis of acute bacterial rhinosinusitis on signs and
symptoms seen in the clinic in line with the procedures
used in this study.
We cannot say whether the rapid reduction of symptoms
observed in both groups reflects an effect of intervention,
placebo, or natural history. Natural history of sinusitis has
Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010
Høsøien et al: Therapeutic ultrasound and sinusitis
Groups Relative risk
between groups
Exp Con Exp relative
(n = 21) (n = 21) to Con
11/18 (61) 18/19 (95) 0.77
(0.50 to 1.04)
12/16 (63) 3/11 (17) 2.75
(1.19 to 7.91)
3/21 (14) 4/20 (20) 0.71
(0.20 to 2.56)
11/21 (52) 6/21 (29) 1.83
(0.87 to 4.12)
not been documented (Gwaltney et al 2004). Information
on the clinical course of untreated sinusitis comes from
patients receiving a placebo in randomised trials for acute
bacterial rhinosinusitis, but there are conflicting results.
Lindbæk et al (1996) reported a significantly faster and
superior effect of amoxicillin compared to placebo within
30 days of symptom onset. However, Rosenfeld et al (2007b)
reported improvement after seven days with and without
antimicrobial intervention and Bucher et al (2003) reported
no advantage of antibiotics over placebo. Since no placebo
group was included in our study, we cannot distinguish
the effect of intervention from placebo. However, there is
some evidence for a superior effect of antibiotic compared
to placebo within a window 7–12 days after initiating
intervention (Haye et al 1998, Rosenfeld et al 2007b).
The mechanism for a beneficial effect of ultrasound is
unknown. Clinically, coloured and purulent discharge is
regularly observed during or immediately after intervention.
Ultrasound works by transporting mechanical energy
through local vibration of tissue particles (Leighton 2007).
Perhaps mechanical vibration detaches purulent matter
from the walls of the sinuses, independent of a viral or
bacterial cause, relieving the pressure and thus easing the
pain. Bartley and Young (2009) point to enhanced bacterial
death from low frequency, high intensity ultrasound in
laboratory settings. When bacteria density reaches a critical
level they organize within ‘slimy’ biofilms for protection,
a potential reason for the ineffectiveness of antibiotics.
Bartley and Young hypothesise that ultrasound may break
down biofilms and that this could either kill or reduce
the viability of bacteria directly or make bacteria more
accessible to antibiotic intervention by increasing cell
membrane permeability.
There is growing concern about resistance and overutilisation
of antibiotics for sinusitis-like symptoms in primary care.
By confirming that there is no difference between the effect
of therapeutic ultrasound compared with antibiotics, except
for a faster benefit in terms of pain around the nose, this
study provides evidence that ultrasound can be used as an
alternative intervention to antibiotics for acute sinusitis.
Furthermore, therapeutic ultrasound had no serious side-
effects. However, it should be kept in mind that both
interventions may have a marginal impact on the natural
course of the disease. The combined effect of ultrasound
and antibiotics for sinusitis should be investigated. n
31
Research
Footnote: aSonopuls 492, Enraf-Nonius BV, PO Box 12080,
3004, The Netherlands.
Ethics: The study was approved by the Regional Committee
for Medical and Health Research Ethics in Trondheim,
Norway (2004). Written consent was obtained from all
participants before the study began.
Competing interests: None declared.
Support: Sør-Trøndelag chapter of the Norwegian
Physiotherapist Association for financial support.
Acknowledgements: Røros Medical Centre for assistance
in patient recruitment.
Correspondence: Dr Ottar Vasseljen, Department of
Public Health and General Practice, Faculty of Medicine,
Norwegian University of Science and Technology, Norway.
Email: ottar.vasseljen@ntnu.no
References
Ahovuo-Saloranta A, Borisenko OV, Kovanen N, Varonen H,
Rautakorpi UM, Williams JW Jr., et al (2008) Antibiotics for
acute maxillary sinusitis. Cochrane Database of Systematic
Reviews April 16: CD000243.
Bartley J, Young D (2009) Ultrasound as a treatment for chronic
rhinosinusitis. Medical Hypotheses 73: 15–17.
Benninger MS, Ferguson BJ, Hadley JA, Hamilos DL, Jacobs
M, Kennedy DW, et al (2003) Adult chronic rhinosinusitis:
definitions, diagnosis, epidemiology, and pathophysiology.
Otolaryngology–Head and Neck Surgery 129: S1–S32.
