The clinician's view of sinusitis

CHESTER T. STAFFORD. MD. Augusta, Georgia

Widespread underdlagnosls and Inadequate treatment of acute sinusitis may be In-

ferred from the prevalence of chronic sinusitis In the United States. Thus the otolaryn-
gologists's role In the management of sinusitis goes beyond treatment of referred pa-
tients. It also Includes the responsibility to educate referring physicians In Improved
diagnostic methods and earlier, more effective forms of therapy. While antral puncture
Isthe sine qua non for determining specific diagnosis, standard radiographs and sound
clinical judgment may offer practical alternatives. Early,aggressive antibiotic therapy
(with ampicillin, amoxlclllln, amoxlclllln-ciavulanate potassium, or appropriate ceph-
alosporlns), plus oral decongestants for symptomatic relief, provides therapeutic ef-
ficacy for acute sinusitis and should be considered the Initial step toward prevention
of chronic sinusitis. (OTOLARYNGOL HEAD NECK SURG 1990;103:870,)

Sinusitis is one of the most frequently overlooked
diseases in clinical practice. Development of sinusitis
in children may often not be considered by busy pri-
mary care practitioners because "all kids have runny
noses." In adults, "a cold" may be presumed to be the
cause of a patient's nasal congestion and associated
symptoms.
Sinusitis is also among the most misunderstood of
the common respiratory diseases. Even when recog-
nized. acute sinusitis is often inappropriately treated-
with antihistamines, which can cause excessive dryness
of mucous membranes and may thicken secretions-
and/ or with abbreviated courses of antibiotics that may
alleviate immediate symptoms, but do not completely
eradicate the infection within the closed sinus cavities.
Inadequate treatment of acute sinusitis appears to often
result in the development of chronic sinusitis, which is
even less well understood and may be even less ade-
quately treated.
Clinical Cluel to SlnulltIl
The signs and symptoms of sinusitis are quite vari-
able and are often nonspecific. Many patients simply
state, "Doctor, I've got a sinus condition." Initial at-
tempts at history-taking may yield no more than symp-
toms suggestive of a common cold, an int1uenza-like
illness. or allergic rhinitis. Many busy physicians tend
to settle for one of these diagnoses without considering
the possibility of sinusitis.
The first firm diagnostic clues to sinusitis may come
from the physical examination, accompanied by de-
tailed history-taking. Facial tenderness and pain accom-
23/0/24795
870
panying nasal congestion and purulent nasal discharge
are common manifestations of acute sinus infection.
Other manifested signs and symptoms may include an-
osmia, pain upon mastication, and halitosis. If an upper
respiratory infection is not immediately evident. a re-
cent history of one can often be elicited. Fever is found
in about 50% of adults and 60% of children. I Headache
is a common feature of sinusitis in adults, but occurs
less frequently in children. Frequent tearing and edema
of the eyelids suggest ethmoid disease; however, in-
flammatory edema can mask orbital cellulitis or abscess
or both, and these should be considered in the differ-
ential diagnosis.
In allergic children. sinusitis should be suspected if
a patient has a sore throat. thick nasal discharge, and
nighttime cough. Increased numbers of polymorpho-
nuclear leukocytes demonstrated on a nasal smear may
heighten the index of suspicion. General symptoms of
headache, facial pain, and fever are often of minimal
value in the diagnosis of sinusitis. Relying on a con-
stellation of symptoms to confirm a diagnosis of si-
nusitis can only result in underdiagnosis because even
the most common symptoms may be absent. Further-
more, elevations of the white blood cell count with shift
of the differential cell count, increased erythrocyte
sedimentation rate, and elevated serum immunoglob-
ulin E levels are of little value in the diagnosis of si-
nusitis.
Acute Versul Chronic Sinulltil
How, then, does one distinguish between acute and
chronic sinusitis? By Kern's definition." acute suppu-
rative sinusitis is any infectious process in a paranasal
sinus lasting from I day to 3 weeks. Accurate descrip-
tion of a patient's sinusitis includes the name and the

