Sinusitis is usually viral. Only use antibiotics if signs and symptoms are greater than 10 days or purulent discharge with a fever greater than 102 degrees. Viral is quick, usually lasting less than a week. Bacterial often has double sickening and purulent discharge. Do not do imaging unless immunocompromised or orbital cranial involvement. Only symptomatic relief for viral.
- Usually caused by H. influenza, Moraxella catarrhalis, Staph aureus, Step. Pyogenes
- Resistance risks: Age <2 >65, antibiotics in last month, hospital stay in the last 5 days, smoking, diabetes, cardiac disease, hepatic or renal disease, immunocompromised.
- Use Amoxicillin/clavulanate 500 mg TID or high dose Amoxicillin/clavulanate 875 BID if > 39-degree temp or resistance as above)
- Doxy is second line
- FQs like levo or moxi in PCN allergy if doxy not available. NO MACROLIDES
- Cephs are not great, but cefpodoxime can be used with clindamycin.
- You can use inhaled steroids or saline irrigation for symptoms
- Duration: 5-7 days
- Treatment failure: Consider endoscopy guided cell culture if not recovered in 3-5 days or worse in 48-72 hours. Rule out other causes. If they didn’t get first-line therapy, try that (or try the right dose if they got substandard dosing).
- Sinusitis for at least 12 weeks.
- Enterobacteriaceae, staph aureus, pseudomonas, ABRS pathogen, anaerobes
- Must have:
- 2 of these – mucopurulent discharge, nasal congestion, decreased sense of smell, facial pain or pressure OR
- 1 of these – purulent mucous or edema in middle meatus or sinus, polyps, radiographic imaging showing sinus inflammation.
- NO ANTIBIOTICS – SALINE IRRIGATION
- Intranasal steroids are the first line and most effective
- Oral antihistamines are effective and can be adjunct
- Topical cromolyn is not very effective
- Leukotriene receptor modifiers are not effective on their own, but they can be helpful in combo or in patients with asthma.
- Mostly just control symptoms.
- Can be on maintenance antihistamines, nasal steroids, or leukotriene modifiers if recurrent. You can also try allergy shots.