Bucher HC, Tschudi P, Young J, Periat P, Welge-Luussen
A, Zust H, et al (2003) Effect of amoxicillin-clavulanate
in clinically diagnosed acute rhinosinusitis: a placebo-
controlled, double-blind, randomized trial in general practice.
Archives of Internal Medicine 163: 1793–1798.
Farrar JT, Berlin JA, Strom BL (2003) Clinically important
changes in acute pain outcome measures: a validation study.
Journal of Pain and Symptom Management 25: 406–411.
Ferech M, Coenen S, Malhotra-Kumar S, Dvorakova K,
Hendrickx E, Suetens C, et al (2006) European Surveillance
of Antimicrobial Consumption (ESAC): outpatient antibiotic
use in Europe. Journal of Antimicrobial Chemotherapy 58:
401–407.
Gwaltney JM, Wiesinger BA, Patrie JT (2004) Acute community-
acquired bacterial sinusitis: the value of antimicrobial
treatment and the natural history. Clinical Infectious Disease
38: 227–233.
Haye R, Lingaas E, Hoivik HO, Odegard T (1998) Azithromycin
versus placebo in acute infectious rhinitis with clinical
symptoms but without radiological signs of maxillary sinusitis.
European Journal of Clinical Microbiology and Infectious
Diseases 17: 309–312.
32 Journal of Physiotherapy 2010 Vol. 56 – © Australian Physiotherapy Association 2010
Hickner JM, Bartlett JG, Besser RE, Gonzales R, Hoffman JR,
Sande MA (2001) Principles of appropriate antibiotic use for
acute rhinosinusitis in adults: background. Annals of Internal
Medicine 134: 498–505.
Leighton TG (2007) What is ultrasound? Progress in Biophysics
and Molecular Biology 93: 3–83.
Lindbaek M (2004) Acute sinusitis: guide to selection of
antibacterial therapy. Drugs 64: 805–819.
Lindbaek M (2007) Acute sinusitis––to treat or not to treat?
JAMA 298: 2543–2544.
Lindbaek M, Hjortdahl P (2002) The clinical diagnosis of acute
purulent sinusitis in general practice––a review. British
Journal of General Practice 52: 491–495.
Lindbaek M, Hjortdahl P, Johnsen UL (1996) Randomised,
double blind, placebo controlled trial of penicillin V and
amoxycillin in treatment of acute sinus infections in adults.
British Medical Journal 313: 325–329.
Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF,
Nicklas RA, et al (2004) Rhinosinusitis: establishing definitions
for clinical research and patient care. Otolaryngology–Head
and Neck Surgery 131: S1–S62.
Neumark T, Brudin L, Engstrom S, Molstad S (2009) Trends
in number of consultations and antibiotic prescriptions
for respiratory tract infections between 1999 and 2005 in
primary healthcare in Kalmar County, Southern Sweden.
Scandinavian Journal of Primary Health Care 27: 18–24.
Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D,
Eisenberg S, Ganiats TG, et al (2007a) Clinical practice
guideline: adult sinusitis. Otolaryngology–Head and Neck
Surgery 137: S1–S31.
Rosenfeld RM, Singer M, Jones S (2007b) Systematic review
of antimicrobial therapy in patients with acute rhinosinusitis.
Otolaryngology–Head and Neck Surgery 137: S32–S45.
Varonen H, Rautakorpi UM, Huikko S, Honkanen PO, Klaukka
T, Laippala P, et al P (2004) Management of acute maxillary
sinusitis in Finnish primary care. Results from the nationwide
MIKSTRA study. Scandinavian Journal of Primary Health
Care 22: 122–127.
Varonen H, Rautakorpi UM, Nyberg S, Honkanen PO, Klaukka
T, Palva E, et al (2007) Implementing guidelines on acute
maxillary sinusitis in general practice––a randomized
controlled trial. Family Practice 24: 201–206.
Williamson IG, Rumsby K, Benge S, Moore M, Smith PW,
Cross M, et al (2007) Antibiotics and topical nasal steroid for
treatment of acute maxillary sinusitis: a randomized controlled
trial. The Journal of the American Medical Association 298:
2487–2496.
Young J, De SA, Merenstein D, van Essen GA, Kaiser L,
Varonen H, Williamson I, et al (2008) Antibiotics for adults
with clinically diagnosed acute rhinosinusitis: a meta-analysis
of individual patient data. Lancet 371: 908–914.