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Volume 103 Number 5 Part 2
November 1990
location (either right or left or bilateral) of the affected
sinus. And when all or several of the sinuses-includ-
ing the ethmoid, frontal, maxillary, and sphenoid
Sinuses-are involved, the condition is classified as
pansinusitis.
Kern" further defines subacute sinusitis as a sinus
infection lasting from 3 weeks to 3 months, during
Which period epithelial damage in the sinuses may be
reversible. After 3 months, however, the disease be-
comes chronic and may involve irreversible mucosal
damage, requiring surgery for sinus ventilation and
drainage. Acute sinusitis, in tum, can be superimposed
On chronic disease.
Diagnostic Measure.
Transillumination, imaging techniques, and cytologic
examination are office procedures commonly used to
assist in the diagnosis of sinusitis. While some of
these techniques are useful, all have inherent limita-
tions.
Transillumination. This traditional first step in dem-
onstrating acute sinusitis has lost favor with many phy-
sicians because of its relatively low sensitivity and spec-
ificity, particularly in patients with high bone density
Or with hypoplasia of the sinuses. Nevertheless, trans-
illumination may occasionally provide useful infor-
mation and should remain part of the physical exami-
nation of the patient who is suspected of having
Sinusitis.
Absent transmission of light through the maxillary
or frontal sinuses or both (from a strong point light
source in a dark room) indicates the need for further
evaluation with more sophisticated diagnostic tech-
niques, as has been discussed earlier. Total opacification
suggests that antral puncture will probably yield posi-
tive culture results for the specific organism causing
the sinusitis. I Good visualization of light on both sides
reduces the possibility of obstruction of the sinuses by
thickened fluid or of hypoplasia of the sinuses, which
actually is not an uncommon finding.
Transillumination probably contributes little to the
evaluation by physicians who perform state-of-the-art
fiberoptic rhinoscopy. For physicians who rely on less
sophisticated technology, however, it can indicate the
need for referral for further evaluation.
Imaging technique.. Dr. Zinreich has described
imaging techniques in detail in this symposium. One
of the most useful diagnostic procedures is nasal en-
doscopy, which is becoming a part of the routine ex-
amination of the nose and throat. In our hospital, we
recently invited an expert endoscopist to train our res-
idents, fellows, and other physicians providing primary
care to patients with sinusitis. Routinely, our otolar-
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Clinician's view of sinusitis 871
yngology section is training not only ENT residents,
but our allergy fellows in these techniques.
You have heard that plain radiographs have limited
value, but occasionally a good Waters view, Caldwell
view, and lateral views can yield useful information.
These, of the many views that are available, appear to
be the best radiographic views for most of the primary
care physicians who are attempting to diagnose acute
sinusitis in the office setting. Computed tomography
(CT) is, of course, far superior to ordinary radiography,
but in our hospital a CT scan of the sinuses costs ap-
proximately $400 compared with about $65 for a good
set of sinus x-ray films.
Ultrasonography. Its lower sensitivity and speci-
ficity compared with sinus radiographs has made ultra-
sonography less popular with many physicians. This
technique may be useful, however, for follow-up in
patients who are pregnant, or perhaps under other cir-
cumstances in which radiation exposure is contraindi-
cated. In those situations, ultrasound appears to be ca-
pable of at least detecting fluid or cysts within the sinus
cavities, although it does have a very poor record in
terms of sensitivity and specificity for detecting mucosal
thickening.
Cytologic examination. Nasal swabs of purulent
secretions taken from the ostia under the middle nasal
turbinate, if plated at the patient's bedside, may yield
some important clues to the identity of specific patho-
gens. Normal flora of the nose are believed to grow
faster than sinus pathogens, as has been suggested by
MacKay. 3 This observation may explain why specimens
transported to a central bacteriology laboratory for cul-
ture may yield useless information. Cultures of speci-
mens collected by antral puncture usually provide a
definitive diagnosis, but this is seldom indicated in first-
line primary care.
Allergists generally perform microscopic examina-
tions of nasal smears collected from most patients being
evaluated for upper respiratory disorders. An abundance
of eosinophils is generally considered indicative of an
underlying allergy. However, a preponderance of poly-
morphonuclear cells is found in patients with sinus in-
fections, including those with an underlying respiratory
allergy, as has been demonstrated by Rachelefsky
et al." Nasal cytology, however, should not be consid-
ered an alternative to sinus imaging in the initial eval-
uation of a patient with allergic rhinitis concomitant
with sinusitis. ~
Management Goal.
There is a need recognized by this national educa-
tional program to view sinusitis as a serious, debilitating
disease that warrants precise diagnosis and specific ef-
.72 STAFFORD
otoIaryngolOGY-
Head and Neck surgery

