Evidence-Based Medicine for Student Health Services Robert J. Flaherty, MD Swingle Student Health Service Montana State University Bozeman, MT 59717  

Sinusitis 
  

Etiology	Monitoring
Epidemiology	Prognosis
Diagnosis	Prevention
Treatment	Patient Education

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Etiology   No evidence is cited.       Epidemiology   No evidence is cited.       Diagnosis   Clinical Diagnosis  Five clinical findings:   Maxillary toothache Poor response to decongestants A history of colored nasal discharge Purulent nasal secretion Transillumination result (useful only if negative) are the best predictors of acute bacterial sinusitis (level I evidence). When <2 of these findings was present sinusitis could be ruled out; however, when >3 are present, the likelihood of sinusitis  is very high. When 2 or 3 findings are present a Waters view may be useful (level III evidence).  Caveats Age group studied: Unknown Type/size: Hierarchical evaluation of the strength of evidence in the medical literature and consensus of experts. Emphasis was placed on randomized, placebo-controlled clinical trials (level I evidence) and well-designed controlled trials without randomization (level II evidence) when available. Opinions of respected authorities based on clinical experience, descriptive studies and reports of expert committees (level III evidence) were assigned a lower weight.  Population characteristics: Unknown Outcome measures: Unknown Citations A practical guide for the diagnosis and treatment of acute sinusitis - Reviewed by the CMA-CPG Database   The following signs and symptoms increase the likelihood of bacterial sinusitis:    "Double-sickening" (an upper respiratory infection that initially improves then worsens) Purulent secretions by history  Purulent secretions in the nasal cavity on examination  Lack of response to decongestants and antihistamines  Unilateral maxillary pain Facial pain on percussion or palpation, sedimentation rate and white blood count have little diagnostic value.  Caveats Age group studied: 15+ Type/size: Population study of 251 patients Population characteristics: Primary care patients Outcome measure: Test characteristics of signs, symptoms, and lab tests for acute sinusitis Citation Diagnosing acute sinusitis: Review of Lindbaek M et al, Use of symptoms, signs, and blood tests to diagnose acute sinus infections in primary care: comparison with computed tomography. Fam Med 1996; 28:183-8 - Reviewed by POEMS/JFP  Similarly: Diagnosing maxillary sinusitis in primary care: Review of Hansen JG et al, Predicting acute maxillary sinusitis in a general practice population. Br Med J 1995; 311:233-6 - Reviewed by POEMS/JFP      Laboratory/X-ray Diagnosis  Regarding the following five clinical findings:   Maxillary toothache Poor response to decongestants A history of colored nasal discharge Purulent nasal secretion Transillumination result (useful only if negative) Radiography is not warranted when <2  or >3 of these findings are present. When 4 or more are present, the likelihood of sinusitis is very high. A Waters view is useful when the diagnosis is in doubt (level III evidence). CT scans are not cost-effective and should not be used routinely to diagnose acute sinusitis (level II evidence).  Caveats Age group studied: Unknown Type/size: Hierarchical evaluation of the strength of evidence in the medical literature and consensus of experts. Emphasis was placed on randomized, placebo-controlled clinical trials (level I evidence) and well-designed controlled trials without randomization (level II evidence) when available. Opinions of respected authorities based on clinical experience, descriptive studies and reports of expert committees (level III evidence) were assigned a lower weight.  Population characteristics: Unknown Outcome measure: Unknown Citations A practical guide for the diagnosis and treatment of acute sinusitis - Reviewed by the CMA-CPG Database        Treatment    Antibiotics  No specific antibiotic is likely to be helpful in most cases of acute maxillary sinusitis. It may be more appropriate to prescribe antibiotics only for patients who are sicker, or at higher risk for complications. When antibiotics are used, clinicians should choose the cheapest and most convenient agent available. Optimal duration of therapy remains controversial.  