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Acute Sinusitis: Practice Essentials, Background, Anatomy

AcuteSinusitis
Author:ItzhakBrook,MD,MScChiefEditor:MichaelStuartBronze,MDmore...

Updated:Mar22,2016

PracticeEssentials
Sinusitisischaracterizedbyinflammationoftheliningoftheparanasalsinuses.
Becausethenasalmucosaissimultaneouslyinvolvedandbecausesinusitisrarely
occurswithoutconcurrentrhinitis,rhinosinusitisisnowthepreferredtermforthis
condition.Rhinosinusitisaffectsanestimated35millionpeopleperyearinthe
UnitedStatesandaccountsforcloseto16millionofficevisitsperyear.[1]Seethe
imagebelow.

Airfluidlevel(arrow)inthemaxillarysinussuggestssinusitis.

Signsandsymptoms
Clinicalfindingsinacutesinusitismayincludethefollowing:
Painovercheekandradiatingtofrontalregionorteeth,increasingwith
strainingorbendingdown
Rednessofnose,cheeks,oreyelids
Tendernesstopressureoverthefloorofthefrontalsinusimmediatelyabove
theinnercanthus
Referredpaintothevertex,temple,orocciput
Postnasaldischarge
Ablockednose
Persistentcoughingorpharyngealirritation
Facialpain
Hyposmia
Symptomsofacutebacterialrhinosinusitisincludethefollowing:
Facialpainorpressure(especiallyunilateral)
Hyposmia/anosmia
Nasalcongestion
Nasaldrainage
Postnasaldrip
Fever
Cough
Fatigue
Maxillarydentalpain
Earfullness/pressure
Thediagnosisofacutebacterialsinusitisshouldbeentertainedundereitherofthe
followingcircumstances:
Presenceofsymptomsorsignsofacuterhinosinusitis10daysormore
beyondtheonsetofupperrespiratorysymptoms
Worseningofsymptomsorsignsofacuterhinosinusitiswithin10daysafter
aninitialimprovement
Thefollowingsignsmaybenotedonphysicalexamination:
Purulentnasalsecretions
Purulentposteriorpharyngealsecretions
Mucosalerythema
Periorbitaledema
Tendernessoverlyingsinuses
Airfluidlevelsontransilluminationofthesinuses(60%reproducibilityratefor
assessingmaxillarysinusdisease)

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Facialerythema
SeeClinicalPresentationformoredetail.

Diagnosis
Acutesinusitisisaclinicaldiagnosis.However,theevaluationmightincludethe
followinglaboratorytests[2]:
Nasalcytology
Nasalsinusbiopsy
Testsforimmunodeficiency,cysticfibrosis,orciliarydysfunction
Nasalcytologyexaminationsmaybeusefultoelucidatethefollowingentities:
Allergicrhinitis[3]
Eosinophilia
Nasalpolyposis
Aspirinsensitivity
Testsforimmunodeficiencyareindicatedifhistoryfindingsindicaterecurrent
infectiontheyincludethefollowing:
Immunoglobulinstudies
HIVserology
Culturesarenotroutinelyobtainedintheevaluationofacutesinusitisbutshouldbe
obtainedinthefollowingcases:
Patientsinintensivecareorwithimmunocompromise
Childrennotrespondingtoappropriatemedicalmanagement
Patientswithcomplicationsofsinusitis
Inadults,culturesaredirectedatthemiddlemeatus.Aspirationofthesinusbydirect
antralpunctureistheonlyaccuratewaytoobtainaculturebutisreservedfor
patientswithanyofthefollowing:
Lifethreateningillness
Immunocompromise
Diseaseunresponsivetotherapy
Computedtomographyscanningisthepreferredimagingmethodforrhinosinusitis.
AcompletesinusCTscanwithfrontalandcoronalplanesisusedifanalternative
diagnosis(eg,tumors)mustbeexcluded.CTscanningischaracteristicinallergic
fungalsinusitisandisoneofthemajorcriteriafordiagnosis.
SeeWorkupformoredetail.

Management
Treatmentofacutesinusitisconsistsofprovidingadequatedrainageoftheinvolved
sinusandappropriatesystemictreatmentofthelikelybacterialpathogens.Drainage
canbeachievedsurgicallywithsinuspunctureandirrigationtechniques.Optionsfor
medicaldrainageareasfollows:
Oralalphaadrenergicvasoconstrictors(eg,pseudoephedrine,and
phenylephrine)for1014days
Topicalvasoconstrictors(eg,oxymetazolinehydrochloride)foramaximumof
35days
Antibiotictreatmentisusuallygivenfor14days.Usualfirstlinetherapyiswithoneof
thefollowing:
Amoxicillin,atdoubletheusualdose(8090mg/kg/d),especiallyinareas
withknownStreptococcuspneumoniaeresistance
Clarithromycin
Azithromycin
Secondlineantibioticshouldbeconsideredforpatientswithanyofthefollowing:
Residenceincommunitieswithahighincidenceofresistantorganisms
Failuretorespondwithin4872hoursofcommencementoftherapy
Persistenceofsymptomsbeyond1014days
Themostcommonlyusedsecondlinetherapiesincludethefollowing:
Amoxicillinclavulanate
Secondorthirdgenerationcephalosporins(eg,cefuroxime,cefpodoxime,
cefdinir)
Macrolides(ie,clarithromycin)
Fluoroquinolones(eg,ciprofloxacin,levofloxacin,moxifloxacin)
Clindamycin
Antibioticselectionwithrespecttopreviousantibioticuseanddiseaseseverityisas
follows:
Adultswithmilddiseasewhohavenotreceivedantibiotics:
Amoxicillin/clavulanate,amoxicillin(1.53.5g/day),cefpodoximeproxetil,or
cefuroximeisrecommendedasinitialtherapy.
Adultswithmilddiseasewhohavehadantibioticsintheprevious46weeks
andadultswithmoderatedisease:Amoxicillin/clavulanate,amoxicillin(33.5
g),cefpodoximeproxetil,orcefiximeisrecommended.
Adultswithmoderatediseasewhohavereceivedantibioticsintheprevious
46weeks:Amoxicillin/clavulanate,levofloxacin,moxifloxacin,ordoxycycline
isrecommended.
Symptomaticoradjunctivetherapiesmayincludethefollowing:

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Humidification/vaporizer
Warmcompresses
Adequatehydration
Smokingcessation
Balancednutrition
Nonnarcoticanalgesia
SeeTreatmentandMedicationformoredetail.