Table 1. Efficacy of selected antimicrobial agents for the common pathogens In acute sinusitis·
Pathogen

Recommended Streplococcu' H"emophllu. MOfOxell" Strepfococcu. St"phylocOCCUl

Antimicrobial doaage: adult ~onJae InftUtmzae c"t"ttholJl pYtJf1fll* aUffIUI
ag'" (chHdren) (30)t (20)t (20)t «5)t «5)t

Ampicillin 500 mg (60 mg/kg) + ± ± + ±

q6h
Amoxicillin 500 mg (60 mg/kg) + ± ± + :t:
q8h
AmoxiciUin- 1 tablet q8h (40 + + + + +
clavulanate po- mg/kg/day in 3
tassium divided doses)
(500/125)
Cefaclor 500 mg q6h (40-60 + + :t: + +
mg/kg q8h)
Cefuroxime axelil 250 mg q12h (125
mg q12h)
Erythromycin and (50 mg/kg erythro- + + + + +
sulfisoxazole mycin, 150
mg/kg sulfisoxa-
zole q6h)
Trimethoprim/sulfa- 1 OS tablet q12h + + + +
melhoxazole (5-20 ml susp
(160/800) q12h)

+. Effective; ±. effective forstrains notproducing ~-Iactamase; -. noteffective.

'Based on available datafrom clinical trials and laboratory studies.
tPercentage of cases of acute sinusitis caused by this pathogen.

fective therapy. Because this disease may have been so
widely overlooked and misunderstood. it is important
for physicians to base treatment on a rational medical
approach. One way to assure effective therapy for pa-
tients with sinusitis is to think about the effect that a
potential therapy may have on the ostiomeatal complex.
Will the therapy control infection and/or relieve ob-
struction? Any effective approach should encompass
these goals.
Management goals for treatment of sinusitis include
the following:
I. Control of infection
2. Reduction of tissue edema
3. Facilitation of drainage
4. Maintenance of patency of the sinus ostia
Antlblotlo Therapy
The primary goal of antibiotic therapy is to control
infection in the closed sinus cavities, but the other ther-
apeutic goals for sinusitis management should also be
kept in mind. Reduction of tissue edema. normalization
of gas exchange. and sinus drainage are necessary for
restoration of normal physiologic function of the si-
nuses. Maintenance of ostial patency is also essential
for clearing infection and preventing chronicity and re-
current acute attacks.
The unreliability of cultures of secretions obtained
by nasal swab dictates empiric antibiotic therapy di-
rected at the most common pathogens. Antral puncture
with aspiration is not usually indicated before the pa-
tient is initially treated with antibiotics. In fact. oto-
laryngologists generally prefer that patients be receiv-
ing antibiotic therapy before antral puncture is per-
formed.
Antibiotic protocol. Drs. Winther and Gwaltney
will present the bacteriology of acute sinus infection
and antibiotic selection in depth. From the clinician's
viewpoint. however. it is essential to have a predeter-
mined rationale for choice of appropriate antimicrobial
agents. The first-line drugs of choice for treatment of
acute sinusitis are ampicillin (500 mg every 6 hours for
14 days), or amoxicillin (500 mg every 8 hours for 14
days), Either should be effective against all likely bac-
teria except Staphylococcus aureus, ~-lactamase­
producing Haemophilus injluenzae and Moraxella ca-
tarrhalis, some anaerobes, and many gram-negative

