AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 8

than 80 percent of patients with a viral URI will have an abnormal sinus CT scan. A CT scan should not be obtained for patients who meet diagnostic criteria for uncompli- cated acute rhinosinusitis. Time will usually differentiate a bacterial from a viral infection. It usually takes 7–10 days for a viral infection to resolve. Symptoms lasting beyond 10 days without evidence of improvement, or symp- toms that worsen within 10 days after an initial improvement, suggest bacterial infection. The organisms responsible are similar to the organisms that cause acute otitis media and include Streptococcus pneumoniae, Haemophilus influenzae,

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Figure 8.2. Acute rhinosinusitis. Note purulent drainage extending from the middle meatus over the inferior turbinate. Symptoms persisting longer than 10 days suggest bacterial infection, and antibiotic therapy is indicated.

and Moraxella catarrhalis. By definition, acute rhinosinusitis (ARS) persists for up to four weeks, and subacute rhinosinusitis lasts more than one month but less than three months. Chronic sinusitis is defined by symptoms that persist more than three months, and usually has a different underlying microbiology with increased numbers of anaerobic organisms. Recurrent acute rhinosinusitis is defined by four or more episodes of ARS per year without symptoms between episodes. The treatment of choice for acute bacterial rhinosinusitis (as well as acute otitis media) has been a 10-day course of high-dose amoxicillin with or without clavulate. For penicillin-allergic patients, either doxycy- cline or a fluoroquinolone (levofloxacin or moxifloxacin) is recommended. Adjunctive measures may include topical decongestants (oxymetazo- line) for three days, oral decongestants, topical nasal steroids, analge- sics, saline irrigation, and mucolytics (guaifenisen). Severe or recurrent cases may require systemic steroids. Patients with sinusitis should be referred to an otolaryngologist if they have three to four infections per year, an infection that does not respond to two courses of antibiotics, nasal polyps on exam, or any complications of sinusitis. Several types of acute sinusitis merit further mention. Given that the paranasal sinuses are located close to the eyes and brain, severe acute

Primary Care Otolaryngology