Background
Sinusitisischaracterizedbyinflammationoftheliningoftheparanasalsinuses.
Becausethenasalmucosaissimultaneouslyinvolvedandbecausesinusitisrarely
occurswithoutconcurrentrhinitis,rhinosinusitisisnowthepreferredtermforthis
condition.[4,5]
Rhinosinusitismaybefurtherclassifiedaccordingtotheanatomicsite(maxillary,
ethmoidal,frontal,sphenoidal),pathogenicorganism(viral,bacterial,fungal),
presenceofcomplication(orbital,intracranial),andassociatedfactors(nasal
polyposis,immunosuppression,anatomicvariants).(SeeAnatomy,Pathophysiology,
andEtiology.)
Acutesinusitisisaclinicaldiagnosisthus,anunderstandingofitspresentationisof
paramountimportanceindifferentiatingthisentityfromallergicorvasomotorrhinitis
andcommonupperrespiratoryinfections.Nospecificclinicalsymptomorsignis
sensitiveorspecificforacutesinusitis,sotheoverallclinicalimpressionshouldbe
usedtoguidemanagement.(SeeClinicalPresentation.)
Theprimarygoalsofmanagementofacutesinusitisaretoeradicatetheinfection,
decreasetheseverityanddurationofsymptoms,andpreventcomplications.(See
TreatmentandManagement.)Mostpatientswithacutesinusitisaretreatedinthe
primarycaresetting.Furtherevaluationbyanotolaryngologistisrecommendedin
anyofthefollowingcases:
Whencontinueddeteriorationoccurswithappropriateantibiotictherapy
Whenepisodesofsinusitisrecur
Whensymptomspersistafter2coursesofantibiotictherapy
Whencomorbidimmunodeficiency,nosocomialinfection,orcomplicationsof
sinusitisarepresent

Definitionofacuterhinosinusitis
Manyclassifications,bothclinicalandradiological,havebeenproposedinthe
literaturetodefineacutesinusitis.Althoughnoconsensusontheprecisedefinition
currentlyexistssubacutesinusitisrepresentsatemporalprogressionofsymptoms
for412weeks.Recurrentacutesinusitisisdiagnosedwhen24episodesof
infectionoccurperyearwithatleast8weeksbetweenepisodesand,asinacute
sinusitis,thesinusmucosacompletelynormalizesbetweenattacks.Chronicsinusitis
isthepersistenceofinsidioussymptomatologybeyond12weeks,withorwithout
acuteexacerbations.[6]

Anatomy
Toproperlydiagnoseandtreatinfectiousdisordersoftheparanasalsinuses,the
clinicianshouldhaveknowledgeofthedevelopmentalmilestones.Thedevelopment
oftheparanasalsinusesbeginsinthethirdweekofgestationandcontinuesuntil
earlyadulthood.

Developmentofparanasalsinuses
Duringthethirdweekofembryonicdevelopment,proliferationandmedialmigration
ofectodermalcellsformthenotochord.Afterthehearttubeandpericardiumhave
rotatedfromthecranialpositiontolieanteriorly,thenotochord,whichisinitiallyin
thecaudalregionoftheembryonicdisc,rotatestolieposteriortotheprimitive
foregut.Theparaxiallayerofmesenchyme,whichliesadjacenttothenotochord,
differentiatesintothesomiteridges,intermediatecellmass,andlateralplate
mesoderm.Fromthesemesodermalstructures,thebranchialarchesdevelop,the
firstofwhichgivesrisetointernalnasalstructures.
Theparanasalsinusesdevelopinconjunctionwiththepalatefromchangesinthe
lateralwallofthenasalcavity.At40weeks'gestation,2horizontalgroovesdevelop
inthemesenchymeofthelateralwallofthenasalcavity.Proliferationof
maxilloturbinatemesenchymebetweenthesegroovesresultsinanoutpouchingof
tissuemediallyintothenasallumen.Thisoutpouchingistheprecursorofthemiddle
andinferiormeatusaswellastheinferiorturbinate.Ethmoidoturbinatefoldsdevelop
superiorlytogiverisetothemiddleandsuperiorturbinates.Oncetheturbinate
structuresareestablished,sinusdevelopmentbeginsandcontinuesuntilearlyadult
life.
Thesinusesopenintothenoseviasmallopeningscalledostia.[5]Themaxillaryand
ethmoidsinusesformat34months'gestation.Thus,aninfantisbornwith34
ethmoidcellsandtinyteardropshapedmaxillarysinuses.Bytheteenageyears,
eachmaxillarysinusprogressivelyenlargestoanadultcapacityof15mL.Inhealthy
individuals,theethmoidsinusesincreaseinnumberto1820,andeachdrainsbyan
individualostiumthatis12mmindiameter.
Thefrontalsinusdevelopsfromananteriorethmoidcellandmovestoits
supraorbitalpositionwhentheindividualisaged67years.Frontalsinusesmay
begintodevelopatthisagebutusuallydonotappearradiologicallyuntilthe
individualisagedapproximately12years.Themaxillary,anteriorethmoid,and
frontalsinusesdrainintothemiddlemeatustheposteriorethmoidandsphenoid
sinusesdrainintothesuperiormeatus(seetheimagebelow).

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Sagittalsectionofthelateralnasalwalldemonstratingopeningsofparanasalsinuses.
Conchaehavebeencuttodepictdetailsofmeatalstructures.

Structureandfunctionofparanasalsinuses
Theparanasalsinusesareairfilledbonycavitiesthatextendfromtheskullbaseto
thealveolarprocessandlaterallyfromthenasalcavitytotheinferomedialaspectof
theorbitandthezygoma.Thesinuscavitiesarelinedwithpseudostratified,ciliated,
columnarepitheliumthatiscontiguous,viaostia,withtheliningofthenasalcavity.
Thisepitheliumcontainsanumberofmucusproducinggobletcells.Thesegoblet
cellsintheepitheliumandthesubmucosalseromucousglandscontributetothe
airwaysurfaceliquid,[7]whichis5100mthickandcoverstheepithelium.
Anteriorandposteriorethmoidsinusesarecomposedofmultipleaircellsseparated
bythinbonypartitions.Eachcellisdrainedbyanindependentostiumthatmeasures
only12mmindiameter.Thesesmallopeningsarereadilycloggedbysecretionsor
areoccludedbyswellingofthenasalmucosa.Thesphenoidsinusessitimmediately
anteriortothepituitaryfossaandjustbehindtheposteriorethmoid.
Thearterialsupplyoftheparanasalsinusesisfrombranchesoftheinternaland
externalcarotidarteries,whilethevenousandlymphaticdrainagepathisthrough
thesinusostiaintothenasalcavityplexus.Inaddition,venousdrainageoccurs
throughvalvelessvesselscorrespondingtothearterialsupply.
Allsinusostiadrainintothenaresatlocationsbeneaththemiddleandsuperior
turbinates.Theposteriorethmoidandsphenoidsinusesdrainintothesuperior
meatusbelowthesuperiorturbinate.Theostiaofthemaxillary,anteriorethmoid,
andfrontalsinusesshareacommonsiteofdrainagewithinthemiddlemeatus.This
regioniscalledtheostiomeatalcomplexandcanbevisualizedbycoronalCTscan.
Thecommondrainagepathwayofthefrontal,maxillary,andanteriorethmoid
sinuseswithinthemiddlemeatusallowsrelativelylocalizedmucosalinfection
processestopromoteinfectioninallthesesinuses.
Thesuccessfulmaintenanceofsinusdrainagerepresentsacomplicatedinteraction
betweenciliaryaction,mucusviscosity,sizeofsinusostia,andorientationofbody
structures.Ciliarybeatattherateof815Hziscontinuouslymovedbytheciliaata
speedof6mm/min.Theciliaryactioncanbeaffectedduetolocalfactors,suchas
infectionandlocalhypoxiathatisassociatedwithcompleteocclusionofsinusostia.
Thesinusmucosahaslesssecretoryandvasomotorfunctionthanthenasalcavity
does.Ciliaareconcentratednearandbeattowardthenaturalsinusostia.Blockage
oftheostiumresultsinstasisofmucousflow,whichcanleadtodevelopmentof
disease.
Theexactfunctionoftheparanasalsinusesisnotwellunderstood.Thepossible
rolesofthesinusesmayincludereducingtheweightoftheskulldampening
pressurehumidifyingandwarminginspiredairabsorbingheatandinsulatingthe
brainaidinginsoundresonanceprovidingmechanicalrigidityandincreasingthe
olfactorysurfacearea.