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VOlume 103 Number 5 Part2
November 1990
Table 2. Sinusitis therapy: Selection based on therapeutic goals
- Antibiotics Amoxicillin/trimethoprim-
sulfamethoxazole
Decongestants Phenylpropanolamine (PPA)
Phenylephrine
Oxymetazoline
Topical steroids Beclomethasone dipropionate
Flunisolide
Mucoevacuants Guaifenesin
Potassium iodide
NOTE, The role of antihistamines has not been established in the treatment of acute sinusitis.
aerobic bacilli. A 2-week course of effective antibiotic
therapy is considered adequate for acute sinusitis, but
3 or 4 weeks-or longer-may be necessary for ad-
equate control of chronic sinus infection.
For patients who are allergic to penicillin, trimeth-
oprim (160 mg)/sulfamethoxazole (800 mg, one tablet
twice daily) (TMP/SMX), is the alternative drug of
choice,6 especially in areas with a high incidence of
~-lactamase-producing H. influenzae, which, along
with pneumococci, are no longer uniformly sensitive
to tetracycline.
When patients fail to respond to ampicillin or amox-
icillin alone, the combination of amoxicillin and cla-
vulanate potassium (500 mg, one tablet every 8 hours)
is likely to be effective. This combination is effective
against S. aureus and ~-lactamase-producing strains
of H. influenzae and M. catarrhalis,
In children, the combination of erythromycin and
SUlfisoxazole is often considered the treatment of
choice, For patients ill enough to require hospitaliza-
tion, a second-generation cephalosporin such as cefu-
roximeshouldbe given. Other cephalosporins may pro-
vide inadequate sinus fluid levels to be effectiveagainst
many common pathogens."
The recommended doses for adults and children, as
well as the reported clinical efficacy of the antibiotics
mentioned in this section, are summarized in Table I.
Aaeulng real coat•. Cost effectiveness must al-
ways be a consideration, and the cost of recommended
antibiotics varies greatly. For example, in our hospital
the wholesale drug cost of 10 days of therapy with
amoxicilJin, ampicillin, or TMP/SMX is less than $6,
compared with about $21 for amoxicillin-clavulanate,
about $27.50 for cefaclor, and $32 for erythromycin.
Physicians,patients, andthird-party payersalike should
understand, however, that even a $100 basic drug cost
for an extended course of an effective antibiotic, along
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Clinician's vfew of sfnusltts 171
AcftOlll
Treats infection
Increases ostial diameter
Facilitates drainage
Reduces inflammation
Reduces mucous secretion
Thins secretions
Aids drainage
with an appropriate decongestant, could save many
times that amount in future examinations and treatment
of chronic sinusitis-not to mention the savings in pain
and inconvenience to our patients.
Decongestant Therap.y
l
There are several goals of decongestant therapy. They
include the reduction of tissue edema, facilitation of
drainage, and maintenance of the patency of the sinus
ostia. In short, decongestants are necessary to meet the
management goals for acute sinusitis. '
Basically, decongestants are available in two forms:
topicaland systemicfor oral administration. Each agent
differs slightly in its mechanisms of action (Table 2).
Topical agent.. Locally active vasoconstrictor
agents provide almost immediatesymptomatic relief by
shrinkingthe inflamed and swollen nasal mucosa, Phe-
nylephrine HCl nasal spray 0.5% and oxymetazoline
HCI nasal spray 0.05% are topical decongestants fre-
quently used in treatment of acute sinusitis in adults.
Phenylephrine spray should be self-administered
with the head in the upright position three or four times
daily for 3 days, and no longer than a week. Oxyme-
tazoline nasal spray should also be administered with
the head erect, two or three sprays in each nostril two
or three times daily, for no longer than 3 to 4 days.
Use of either agent for longer than recommended pe-
riods or with more frequent applications entails a high
risk of rebound vasodilatation.
Oral systemic agent.. When decongestion is
necessary for longer than 3 days, an oral syS#Cmic
agent such as phenylpropanolamine (PPA) or pseudo-
ephedrine is preferred. Oral decongestants are a-
adrenergic agonists that reduce nasal blood flow. The-
oretically, these oral systemic agents have the potential
to act on tissuesdeep in the ostiomeatalcomplex, where
topical agents may not penetrate effectively. Roth

