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Richtlijn acute rinosinusitisPublished by: Werkgroep Ontwikkeling Richtlijnen Eerste Lijn (Worel)Last published: 2023Guide de pratique clinique rhinosinusite aiguëPublished by: Groupe de travail Développement de recommandations de première ligneLast published: 2023The goals of treatment are to relieve symptoms, eradicate infection, and prevent complications.[27] Management varies depending on whether the aetiology is viral or bacterial, and should involve shared decision-making with the patient.[1] Due to a paucity of high-quality evidence on the management of acute rhinosinusitis, recommended treatment strategies and duration may vary.
Acute viral rhinosinusitis
This is generally a self-limiting disease, and treatment is primarily symptomatic. The disease course is usually less than 10 days, but symptoms tend to improve after approximately 3-5 days.[28] Adequate rest and hydration, warm facial packs, and nasal saline irrigation may be useful, as well as use of vitamin C, zinc, or over-the-counter medications, depending on the specific symptoms.[4] Treatments should be tried for 5-10 days before re-assessing the patient. Antibiotics should not be given to patients with suspected acute viral rhinosinusitis.[1][3]
Analgesics/antipyretics
Recommended for pain and/or fever.
Examples include paracetamol, ibuprofen, or paracetamol/codeine. Selection of agent depends on the subjective level of pain the patient is experiencing. Codeine is contraindicated in children aged younger than 12 years, and it is not recommended in adolescents aged 12-18 years who are obese or have conditions such as obstructive sleep apnoea or severe lung disease as it may increase the risk of breathing problems.[29] Codeine is generally recommended only for the treatment of acute moderate pain, which cannot be successfully managed with other analgesics, in children aged 12 years and older. It should be used at the lowest effective dose for the shortest period and treatment limited to 3 days.[30][31]
Decongestants
May restore sinus ostial patency and provide symptomatic relief of nasal congestion.[1][15] However, evidence is lacking.[32]
Topical agents (e.g., oxymetazoline) are often preferred over systemic agents (e.g., pseudoephedrine) because of increased potency and less risk of adverse effects. Pseudoephedrine-containing medicines are associated with a risk of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome. These are rare conditions with potentially serious and life-threatening complications. Pseudoephedrine-containing medicines should not be used in patients with severe or uncontrolled hypertension, or those with severe acute or chronic renal disease or failure.[33]
Topical agents should only be used for up to 3-5 days, to prevent the occurrence of rebound congestion.
Intranasal corticosteroids
Recommended in patients with congestion; considered beneficial and have a low incidence of systemic adverse effects.[1][34][35][36] [
]
May decrease allergic response in patients with allergic rhinitis, and therefore decrease swelling associated with rhinosinusitis.[1]
At least 1 month of therapy is usually recommended; however, this will depend on the disease course.
Topical anticholinergics (e.g., ipratropium)
Recommended in adults with rhinorrhoea.[37]
Intranasal saline irrigations/sprays
May also be useful for treating congestion by reducing inflammation and thinning mucus, and have the added advantage of decreasing medication use.
Saline nasal irrigations may be helpful in relieving nasal symptoms; however, they should be used cautiously as patients who have not had an endoscopic sinus surgery may develop facial pressure or discomfort when the saline irrigations get trapped in the non-operated sinuses.[38]
The following instructions for a home-prepared saline irrigation may be helpful for patients: University of Michigan Health System: saltwater washes (nasal saline lavage or irrigation) for sinusitis Opens in new window
Add 240 mL (1 cup) of distilled water to a clean container. If using tap water, boil it first to sterilise it, and then let it cool down.
Add 2.5 g (half a teaspoon) of salt to the water.
Add 2.5 g (half a teaspoon) of baking soda.
This solution can be stored at room temperature for 3 days.
To use the home-made solution, fill a large medical syringe, squeeze bottle, or nasal cleansing pot with the solution, insert the tip into the nostril, and squeeze gently.
Aim the stream of solution towards the back of the head.
The solution should go through the nose and out of the mouth or the other nostril.
Gently blow the nose after using the solution, unless instructed otherwise.
Repeat several times every day.
Clean the syringe or bottle after each use.
Expectorants
Guaifenesin should not be used due to a lack of evidence of efficacy.[1]
Acute bacterial rhinosinusitis
Consensus on a universal treatment protocol for acute bacterial rhinosinusitis is lacking. However, symptom-based therapy, with or without antibiotic therapy, is generally considered an acceptable approach.[1][3][36][39][40]
For non-severe symptoms in immunocompetent people, some guidelines recommend watchful waiting for up to 10 days with symptomatic therapy before instituting subsequent antibiotic therapy, as the majority of non-severe cases will resolve without them.[1][41] However, immediate antibiotic therapy can shorten the duration of symptoms, so may be used if the benefits (i.e., eradication of infection, improvement in symptoms, reduced duration of illness) outweigh the risks (i.e., adverse effects, cost, need for follow-up, increased bacterial resistance) of therapy.[1][3][42]
Patients with severe symptoms or worsening symptoms are more likely to have bacterial infection compared with patients with mild symptoms, particularly if the symptoms have lasted for more than 10 days.[3] In this context, current guidelines recommend more broad-spectrum first-line therapy for acute bacterial rhinosinusitis (ABRS).[1][3] There are several sets of guidelines in existence, and practices may vary.