Pathophysiology
Thesinusesarenormallysterileunderphysiologicconditions.Secretionsproduced
inthesinusesflowbyciliaryactionthroughtheostiaanddrainintothenasalcavity.
Inthehealthyindividual,flowofsinussecretionsisalwaysunidirectional(ie,toward
theostia),whichpreventsbackcontaminationofthesinuses.Inmostindividuals,the
maxillarysinushasasingleostium(2.5mmindiameter,5mm2incrosssectional
area)servingastheonlyoutflowtractfordrainage.Thisslenderconduitsitshighon
themedialwallofthesinuscavityinanondependentposition.Mostlikely,the
edemaofthemucosaatthese1to3mmopeningsbecomescongestedbysome
means(eg,allergy,viruses,chemicalirritation)thatcausesobstructionoftheoutflow
tractstasisofsecretionswithnegativepressure,leadingtoinfectionbybacteria.
Retainedmucus,wheninfected,leadstosinusitis.Anothermechanismhypothesizes
thatbecausethesinusesarecontinuouswiththenasalcavity,colonizedbacteriain
thenasopharynxmaycontaminatetheotherwisesterilesinuses.Thesebacteriaare
usuallyremovedbymucociliaryclearancethus,ifmucociliaryclearanceisaltered,
bacteriamaybeinoculatedandinfectionmayoccur,leadingtosinusitis.[8,5]
Dataareavailablethatsupportthefactthathealthysinusesarecolonized.The
bacterialfloraofnoninflamedsinuseswerestudiedforaerobicandanaerobic
bacteriain12adultswhounderwentcorrectivesurgeryforseptaldeviation.[9]
Organismswererecoveredfromallaspirates,withanaverageof4isolatespersinus
aspirate.ThepredominantanaerobicisolateswerePrevotella,Porphyromonas,
FusobacteriumandPeptostreptococcusspecies.Themostcommonaerobic
bacteriawereSpyogenes,Saureus,Spneumonia,andHinfluenzae.Inanother
study,specimenswereprocessedforaerobicbacteriaonly,andStaphylococcus
speciesandalphahemolyticstreptococciwereisolated.[10]Organismswere
recoveredin20%ofmaxillarysinusesofpatientswhounderwentsurgical
repositioningofthemaxilla.
Incontrast,anotherreportofaspiratesof12volunteerswithnosinusdisease
showednobacterialgrowth.[11]Jiangetalevaluatedthebacteriologyofmaxillary

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sinuseswithnormalendoscopicfindings.[12]Organismswererecoveredfrom14
(47%)of30swabspecimensand7(41%)of17ofmucosalspecimens.Gordtsetal
reportedthemicrobiologyofthemiddlemeatusinnormaladultsandchildren.[13]
Thisstudynotedin52patientsthat75%hadbacterialisolatespresent,most
commonlycoagulasenegativestaphylococci(CNS)(35%),Corynebacterium
species(23%),andSaureus(8%)inadults.Lownumbersofthesespecieswere
present.Inchildren,themostcommonorganismswereHinfluenzae(40%),M
catarrhalis(34%),andSpneumoniae(50%),amarkeddifferencefromfindingsin
adults.NonhemolyticstreptococciandMoraxellaspecieswereabsentinadults.
Thepathophysiologyofrhinosinusitisisrelatedto3factors:
Obstructionofsinusdrainagepathways(sinusostia)
Ciliaryimpairment
Alteredmucusquantityandquality

Obstructionofsinusdrainage
Obstructionofthenaturalsinusostiapreventsnormalmucusdrainage.Theostia
canbeblockedbymucosalswellingorlocalcauses(eg,trauma,rhinitis),aswellas
bycertaininflammationassociatedsystemicdisordersandimmunedisorders.
Systemicdiseasesthatresultindecreasedmucociliaryclearance,includingcystic
fibrosis,respiratoryallergies,andprimaryciliarydyskinesia(Kartagenersyndrome),
canbepredisposingfactorsforacutesinusitisinrarecases.Patientswith
immunodeficiencies(eg,agammaglobulinemia,combinedvariable
immunodeficiency,andimmunodeficiencywithreducedimmunoglobulinG[IgG]
andimmunoglobulinA[IgA]bearingcells)arealsoatincreasedriskofdeveloping
acutesinusitis.
Mechanicalobstructionbecauseofnasalpolyps,foreignbodies,deviatedsepta,or
tumorscanalsoleadtoostialblockage.Inparticular,anatomicalvariationsthat
narrowtheostiomeatalcomplex,includingseptaldeviation,paradoxicalmiddle
turbinates,andHallercells,makethisareamoresensitivetoobstructionfrom
mucosalinflammation.Usually,themarginsoftheedematousmucosahavea
scallopedappearance,butinseverecases,mucusmaycompletelyfillasinus,
makingitdifficulttodistinguishanallergicprocessfrominfectioussinusitis.
Characteristically,alloftheparanasalsinusesareaffectedandtheadjacentnasal
turbinatesareswollen.Airfluidlevelsandboneerosionarenotfeaturesof
uncomplicatedallergicsinusitishowever,swollenmucosainapoorlydrainingsinus
ismoresusceptibletosecondarybacterialinfection.
Hypoxiawithintheobstructedsinusisthoughttocauseciliarydysfunctionand
alterationsinmucusproduction,furtherimpairingthenormalmechanismformucus
clearance.