.74 STAFFORD
et al. 8 have demonstrated that systemic decongestants,
like topical agents, improve nasal airway patency. The
efficacy of topical preparations may diminish after sev-
eral days of treatment. This does not occur with the
oral systemic formulations. Melen et al. 9 demonstrated
that PPA increases the functional diameter of the rnax-x-- diography, and pharmacists' records of prescriptions
iIIary ostium. Oral decongestants are also available in
combination with mucoevacuants, such as guaifenesin,
that may help to thin secretions and facilitate drainage. with an increased index of suspicion of the probability
PPA and pseudoephedrine are generally considered
equally safe and effective as oral decongestants. In the
past, some clinicians had expressed concern about PPA
producing or potentiating hypertension or other central
nervous system stimulant responses. However, a num-
ber of controlled clinical studies have supported the
overall' safety of PPA when taken at appropriate doses
in approved dosage form.!":!' Additionally, concerns
over the possibility that PPA might raise blood pressures
significantly were addressed recently by Kroenke
et a1. , 14 who concluded that PPA affects blood pressure
no more than does placebo, in patients with stable hy-
pertension.
Antihistamines have not proved to be effective in the
management of acute sinusitis and are not usually in-
dicated as symptomatic or adjunctive therapy. Because
of their anticholinergic action, classic antihistamines
can cause dryness of mucous membranes and may in-
terfere with the clearance of purulent mucous secre-
tions. Even the newer, nonsedating antihistamines that
have no significant anticholinergic effects have no role
in the treatment of most patients with acute sinusitis.
The appropriate role of antihistamines is for treatment 10. Goodman RP, Wright JT, Barlascini CO. et al. The effect of
of allergic manifestations. Antihistamines are indicated
only when patients manifest profuse, thin, watery rhi-
norrhea, sneezing, and pruritus.
Indloatlons tor Follow-up
If antibiotic therapy initiated on the day of diagnosis
for acute sinusitis has not provided adequate relief of
symptoms after 7 days, a 10- to 14-day course of ther-
apy should be prescribed with another antibiotic with
a broader spectrum of sensitivity." If symptoms persist
after 21 days of antibiotic therapy, referral for more
definitive studies is probably indicated.
Failure of appropriate antibiotic therapy suggests that
the patient's sinusitis has extended beyond the acute
stage. Failure of ampicillin or amoxicillin, followed by
failure of the amoxicillin-clavulanate combination, sug-
gests the possibility of an unusual pathogen or an an-
atomic abnormality. Endoscopic nasal surgery may be
necessary to reopen and maintain the patency of the
sinus ostia and ostiomeatal channels to allow healing.
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OtolaryngologV-
Head and Neck Surgery
CONCLUSION
Early diagnosis and early, aggressive antibiotic ther-
apy may reduce patient suffering and save a sizable
proportion of health care dollars spent on treatment of
sinusitis. From hospital medical records, orders for ra-
filled, we believe that early diagnosis and early effective
therapy are the exceptions rather than the rule. Only
of acute sinusitis can we effectively reverse these
trends.
REFERENCES
1. Gwaltney J Jr. Diagnostic and medical management of acute
sinusitis. Presentation at The American Academy of Allergy and
Immunology. San Antonio. Texas, Feb. 5, 1989.
2. Kern EB. Sinusitis. J Allergy Clin Immunol 1984;73:25-31.
3. MacKay ON. Antibiotic treatment of rhinitis and sinusitis. Am
J Rhinol 1987;1:83-5.
