Rhinosinusitis, Acute Bacterial

Key Features

Essentials of Diagnosis

• Upper respiratory infection symptoms are present 10 or more days beyond onset, or symptoms worsen within 10 days after an initial period of improvement

• Symptoms may include nasal congestion, nasal drainage, postnasal drainage, facial pain, headache, and fever

• Symptoms resolve completely within 30 days

General Considerations

• Almost always preceded by a cold

• Other predisposing conditions include allergies and trauma

• Maxillary and ethmoid sinuses are most commonly involved

• Viral upper respiratory infections may cause sinus mucosal injury and swelling, resulting in sinus outflow obstruction, loss of ciliary activity, and mucous hypersecretion

• Common causative bacterial pathogens

  • Steptococcus pneumoniae

  • Haemophilus influenzae (nontypeable)

  • Moraxella catarrhalis

  • β-hemolytic streptococci

Clinical Findings

• Onset may be gradual or sudden

• Nasal drainage, nasal congestion

• Facial pressure or pain

• Postnasal drainage

• Hyposmia or anosmia

• Fever, cough, fatigue

• Maxillary dental pain

• Ear pressure or fullness

Diagnosis

• In complicated or immunocompromised patients, sinus aspiration and culture by an otolaryngologist should be considered for diagnostic purposes and to facilitate culture-directed antibiotic therapy

• Gram stain or culture of nasal discharge does not necessarily correlate with cultures of sinus aspirates

• If the patient is hospitalized because of rhinosinusitis-related complications, blood cultures should also be obtained

Treatment

• For children with cold symptoms that are not improving by 10 days, observation for up to 3 more days or antibiotic therapy may be chosen, depending on individual circumstances, such as ability to follow up and treat with antibiotics if needed

• For children with uncomplicated infection who have worsening or severe symptoms (fever of at least 39°C and purulent nasal drainage for at least 3 consecutive days), antibiotic therapy is recommended

  • First-line antibiotic therapy should be amoxicillin or amoxicillin-clavulanate

  • Cefuroxime, cefpodoxime, and cefdinir are recommended for patients with a non–type I hypersensitivity to penicillin

  • Other agents that may be used, particularly in more severe cases where resistant S pneumoniae and H influenzae are suspected, include clindamycin, linezolid, and quinolone

  • Due to high resistance of S pneumoniae and H influenzae, the use of trimethoprim-sulfamethoxazole and azithromycin is not advised

• Duration of therapy: 7 days after symptoms have resolved

• Second-line therapies

  • Should be initiated when there is no improvement after 48–72 hours of antibiotic therapy

  • If the patient is already taking amoxicillin–clavulanate or a cephalosporin, intravenous antibiotic therapy should be considered

• For patients who have evidence of invasive infection or CNS complications,

  • Intravenous therapy with nafcillin or clindamycin plus a third-generation cephalosporin such as cefotaxime should be initiated until culture results become available

Outcome

Complications

• Complications occur when infection spreads to adjacent structures, such as the eye and the brain

• Orbital complications are the most common, arising from the ethmoid sinuses

• Most common complication of frontal sinusitis is osteitis of the frontal bone, also known ...