Impairedciliaryfunction
Contrarytoearliermodelsofsinusphysiology,thedrainagepatternsofthe
paranasalsinusesdependnotongravitybutonthemucociliarytransport
mechanism.Themetachronouscoordinationoftheciliatedcolumnarepithelialcells
propelsthesinuscontentstowardthenaturalsinusostia.Anydisruptionoftheciliary
functionresultsinfluidaccumulationwithinthesinus.Poorciliaryfunctioncanresult
fromthelossofciliatedepithelialcellshighairflowviral,bacterial,orenvironmental
ciliotoxinsinflammatorymediatorscontactbetween2mucosalsurfacesscarsand
Kartagenersyndrome.[14]
Ciliaryactioncanbeaffectedbygeneticfactors,suchasKartagenersyndrome.
Kartagenersyndromeisassociatedwithimmobileciliaandhencetheretentionof
secretionsandpredispositiontosinusinfection.Ciliaryfunctionisalsoreducedin
thepresenceoflowpH,anoxia,cigarettesmoke,chemicaltoxins,dehydration,and
drugs(eg,anticholinergicmedicationsandantihistamines).
Exposuretobacterialtoxinscanalsoreduceciliaryfunction.Approximately10%of
casesofacutesinusitisresultfromdirectinoculationofthesinuswithalarge
amountofbacteria.Dentalabscessesorproceduresthatresultincommunication
betweentheoralcavityandsinuscanproducesinusitisbythismechanism.
Additionally,ciliaryactioncanbeaffectedaftercertainviralinfections.
Severalotherfactorscanleadtoimpairedciliaryfunction.Coldairissaidtostunthe
ciliaryepithelium,leadingtoimpairedciliarymovementandretentionofsecretionsin
thesinuscavities.Onthecontrary,inhalingdryairdesiccatesthesinusmucous
coat,leadingtoreducedsecretions.Anymasslesionwiththenasalairpassages
andsinuses,suchaspolyps,foreignbodies,tumors,andmucosalswellingfrom
rhinitis,mayblocktheostiaandpredisposetoretainedsecretionsandsubsequent
infection.Facialtraumaorlargeinoculationsfromswimmingcanproducesinusitis
aswell.Drinkingalcoholcanalsocausenasalandsinusmucosatoswellandcause
impairmentofmucousdrainage.

Alteredqualityandquantityofmucus
Sinonasalsecretionsplayanimportantroleinthepathophysiologyofrhinosinusitis.
Themucousblanketthatlinestheparanasalsinusescontainsmucoglycoproteins,
immunoglobulins,andinflammatorycells.Itconsistsof2layers:(1)aninnerserous
layer(ie,solphase)inwhichciliarecoverfromtheiractivebeatand(2)anouter,
moreviscouslayer(ie,gelphase),whichistransportedbytheciliarybeat.Proper
balancebetweentheinnersolphaseandoutergelphaseisofcriticalimportancefor
normalmucociliaryclearance.
Ifthecompositionofmucusischanged,sothatthemucusproducedismoreviscous
(eg,asincysticfibrosis),transporttowardtheostiaconsiderablyslows,andthegel
layerbecomesdemonstrablythicker.Thisresultsinacollectionofthickmucusthat
isretainedinthesinusforvaryingperiods.Inthepresenceofalackofsecretionsor
alossofhumidityatthesurfacethatcannotbecompensatedforbymucousglands
orgobletcells,themucusbecomesincreasinglyviscous,andthesolphasemay
becomeextremelythin,thusallowingthegelphasetohaveintensecontactwiththe

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ciliaandimpedetheiraction.Overproductionofmucuscanoverwhelmthe
mucociliaryclearancesystem,resultinginretainedsecretionswithinthesinuses.

Acutesinusitisintheintensivecaresetting
Acutesinusitisintheintensivecarepopulationisadistinctentity,occurringin18
32%ofpatientswithprolongedperiodsofintubation,andisusuallydiagnosed
duringtheevaluationofunexplainedfever.Casesinwhichthecauseisobstruction
areusuallyevidentandcanincludethepresenceofprolongednasogastricor
nasotrachealintubation.Moreover,patientsinanintensivecaresettingaregenerally
debilitated,predisposingthemtosepticcomplications,includingsinusitis.Finally,
sinusitisinintensivecaresettingsisassociatedwithnasalcatheterplacement.

Etiology
Purulentsinusitiscanoccurwhenciliaryclearanceofsinussecretionsdecreasesor
whenthesinusostiumbecomesobstructed,whichleadstoretentionofsecretions,
negativesinuspressure,andreductionofoxygenpartialpressure.Thisenvironment
isthensuitableforgrowthofpathogenicorganisms.Factorsthatpredisposethe
sinusestoobstructionanddecreasedciliaryfunctionareallergic,nonallergic,orviral
insults,whichproduceinflammationofthenasalandsinusmucosaandresultin
ciliarydysmotilityandsinusobstruction.
Inindividualswithrecurrentorpersistentsinusitis,suspectotherpredisposing
conditionssuchascysticfibrosis,ciliarydyskinesia,allergicinflammation,
immunodeficiency,orananatomicproblem.Thesepredisposingfactorsarealso
citedbythe2005practiceparameterfordiagnosisandmanagementofsinusitis
issuedbytheAmericanAcademyofAllergy,AsthmaandImmunology(AAAAI),as
arecocaineaddictionandnasalpolypsandothercausesofostiomeatalobstruction.
[2]

Acuteviralrhinosinusitis
Thevastmajorityofrhinosinusitisepisodesarecausedbyviralinfection.Mostviral
upperrespiratorytractinfectionsarecausedbyrhinovirus,butcoronavirus,influenza
AandB,parainfluenza,respiratorysyncytialvirus,adenovirus,andenterovirusare
alsocausativeagents.Rhinovirus,influenza,andparainfluenzavirusesarethe
primarypathogensin315%ofpatientswithacutesinusitis.Inabout0.52%of
cases,viralsinusitiscanprogresstoacutebacterialsinusitis.[15,16]
Viralupperrespiratorytractinfectionsarethemostimportantriskfactorforthe
developmentofacutebacterialsinusitis.[17]Approximately90%ofpatientswhohave
viralupperrespiratorytractinfectionshavesinusinvolvement,butonly510%of
thesepatientshavebacterialsuperinfectionrequiringantimicrobialtreatment.[18]