Antibiotic therapy
Guidelines generally do not recommend antibiotics for immunocompetent patients with non-severe illness. Such cases are either viral rhinosinusitis or mild bacterial rhinosinusitis, both of which resolve without treatment.[1][3][41] To this end, a randomised controlled trial (RCT) compared a 10-day course of amoxicillin with placebo for adults presenting to community practices with clinically diagnosed, uncomplicated moderate to severe acute rhinosinusitis. It found no difference in terms of improvement in disease-specific quality of life after 3-4 days of treatment.[43] One meta-analysis of six RCTs found moderate-certainty evidence that antibiotic therapy reduced the risk of treatment failure compared with placebo in children, but only 41% of children treated with placebo experienced treatment failure and none developed major complications.[44] One 2023 RCT found that antibiotic therapy in paediatric patients with acute rhinosinusitis provided minimal benefit if the patient did not have nasopharyngeal pathogens on presentation.[45]
Guidelines generally recommend antibiotic therapy for immunocompromised patients or those with severe illness. Indicators of severe illness include:[1][3][42][46]
Fever (>39°C [>102.2°F])
Moderate to severe facial or dental pain
Unilateral sinus tenderness
Periorbital oedema
Worsening of symptoms after 3-5 days
Lack of improvement after 7-10 days of observation.
A risk-benefit analysis for use of antibiotics must consider the high rate of spontaneous resolution without treatment, shortened duration of symptoms with treatment, as well as cost, adverse effects of antibiotics, need for follow-up, and increased bacterial resistance.[7][47]
Although guidelines vary in their recommendations, studies have not demonstrated a difference in clinical outcomes between various antibiotic regimens.[48]
Amoxicillin with or without clavulanic acid has generally been recommended as a first-line agent for non-severe disease in immunocompetent people, owing to its safety, efficacy, and low cost.[1] One paediatric cohort study found there was no difference in treatment failure rates between the use of amoxicillin or amoxicillin/clavulanate for acute rhinosinusitis, but amoxicillin/clavulanate was associated with a higher risk of gastrointestinal symptoms and thrush.[49] A pharmacokinetically enhanced extended-release formulation of amoxicillin/clavulanic acid can be used for the treatment of acute bacterial rhinosinusitis caused by penicillin-resistant Streptococcus pneumoniae.[50] High-dose amoxicillin/clavulanic acid is recommended as first-line therapy for patients who have severe disease or are immunocompromised.[1]
Guidance from the UK’s National Institute for Health and Care Excellence (NICE) recommends phenoxymethylpenicillin as a first-line option in patients who have experienced symptoms for 10 days or more, but who are not systemically very unwell. If patients are systemically very unwell, and have had sinusitis symptoms for 10 days or more, then the first-line recommendation from NICE is amoxicillin/clavulanic acid.[51]
For penicillin-allergic patients, a reasonable alternative is therapy with clindamycin plus an oral third-generation cephalosporin (e.g., cefuroxime, cefpodoxime).[2][52] There is a risk of cross-sensitivity with cephalosporins in these patients, although this risk is low if the allergic manifestation is simply a rash without respiratory involvement.[53]
Doxycycline is a suitable alternative in adults with allergies to beta-lactam antibiotics; however, it is not recommended in children due to risks of tooth discoloration and dental enamel hypoplasia.[54]
Trimethoprim/sulfamethoxazole or a macrolide (e.g., azithromycin) have been used in patients with an allergy to penicillins, but in some areas there are now relatively high rates of resistance to these drugs that limit their usefulness.[1][55]
NICE recommends clarithromycin, erythromycin (in pregnant women), or doxycycline (in adults and young people aged 12 or over) as first-line choices for people with penicillin allergy or intolerance.[51]
Fluoroquinolones should only be used in patients with severe acute bacterial rhinosinusitis who do not have other treatment options.[56] They may be tried in adults if treatment with a penicillin or cephalosporin is not possible. Fluoroquinolones should be used with caution in children due to risk of musculoskeletal adverse effects.[57] Systemic fluoroquinolone antibiotics may cause serious, disabling, and potentially long-lasting or irreversible adverse events. This includes, but is not limited to, tendinopathy/tendon rupture; peripheral neuropathy; arthropathy/arthralgia; aortic aneurysm and dissection; heart valve regurgitation; dysglycaemia; and central nervous system effects including seizures, depression, psychosis, and suicidal thoughts and behaviour.[58]
Prescribing restrictions apply to the use of fluoroquinolones, and these restrictions may vary between countries. In general, fluoroquinolones should be restricted for use in serious, life-threatening bacterial infections only. Some regulatory agencies may also recommend that they must only be used in situations where other antibiotics, that are commonly recommended for the infection, are inappropriate (e.g., resistance, contraindications, treatment failure, unavailability).