4. Rachelefsky GS. Katz RM. Siegel SC. Chronic sinusitis in chil-
dren with respiratory allergy: the role of antimicrobials. J Allergy
Clin Immunol 1982;69:382-7.
S. Gill FF. Neiburger JB. The role of nasal cytology in the diagnosis
of chronic sinusitis. Am J Rhinology 1989;3:13-5.
6. Hamory BH. Sande MA, Sydnor A Jr, Seale DL, Gwaltney JM
Jr. Etiology and antimicrobial therapy of acute maxillary sinus-
itis. J Infect Dis 1979;139:197-202.
7. Malow JB, Creticos CM. Nonsurgical treatment of sinusitis.
Otolaryngol Clin North Am 1989;22:809-18.
8. Roth RP, Cantekin VI. Bluestone CD. Nasal decongestant ac-
tivity of pseudoephedrine. Ann Otol Rhinol Laryngol 1987;
86:235-41.
9. Melen 1. Friberg B. Andreasson L, et al. Effects of phenylpro-
panolamine on ostial and nasal patency in patients treated for
chronic maxillary sinusitis. Acta Otolaryngol 1986;10I:494-500.
phenylpropanolamine on ambulatory blood pressure. Clin Phar-
macol Ther 1986;40:144-7.
II. Liebson 1, Bigelow G, Griffiths RR, Funderburk FP. Phenyl-
propanolamine: effects on subjective and cardiovascular vari-
ables at recommended over-the-counter dose levels. J Clin Phar-
macol 1987;27:685-93.
12. Silverman HI. Kreger BE, Lewis GP. Lack of side effects from
orally administered phenylpropanolamine and phenylpropanol-
amine with caffeine: II controlled three phase study. Curr Ther
Res 1980;28:185-94.
13. Blackburn GL, Morgan JP, Lavin PT, Noble R, Funderburk FR,
lstfan N. Determinants of the pressor effect of phenylpropanol-
amine in healthy subjects. JAMA 1989;261:3267-72.
14. Kroenke K. Omori OM, Simmons 10, Wood DR, Meier NJ.
The safely of phenylpropanolamine in patients with stable hy-
pertension. Ann Intern Med 1989;111:1043-4.
15. Reilly J5, Kenna MA. Managing the spectrum of childhood
sinusitis. J Respir Dis 1987;8:75-85.
DISCUSSION
Dr. Kennedy: In regard to your citation of Dr. Kern' s
classification of sinus disease, I believe his position was
Volume 103 Number 5 Part 2
November 1990
that mucosal disease in chronic sinusitis becomes ir-
reversible after 3 months. That does not seem to be the
case; with good ventilation and drainage, mucosal dam-
age may reverse over time.
Dr. Stafford: We now have better methods of visu-
alizing the mucosa than Dr. Kern had.
Dr. Kennedy: Exactly. And I support your defense
of transillumination as a useful diagnostic tool. Trans-
illumination provides similar information to ultraso-
nography. Ultrasonography is difficult to do and has
highly variable results, and provides no information
about the ethmoid sinus.
Although failure of a sinus to transilluminate does
not confirm sinusitis, it still provides useful informa-
tion; opacity could occur because of a small hypoplastic
sinus. If a sinus does illuminate, symptoms could be
the result of a cyst within the sinus or minor mucosal
thickening. This is useful information.
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Clinician's view of sinusitis .71
Now, with regard to the use of topical or systemic
corticosteroids as second-line therapy, will you discuss
your approach to both acute and chronic sinusitis?
Dr. Stafford: When a patient with acute sinusitis has
a closed-off cavity, we prefer to use topical vasocon-
strictor drugs long enough to open the ostia. We feel
that antiinflammatory topical corticosteroids then help
maintain patency.
Dr. Druce: Though many physicians are concerned
that corticosteroids might exacerbate sinus infection,
this does not seem to be the case when antibiotics are
being administered.
However, I know of no reason to use systemic cor-
ticosteroids in therapy for acute or chronic sinusitis,
unless the patient also has a systemic condition that
warrants their use.