Acutebacterialrhinosinusitis
Acutebacterialrhinosinusitisisveryfrequentlyassociatedwithviralupper
respiratorytractinfection,althoughallergy,trauma,neoplasms,granulomatousand
inflammatorydiseases,midlinedestructivedisease,environmentalfactors,dental
infection,andanatomicvariation,whichmayimpairnormalmucociliaryclearance,
mayalsopredisposetobacterialinfection.
Saureusisacommonpathogeninsphenoidsinusitis.Thevaccinationofchildren
withthe7valentpneumococcalvaccineintroducedin2000intheUnitedStates
broughtaboutthedeclineintherecoveryrateofSpneumoniaeandanincreaseinH
influenza.[19,20]Inaddition,therateofrecoveryofSpneumoniaepenicillinresistant
strainswasdifferentaftervaccination.
Paeruginosaandothergramnegativerodshavebeenrecoveredinacutesinusitis
ofnosocomialorigin(especiallyinpatientswhohavenasaltubesorcatheters),
immunocompromisedpersons,patientswithHIVinfection,andthosewithcystic
fibrosis.
Sixtysixpercentofpatientswithacutesinusitisgrowatleast1pathogenicbacterial
speciesonsinusaspirates,while2630%percentofpatientshavemultiple
predominantbacterialspecies.Thebacteriamostcommonlyinvolvedinacute
sinusitisarepartofthenormalnasalflora.Thesebacteriacanbecomesinus
pathogenswhentheyaredepositedintothesinusesbysneezing,coughing,or
directinvasionunderconditionsthatoptimizetheirgrowth.
Themostcommonpathogensisolatedfrommaxillarysinusculturesinpatientswith
acutebacterialrhinosinusitisincludeStreptococcuspneumoniae,Haemophilus
influenzae,andMoraxellacatarrhalis.Streptococcuspyogenes,Staphylococcus
aureus,andanaerobesarelesscommonlyassociatedwithacutebacterial
rhinosinusitistheyhavebeenfoundinfewerthan10%ofpatientswithacute
bacterialsinusitis,despitetheampleenvironmentavailablefortheirgrowth.The
exceptionsareinsinusitisresultingfromadentalsourceandinpatientswithchronic
sinusdisease,inwhomanaerobicorganismsareusuallyisolated.
Spneumoniaearegrampositive,catalasenegative,facultativelyanaerobiccocci
thataccountfor2043%ofacutebacterialrhinosinusitiscasesinadults.Theriseof
antimicrobialresistanceinSpneumoniaeisamajorconcern.
A1998surveillancestudyofrespiratorytractisolatesestimatedthat12.3%ofS
pneumoniaeisolatesobtainedfromtheparanasalsinuseshadintermediate
resistancetopenicillin37.4%werepenicillinresistant.Theparanasalsinuses
representedtheanatomiclocationwiththehighestresistancerate.[21]Resistanceto
macrolide,clindamycin,trimethoprimsulfamethoxazole,anddoxycyclinewasmore
commoninisolateswithintermediatepenicillinresistanceandthosethatwere
penicillinresistant.
Hinfluenzaearegramnegative,facultativelyanaerobicbacilli.HinfluenzatypeB
wasaleadingcauseofmeningitisuntilthewidespreaduseofthevaccine.
NontypeablestrainsofHinfluenzaeareresponsiblefor2235%ofacutebacterial

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rhinosinusitiscasesinadults.Betalactamaseproductionisthemechanismof
antimicrobialresistanceforthisorganism.Ofisolatesfromtheparanasalsinus,
32.7%werefoundtobebetalactamasepositiveforHinfluenzaotherreports
suggestarateof44%.
Mcatarrhalisaregramnegative,oxidasepositive,aerobicdiplococci.Mcatarrhalis
istheresponsiblepathogenin210%ofacutebacterialrhinosinusitiscasesin
adults.Betalactamaseproductionisthemechanismofantimicrobialresistancefor
Mcatarrhalisaswell.Ofisolatesfromtheparanasalsinus,98%werefoundtobe
betalactamasepositiveforMcatarrhalis.
Saureus,thoughaccountingfor10%ofepisodesofacutebacterialrhinosinusitis,is
nowrecognizedasanincreasinglycommonpathogeninacutebacterial
rhinosinusitis.[22]WhilemethicillinresistantSaureus(MRSA)stillrepresentsa
minorityofepisodesofSaureusrhinosinusitis,increasingtrendsofdrugresistantS
aureusmayalterfuturetreatmentrecommendations.[23]
Gramnegativeorganisms,includingPseudomonasaeruginosa(15.9%),Escherichia
coli(7.6%),Proteusmirabilis(7.2%),Klebsiellapneumoniae,andEnterobacter
species,predominateinnosocomialsinusitis,accountingfor60%ofcases.
Polymicrobialinvasionisseenin25100%ofcultures.Theotherpathogenic
organismsfoundinnosocomialpatientsaregrampositiveorganisms(31%)and
fungi(8.5%).

Acuteinvasivefungalrhinosinusitis
Rarely,sinusitisiscausedbyfungi.Fungalsinusitis(eg,allergicfungalsinusitis)may
appearsimilartolowerairwaydisorderandallergicbronchopulmonaryaspergillosis.
FungalagentsassociatedwiththisconditionincludeAspergillusandAlternaria
species.BipolarisandCurvulariaspeciesarethemostcommonfungirecoveredin
allergicfungalsinusitis,accountingfor60%and20%,respectively,inmoststudies.
Curvulariaspeciesisoccasionallyreportedasthemostcommoncausativeorganism
inthedeepsouthernUnitedStates.
PleasegotothemainarticleFungalSinusitisformoreinformation.

Epidemiology
Sinusitisaffects1outofevery7adultsintheUnitedStates,withmorethan30
millionindividualsdiagnosedeachyear.Sinusitisismorecommonfromearlyfallto
earlyspring.Rhinosinusitisaffectsanestimated35millionpeopleperyearinthe
UnitedStatesandaccountsforcloseto16millionofficevisitsperyear.[1]
AccordingtotheNationalAmbulatoryMedicalCareSurvey(NAMCS),approximately
14%ofadultsreporthavinganepisodeofrhinosinusitiseachyear,anditisthefifth
mostcommondiagnosisforwhichantibioticsareprescribed,accountingfor0.4%of
ambulatorydiagnoses.[24]
In1996,Americansspentapproximately$3.39billiontreatingrhinosinusitis.[25]The
economicburdenofacutesinusitisinchildrenis$1.77billionperyear.[25]

Internationalprevalence
Acutesinusitisaffects3in1000peopleintheUnitedKingdom.Chronicsinusitis
affects1in1000people.Sinusitisismorecommoninwinterthaninsummer.
Rhinoviralinfectionsareprevalentinautumnandspring.Coronaviralinfection
occursmostlyfromDecembertoMarch.

Acutesinusitisinchildren
Anaveragechildislikelytohave68colds(ie,upperrespiratorytractinfections)per
year,andapproximately0.52%ofupperrespiratorytractinfectionsinadultsand6
13%ofviralupperrespiratorytractinfectionsinchildrenarecomplicatedbythe
developmentofacutebacterialsinusitis.[26,27]

Sexdistributionforacutesinusitis
Womenhavemoreepisodesofinfectivesinusitisthanmenbecausetheytendto
havemoreclosecontactwithyoungchildren.Therateinwomenis20.3%,
comparedwith11.5%inmen.

