Management


  • options for initial management for uncomplicated 
acute bacterial sinusitis include either

    • Initial antibiotic therapy

    • 3 additional days of observation if
      • symptoms (nasal discharge and/or cough) for 
>10 days without improvement

      • no co-existing illness

      • follow-up for and begin antibiotics if 
symptoms worsen at any time or fail to 
improve within 3 days 

  • Antibiotic therapy
    • Indications
      • severe symptoms

      • worsening symptoms after initial improvement

      • orbital or cranial complications

      • infectious complications (co-existing acute otitis media, pneumonia, adenitis, or streptococcal pharyngitis)

    • Choices
      • amoxicillin
        • 45 mg/kg/day in 2 divided doses for uncomplicated cases 

        • 80-90 mg/kg/day (maximum 2 g/dose) if > 10% local prevalence of resistant Streptococcus pneumoniae
      • amoxicillin 80 to 90 mg/kg/day plus clavulanate 6.4 mg/kg/day in 2 divided doses for
        • age < 2 years

        • moderate-to-severe illness

        • children attending day care

        • antibiotic exposure within prior 4 weeks

      • Options if penicillin-allergic
        • cefdinir 14 mg/kg/day in 1-2 doses (maximum 600 mg/day)

        • cefuroxime 15 mg/kg twice daily (maximum 500 mg/dose)

        • cefpodoxime 5 mg/kg every 12 hours (maximum 200 mg/dose)

        • cefixime 8 mg/kg/day orally in 2 divided doses plus clindamycin 30-40 mg/kg/day orally in 
3 divided doses

        • levofloxacin 10 to 20 mg/kg orally once or 
twice daily

        • ceftriaxone 50 mg/kg intramuscularly or IV 
in single dose if unable to use oral medication (followed by oral antibiotic therapy upon 
clinical improvement)

  • IV antibiotic options for severe illness requiring hospitalization 

    • ampicillin-sulbactam 200-400 mg/kg/day IV in 
4 divided doses

    • levofloxacin 10-20 mg/kg IV once daily or in 
2 divided doses

    • ceftriaxone 50 mg/kg/day IV in 2 divided doses

    • cefotaxime 100-200 mg/kg/day IV in 4 divided doses

  • If symptoms worsen or fail to improve within 72 hours, change therapy from

    • observation to amoxicillin

    • amoxicillin to high-dose amoxicillin-clavulanate

    • high-dose amoxicillin-clavulanate to either
      • levofloxacin or 

      • cefixime plus either clindamycin or linezolid

    • optimal duration of antibiotic therapy may be either
      • 10 to 14 days 

      • 7 days after resolution of symptoms

  • Symptomatic treatment may be considered with 

    • intranasal corticosteroids (especially if allergic 
rhinitis) 

    • normal saline nasal irrigation 

  • treatments not recommended as adjunctive therapy 
include

    • topical or oral decongestants 

    • antihistamines (may worsen congestion by drying nasal mucosa)

  • no recommendations regarding mucolytics

  • functional endoscopic sinus surgery (FESS) reserved for recurrent acute or chronic infective sinusitis refractory to medical treatment

  • referral

    • consider referral to otolaryngologist if acutely ill with toxic appearance (for consideration of maxillary sinus aspiration to guide antimicrobial therapy)

    • refer to a specialist (such as otolaryngologist, infectious disease specialist, or allergist) if
      • seriously ill and immunocompromised 

      • continued clinical deterioration despite extended courses of antimicrobial therapy

      • recurrent bouts of acute rhinosinusitis with interval clearing


Prognosis


  • most cases resolve without treatment

  • acute sinusitis symptoms may last up to 30 days in 
children treated with antibiotics, but majority resolve in <19 days 


Complications 


  • orbital inflammation and infection

  • intracranial complications 

    • most commonly found in males with frontal sinusitis

    • may include
      • venous sinus thrombosis

      • bacterial meningitis

      • brain abscess 

      • subdural or epidural empyema

  • osteomyelitis and/or Pott puffy tumor (osteomyelitis of frontal bone)


Prevention


  • practices reported to prevent recurrence or chronicity include

    • completing full course of recommended treatment 

    • limiting exposure to crowded areas (such as day care) and environmental factors (such as cigarette smoke)

    • daily saline washes to clear secretions and enhance mucociliary transport

    • laparoscopic sinus surgery

    • adenoidectomy

    • treating underlying risk factors


Alan Drabkin, MD, is a senior clinical writer for DynaMed, a database of comprehensive updated summaries covering more than 3,200 clinical topics, and assistant clinical professor of population medicine at Harvard medical School