Consult your local guidelines and drug formulary for more information on suitability, contraindications, and precautions.
The recommended treatment course is unclear.[42] However, a 5-7 day course for adults and 10-14 day course for children is reasonable for most antibiotics for non-severe illness.[1][3] NICE recommends a 5-day course for adults and for children.[51][Evidence A] A 10-14 day course is reasonable for immunocompromised patients or those with severe disease.[1][3]
If there is no symptom improvement after 3-5 days of antibiotic treatment, an alternative should be considered.[3]
Intravenous antibiotics (e.g., third-generation cephalosporin, fluoroquinolone) may be required in patients with infection that requires hospitalisation.
Antibiotic resistance
The prevalence of penicillin-resistant S pneumoniae, both intermediate- and high-level resistance, may be up to 35%.[1][13] Even so, high-dose amoxicillin remains effective against intermediate-resistant pneumococci of variable susceptibilities.[59]
The prevalence of macrolide-resistant S pneumoniae is likely to be >40%.[1][13]
H influenzae and M catarrhalis develop penicillin resistance as a result of beta lactamase production, with prevalence ranging from 27% to 60%, and approaching 100% in some study populations.[1][2][13]
Antibiotic resistance depends on the geographic location. Therefore, an understanding of local antibiotic protocols is important before prescribing a specific antibiotic. If the patient does not respond to treatment after 3-5 days, an alternative antibiotic (such as high-dose amoxicillin/clavulanic acid, a quinolone, or a cephalosporin), or an alternative, non-infectious aetiology, should be considered.[3]
Inappropriate prescribing can contribute to resistance; for example, one US study found that only 50% of antibiotic prescriptions to outpatients with pharyngitis, rhinosinusitis, or acute otitis media were for first-line recommended agents (defined as amoxicillin or amoxicillin/clavulanate for rhinosinusitis).[60] One systematic review found that otolaryngologists did not adhere to rhinosinusitis guidelines as they did not distinguish presumed acute bacterial rhinosinusitis from acute rhinosinusitis caused by viral upper respiratory tract infections (URTIs) and did not follow guideline-recommended first-line therapy when treating suspected bacterial rhinosinusitis.[61]
Symptomatic therapy
Measures are the same as those used for acute viral rhinosinusitis.
Adequate rest and hydration, warm facial packs, and nasal saline irrigation may be useful, as well as use of vitamin C, zinc, or over-the-counter medications including analgesics/antipyretics, decongestants, and intranasal saline sprays.[38] There may be a modest clinical benefit from use of intranasal corticosteroids.[1][4][36] [
]
No studies conclusively support the use of the other symptomatic therapies.[32] Products available over the counter can contain numerous different active ingredients and doses; therefore, clinicians should be cautious when recommending specific products for symptom relief.[62] Honey can reduce cough frequency and severity associated with URTI symptoms, with moderate evidence supporting its use in preference to usual care for other URTI symptoms; however, most evidence comes from studies of children.[63]
Specialist referral
Referral to an ear, nose, and throat specialist may be indicated when:[1][3]
Patient is immunocompromised
A complication of rhinosinusitis is suspected (facial cellulitis, orbital cellulitis or abscess, intracranial infection)
Cranial nerve deficits such as facial nerve paralysis or ophthalmoplegia are present, suggesting possible invasive fungal or orbital rhinosinusitis
Condition is refractory to antibiotic treatment
Condition is recurrent (i.e., 4 or more episodes per year) or significantly affects quality of life
There is a suspected allergic or immunological basis for the condition, or there are comorbidities (e.g., asthma, nasal polyps) present that complicate management, or rhinosinusitis is associated with unusual opportunistic infections.
The specialist may be able to enhance care:
Through confirmation of the diagnosis or provision of an alternative diagnosis
By obtaining a sinus culture
By adjusting antibiotic therapy to cover less common pathogens, such as anaerobes, Pseudomonas aeruginosa, or Staphylococcus aureus
By obtaining and interpreting imaging studies
Through consideration of surgery.[3]
Acute invasive fungal rhinosinusitis is a rare, rapidly progressive and life-threatening infection with a high mortality rate warranting immediate emergency referral and ENT consultation. Management consists of surgical debridement, systemic antifungal therapy, and correction of predisposing conditions.[3][64]
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