Prognosis
Sinusitisdoesnotcauseanysignificantmortalitybyitself.However,complicated
sinusitismayleadtomorbidityand,inrarecases,mortality.
Approximately40%ofacutesinusitiscasesresolvespontaneouslywithout
antibiotics.Thespontaneouscureforviralsinusitisis98%.Patientswithacute
sinusitis,whentreatedwithappropriateantibiotics,usuallyshowprompt
improvement.Therelapserateaftersuccessfultreatmentislessthan5%.
Intheabsenceofresponsewithin48hoursorworseningofsymptoms,reevaluate
thepatient.Untreatedorinadequatelytreatedrhinosinusitismayleadto
complicationssuchasmeningitis,cavernoussinusthrombophlebitis,orbitalcellulitis
orabscess,andbrainabscess.
Inpatientswithallergicrhinitis,aggressivetreatmentofnasalsymptomsandsignsof
mucosaledema,whichcancauseobstructionofthesinusoutflowtracts,may
decreasesecondarysinusitis.Iftheadenoidsarechronicallyinfected,removing
themeliminatesanidusofinfectionandcandecreasesinusinfection.

PatientEducation
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Forexcellentpatienteducationresources,visiteMedicineHealthsHeadacheCenter.
Also,seeeMedicineHealth'spatienteducationarticleSinusInfection.
ClinicalPresentation

ContributorInformationandDisclosures
Author
ItzhakBrook,MD,MScProfessor,DepartmentofPediatrics,GeorgetownUniversitySchoolofMedicine
ItzhakBrook,MD,MScisamemberofthefollowingmedicalsocieties:AmericanAssociationforthe
AdvancementofScience,AmericanCollegeofPhysiciansAmericanSocietyofInternalMedicine,American
MedicalAssociation,AmericanSocietyforMicrobiology,AssociationofMilitarySurgeonsoftheUS,Infectious
DiseasesSocietyofAmerica,InternationalImmunocompromisedHostSociety,InternationalSocietyforInfectious
Diseases,MedicalSocietyoftheDistrictofColumbia,NewYorkAcademyofSciences,PediatricInfectious
DiseasesSociety,SocietyforExperimentalBiologyandMedicine,SocietyforPediatricResearch,Southern
MedicalAssociation,SocietyforEar,NoseandThroatAdvancesinChildren,AmericanFederationforClinical
Research,SurgicalInfectionSociety,ArmedForcesInfectiousDiseasesSociety
Disclosure:Nothingtodisclose.
Coauthor(s)
LinasRiauba,MDAssistantProfessorofClinicalMedicine,DepartmentofMedicine,SectionofInfectious
Disease,UniversityHospital,UniversityofMedicineandDentistryofNewJersey,NewJerseyMedicalSchool
LinasRiauba,MDisamemberofthefollowingmedicalsocieties:AmericanMedicalAssociation,Infectious
DiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.
BrianEBenson,MDChief,DivisionofLaryngealSurgeryandVoiceDisordersDirector,TheVoiceCenterat
HackensackUniversityMedicalCenterClinicalAssistantProfessor,DepartmentofOtolaryngology/Head&Neck
Surgery,UMDNJ,NewJerseyMedicalSchool
BrianEBenson,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanAcademyof
OtolaryngicAllergy,AmericanAcademyofOtolaryngologyHeadandNeckSurgery,SigmaXi
Disclosure:Nothingtodisclose.
ChiefEditor
MichaelStuartBronze,MDDavidRossBoydProfessorandChairman,DepartmentofMedicine,StewartGWolf
EndowedChairinInternalMedicine,DepartmentofMedicine,UniversityofOklahomaHealthScienceCenter
MasteroftheAmericanCollegeofPhysiciansFellow,InfectiousDiseasesSocietyofAmerica
MichaelStuartBronze,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
MedicalAssociation,OklahomaStateMedicalAssociation,SouthernSocietyforClinicalInvestigation,Association
ofProfessorsofMedicine,AmericanCollegeofPhysicians,InfectiousDiseasesSocietyofAmerica
Disclosure:Nothingtodisclose.
Acknowledgements
MichaelCunningham,DOSrClinicalInstructor,DepartmentofEmergencyMedicine,UniversityofRochester
SchoolofMedicineandDentistry
MichaelCunningham,DOisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,AmericanOsteopathicAssociation,MedicalSocietyoftheStateofNewYork,andNational
AssociationofEMSPhysicians
Disclosure:Nothingtodisclose.
TraceyQuailDavidoff,MDSeniorClinicalInstructor,DepartmentofEmergencyMedicine,RochesterGeneral
Hospital
TraceyQuailDavidoff,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergency
Physicians,AmericanCollegeofForensicExaminers,AmericanCollegeofPhysicians,andAmericanMedical
Association
Disclosure:Nothingtodisclose.
ThomasEHerchline,MDProfessorofMedicine,WrightStateUniversityBoonshoftSchoolofMedicineMedical
Director,PublicHealth,DaytonandMontgomeryCounty,Ohio
ThomasEHerchline,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,Infectious
DiseasesSocietyofAmerica,andInfectiousDiseasesSocietyofOhio
Disclosure:Nothingtodisclose.
ErhunSerbetci,MDDirector,DepartmentofOtolaryngology,SectionofNoseandSinusSurgery,Associate
Professor,InternationalHospitalofIstanbul,Turkey
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

References
1.LucasJW,SchillerJS,BensonV.SummaryhealthstatisticsforU.S.adults:NationalHealthInterview
Survey,2001.VitalHealthStat10.2004Jan.1134.[Medline].
2.SlavinRG,SpectorSL,BernsteinIL,KalinerMA,KennedyDW,VirantFS,etal.Thediagnosisand
managementofsinusitis:apracticeparameterupdate.JAllergyClinImmunol.2005Dec.116(6Suppl):S13
47.[Medline].[FullText].
3.LuskRP,StankiewiczJA.Pediatricrhinosinusitis.OtolaryngolHeadNeckSurg.1997Sep.117(3Pt2):S53
7.[Medline].

http://emedicine.medscape.com/article/232670-overview

8/10

4/6/2016

Acute Sinusitis: Practice Essentials, Background, Anatomy

4.LanzaDC,KennedyDW.Adultrhinosinusitisdefined.OtolaryngolHeadNeckSurg.1997Sep.117(3Pt
2):S17.[Medline].
5.AmericanAcademyofPediatricsSubcommitteeonManagementofSinusitisandCommitteeonQuality
Management.Clinicalpracticeguideline:managementofsinusitis.Pediatrics.2001Sep.108(3):798808.
[Medline].
6.MeltzerEO,HamilosDL,HadleyJA,etal.Rhinosinusitis:Establishingdefinitionsforclinicalresearchand
patientcare.OtolaryngolHeadNeckSurg.2004Dec.131(6Suppl):S162.[Medline].
7.StarkJM,ColasurdoGN.LungDefense:intrinsic,innateandadaptive.ChernickV,BoatTF,WilmottRW,
BushA,eds.Kendig'sDisordersoftheRespiratoryTractinChildren.7thEd.Philadelphia,PA:Saunders
Elsevier2006.Vol.12:206.
8.CherryJD,ShapiroNL,DevilleJG.Sinusitis.FeiginRD,CherryJD,DemmierGJ,KaplanSL,eds.Textbook
ofpediatricinfectiousdisease.5thed.Philadelphia,PA:WBSaunders2004.201.
9.BrookI.Aerobicandanaerobicbacterialfloraofnormalmaxillarysinuses.Laryngoscope.1981Mar.
91(3):3726.[Medline].
10.SuWY,LiuC,HungSY,TsaiWF.Bacteriologicalstudyinchronicmaxillarysinusitis.Laryngoscope.1983
Jul.93(7):9314.[Medline].
11.SobinJ,EngquistS,NordCE.Bacteriologyofthemaxillarysinusinhealthyvolunteers.ScandJInfectDis.
1992.24(5):6335.[Medline].
12.JiangRS,LiangKL,JangJW,HsuCY.Bacteriologyofendoscopicallynormalmaxillarysinuses.JLaryngol
Otol.1999Sep.113(9):8258.[Medline].
13.GordtsF,HalewyckS,PierardD,KaufmanL,ClementPA.Microbiologyofthemiddlemeatus:a
comparisonbetweennormaladultsandchildren.JLaryngolOtol.2000Mar.114(3):1848.[Medline].
14.HamilosDL.Clinicalmanifestations,pathophysiology,anddiagnosisofchronicrhinosinusitis.UpToDate.
Availableathttp://www.uptodate.com.Accessed:June7th,2009.
15.AhSeeK.Sinusitis(acute).ClinEvid(Online).2008Mar10.2008:[Medline].
16.HwangPH,GetzA.Acutesinusitisandrhinosinusitisinadults.UpToDate.Availableat
http://www.uptodate.com.Accessed:June7th,2009.
17.RevaiK,DobbsLA,NairS,PatelJA,GradyJJ,ChonmaitreeT.Incidenceofacuteotitismediaandsinusitis
complicatingupperrespiratorytractinfection:theeffectofage.Pediatrics.2007Jun.119(6):e140812.
[Medline].
18.GwaltneyJMJr.Acutecommunityacquiredsinusitis.ClinInfectDis.1996Dec.23(6):120923quiz12245.
[Medline].
19.BrookI,FootePA,HausfeldJN.Frequencyofrecoveryofpathogenscausingacutemaxillarysinusitisin
adultsbeforeandafterintroductionofvaccinationofchildrenwiththe7valentpneumococcalvaccine.J
MedMicrobiol.2006Jul.55:9436.[Medline].
20.BrookI,GoberAE.Frequencyofrecoveryofpathogensfromthenasopharynxofchildrenwithacute
maxillarysinusitisbeforeandaftertheintroductionofvaccinationwiththe7valentpneumococcalvaccine.
IntJPediatrOtorhinolaryngol.2007Apr.71(4):5759.[Medline].
21.JacobsMR,BajaksouzianS,WindauA,GoodCE,LinG,PankuchGA,etal.SusceptibilityofStreptococcus
pneumoniae,Haemophilusinfluenzae,andMoraxellacatarrhalisto17oralantimicrobialagentsbasedon
pharmacodynamicparameters:19982001USSurveillanceStudy.ClinLabMed.2004Jun.24(2):50330.
[Medline].
22.PayneSC,BenningerMS.Staphylococcusaureusisamajorpathogeninacutebacterialrhinosinusitis:a
metaanalysis.ClinInfectDis.2007Nov15.45(10):e1217.[Medline].
23.BrookI,FootePA,HausfeldJN.IncreaseinthefrequencyofrecoveryofmeticillinresistantStaphylococcus
aureusinacuteandchronicmaxillarysinusitis.JMedMicrobiol.2008Aug.57:10157.[Medline].
24.BishaiWR.Issuesinthemanagementofbacterialsinusitis.OtolaryngolHeadNeckSurg.2002Dec.127(6
Suppl):S39.[Medline].
25.RayNF,BaraniukJN,ThamerM,RinehartCS,GergenPJ,KalinerM,etal.Healthcareexpendituresfor
sinusitisin1996:contributionsofasthma,rhinitis,andotherairwaydisorders.JAllergyClinImmunol.1999
Mar.103(3Pt1):40814.[Medline].
26.FendrickAM,SaintS,BrookI,JacobsMR,PeltonS,SethiS.Diagnosisandtreatmentofupperrespiratory
tractinfectionsintheprimarycaresetting.ClinTher.2001Oct.23(10):1683706.[Medline].
27.WaldER,GuerraN,ByersC.Upperrespiratorytractinfectionsinyoungchildren:durationofandfrequency
ofcomplications.Pediatrics.1991Feb.87(2):12933.[Medline].
28.GwaltneyJMJr,HendleyJO,SimonG,JordanWSJr.Rhinovirusinfectionsinanindustrialpopulation.II.
Characteristicsofillnessandantibodyresponse.JAMA.1967Nov6.202(6):494500.[Medline].
29.[Guideline]RosenfeldRM,AndesD,BhattacharyyaN,CheungD,EisenbergS,GaniatsTG,etal.Clinical
practiceguideline:adultsinusitis.OtolaryngolHeadNeckSurg.2007Sep.137(3Suppl):S131.[Medline].
30.[Guideline]RosenfeldRM,PiccirilloJF,ChandrasekharSS,BrookI,AshokKumarK,KramperM,etal.
Clinicalpracticeguideline(update):adultsinusitis.OtolaryngolHeadNeckSurg.2015Apr.152(2
Suppl):S1S39.[Medline].
31.HansenJG,SchmidtH,RosborgJ,LundE.Predictingacutemaxillarysinusitisinageneralpractice
population.BMJ.1995Jul22.311(6999):2336.[Medline].[FullText].
32.HicknerJM,BartlettJG,BesserRE,GonzalesR,HoffmanJR,SandeMA.Principlesofappropriate
antibioticuseforacuterhinosinusitisinadults:background.AnnInternMed.2001Mar20.134(6):498505.
[Medline].
33.McQuillanL,CraneLA,KempeA.Diagnosisandmanagementofacutesinusitisbypediatricians.
Pediatrics.2009Feb.123(2):e1938.[Medline].
34.SavolainenS,JousimiesSomerH,KarjalainenJ,YlikoskiJ.Dosimplelaboratorytestshelpinetiologic
diagnosisinacutemaxillarysinusitis?.ActaOtolaryngolSuppl.1997.529:1447.[Medline].

http://emedicine.medscape.com/article/232670-overview

9/10

4/6/2016

Acute Sinusitis: Practice Essentials, Background, Anatomy

35.GordtsF,AbuNasserI,ClementPA,PierardD,KaufmanL.Bacteriologyofthemiddlemeatusinchildren.
IntJPediatrOtorhinolaryngol.1999May5.48(2):1637.[Medline].
36.[Guideline]KaplanA.Canadianguidelinesforacutebacterialrhinosinusitis:clinicalsummary.CanFam
Physician.2014Mar.60(3):22734.[Medline].
37.ZalmanoviciA,YapheJ.Steroidsforacutesinusitis.CochraneDatabaseSystRev.2007Apr18.
CD005149.[Medline].
38.WilliamsonIG,RumsbyK,BengeS,MooreM,SmithPW,CrossM,etal.Antibioticsandtopicalnasal
steroidfortreatmentofacutemaxillarysinusitis:arandomizedcontrolledtrial.JAMA.2007Dec5.
298(21):248796.[Medline].
39.vanLoonJW,vanHarnRP,VenekampRP,etal.Limitedevidenceforeffectsofintranasalcorticosteroidson
symptomreliefforrecurrentacuterhinosinusitis.OtolaryngolHeadNeckSurg.Nov2013.149(5):66873.
[Medline].
40.AhovuoSalorantaA,BorisenkoOV,KovanenN,VaronenH,RautakorpiUM,WilliamsJWJr,etal.
Antibioticsforacutemaxillarysinusitis.CochraneDatabaseSystRev.2008Apr16.CD000243.[Medline].
41.YoungJ,DeSutterA,MerensteinD,vanEssenGA,KaiserL,VaronenH,etal.Antibioticsforadultswith
clinicallydiagnosedacuterhinosinusitis:ametaanalysisofindividualpatientdata.Lancet.2008Mar15.
371(9616):90814.[Medline].
42.GarbuttJM,BanisterC,SpitznagelE,PiccirilloJF.Amoxicillinforacuterhinosinusitis:arandomized
controlledtrial.JAMA.2012Feb15.307(7):68592.[Medline].
43.ChowAW,BenningerMS,BrookI,BrozekJL,GoldsteinEJ,HicksLA,etal.IDSAClinicalPractice
GuidelineforAcuteBacterialRhinosinusitisinChildrenandAdults.ClinInfectDis.2012Apr.54(8):e72
e112.[Medline].
44.SngWJ,WangDY.Efficacyandsideeffectsofantibioticsinthetreatmentofacuterhinosinusitis:a
systematicreview.Rhinology.2015Mar.53(1):39.[Medline].
45.ZalmanoviciA,YapheJ.Intranasalsteroidsforacutesinusitis.CochraneDatabaseSystRev.2009Oct7.
CD005149.[Medline].
46.KaperNM,BreukelL,VenekampRP,etal.Absenceofevidenceforenhancedbenefitofantibiotictherapy
onrecurrentacuterhinosinusitisepisodes:asystematicreviewoftheevidencebase.OtolaryngolHead
NeckSurg.2013Nov.149(5):6647.[Medline].
47.FalagasME,GiannopoulouKP,VardakasKZ,DimopoulosG,KarageorgopoulosDE.Comparisonof
antibioticswithplacebofortreatmentofacutesinusitis:ametaanalysisofrandomisedcontrolledtrials.
LancetInfectDis.2008Sep.8(9):54352.[Medline].
48.[Guideline]NationalGuidelinesClearinghouse.Clinicalpracticeguideline:adultsinusitis.National
GuidelinesClearinghouse.Availableathttp://guideline.gov/content.aspx?id=12385.Accessed:September
29,2010.
49.MarpleBF,RobertsCS,FrytakJR,SchabertVF,WegnerJC,BhattacharyyaH,etal.Azithromycinextended
releasevsamoxicillin/clavulanate:symptomresolutioninacutesinusitis.AmJOtolaryngol.2010JanFeb.
31(1):18.[Medline].
50.PlattMP,CunnaneME,CurtinHD,MetsonR.Anatomicalchangesoftheethmoidcavityafterendoscopic
sinussurgery.Laryngoscope.2008Dec.118(12):22404.[Medline].
51.HuangBY,LloydKM,DelGaudioJM,JablonowskiE,HudginsPA.Failedendoscopicsinussurgery:
spectrumofCTfindingsinthefrontalrecess.Radiographics.2009JanFeb.29(1):17795.[Medline].
52.HnatukLA,MacdonaldRE,PapsinBC.Isolatedsphenoidsinusitis:theTorontoHospitalforSickChildren
experienceandreviewoftheliterature.JOtolaryngol.1994Feb.23(1):3641.[Medline].
53.DelGaudioJM,EvansSH,SobolSE,ParikhSL.Intracranialcomplicationsofsinusitis:whatistheroleof
endoscopicsinussurgeryintheacutesetting.AmJOtolaryngol.2010JanFeb.31(1):258.[Medline].
54.AnonJB,JacobsMR,PooleMD,AmbrosePG,BenningerMS,HadleyJA,etal.Antimicrobialtreatment
guidelinesforacutebacterialrhinosinusitis.OtolaryngolHeadNeckSurg.2004Jan.130(1Suppl):145.
[Medline].
55.Barclay,L.AcuteBacterialSinusitisAddressedinNewAAPGuidelines.MedscapeMedicalNews.Available
athttp://www.medscape.com/viewarticle/806791.Accessed:July2,2013.
56.WaldER,ApplegateKE,BordleyC,DarrowDH,GlodeMP,MarcySM,etal.ClinicalPracticeGuidelinefor
theDiagnosisandManagementofAcuteBacterialSinusitisinChildrenAged1to18Years.Pediatrics.2013
Jun24.[Medline].
57.ChanKH,AbzugMJ,CoffinetL,SimoesEA,CoolC,LiuAH.Chronicrhinosinusitisinyoungchildrendiffers
fromadults:ahistopathologystudy.JPediatr.2004Feb.144(2):20612.[Medline].
58.SeoJ,KimHJ,ChungSK,KimE,LeeH,ChoiJW,etal.Cervicofacialtissueinfarctioninpatientswithacute
invasivefungalsinusitis:prevalenceandcharacteristicMRimagingfindings.Neuroradiology.2013Feb2.
[Medline].

MedscapeReference2011WebMD,LLC

http://emedicine.medscape.com/article/232670-overview

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