Caveats Age group studied: Adults >13y Type/size: Meta-analysis (16 studies = 3310 patients) Population characteristics: Otherwise healthy adults Outcome measure: Clinical cure, clinical success, and adverse events Citations Antibiotics for acute maxillary sinusitis: Review of de Bock GH et al, Antimicrobial treatment in acute maxillary sinusitis: A meta-analysis. J Clin Epidemiol 1997;50:881-890 - Reviewed by POEMS/JFP  Similarly: Antibiotics for acute maxillary sinusitis in adults: Review of Stalman W et al, Maxillary sinusitis in adults: an evaluation of placebo-controlled  double-blind trials. Family Practice 1997; 14(2):124-129s - Reviewed by POEMS/JFP   Similarly: Amoxicillin in acute maxillary sinusitis: Review of Van Buchem FL et al, Primary-care- based randomised placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis. Lancet 1997;349:683-7 - Reviewed by POEMS/JFP   Also reviewed in: Amoxicillin did not improve the clinical course of acute maxillary sinusitis in primary care  - Reviewed by Evidence-Based Medicine  In the event that antibiotics are used, first-line therapy should be a 10-day course of amoxicillin or trimethoprim­ sulfamethoxazole (level I evidence) and a decongestant (level III evidence). Patients not responding to first-line therapy should be switched to a second-line agent (any agent with an approved indication for acute bacterial sinusitis other than amoxicillin and TMP­SMX). As well, patients with recurrent episodes of acute sinusitis who have been assessed and found not to have anatomic anomalies may also benefit from second-line therapy (level III evidence).    Caveats Age group studied: Unknown Type/size: Hierarchical evaluation of the strength of evidence in the medical literature and consensus of experts. Emphasis was placed on randomized, placebo-controlled clinical trials (level I evidence) and well-designed controlled trials without randomization (level II evidence) when available. Opinions of respected authorities based on clinical experience, descriptive studies and reports of expert committees (level III evidence) were assigned a lower weight.  Population characteristics: Unknown Outcome measure: Unknown Citations A practical guide for the diagnosis and treatment of acute sinusitis - Reviewed by the CMA-CPG Database   In the event that antibiotics are used, three days of trimethoprim/sulfasoxazole (TMP/SMX) is as effective as 10 days of TMP/SMX in the treatment of acute maxillary sinusitis (77% and 76% cured or much improved at 14 days).   Caveats Age group studied: Adult males Type/size: RCT of 80 patients Population characteristics: VA outpatients and staff Outcome measure: Number of days to cure or much improvement, relapse rate and x-ray improvement All patients received oxymatazolone nasal spray x 3 days But then, if antibiotics are ineffective in the treatment of sinusitis, there would not be any difference among regimens (!) Citations Acute sinusitis: 3 vs. 10 days of TMP/SMX: Review of Williams JW et al, Randomized controlled trial of 3 vs. 10 days of trimethoprim/sulfamethoxazole for acute maxillary sinusitis. JAMA 1995; 273:1015-21 - Reviewed by POEMS/JFP  Cefprozil, cefpodoxime proxetil, loracarbef, cefixime, and ceftibuten were compared to conventional antibiotic therapies (usually amoxicillin/clavulanate, cefaclor or cephalexin) for community acquired infections. Infections included acute otitis media, pharyngitis, sinusitis, bronchitis, pneumonia, urinary tract infection and skin and skin-structure infections. The newer agents appear to be as clinically effective as conventional therapies (but not more effective) for the treatment of common community-acquired infections. They may also have the potential to improve compliance due to their once/twice daily mode of  administration.   Caveats Age group studied: Unknown Type/size: Analytical review of studies: acute otitis media: 19 studies, pharyngitis: 13 studies, sinusitis: 4 studies, bronchitis: 10 studies, pneumonia: 7 studies, urinary tract infection: 11 studies, skin and skin-structure infections: 4 studies. Most studies consisted of 30-50 patients in each arm Population: Unknown Outcome measure: Clinical response to therapy For some of these infections other studies show that there is no evidence that any antibiotic therapy is beneficial Citations Comparison of cefprozil, cefpodoxime proxetil, loracarbef, cefixime, and ceftibuten - Reviewed by DARE  Amoxicillin and trimethoprim/sulfasoxazole are essentially as effective as more expensive antibiotics for the initial treatment of uncomplicated acute sinusitis.   Caveats Age group studied: Unknown Type/size: Meta-analysis of 27 RCTs (2717 patients) Population characteristics: Outpatients with acute sinusitis or acute exacerbations of chronic sinusitis Outcome measures: Clinical failures and cures But is this finding because NO antibiotic is particularly effective for the treatment of sinusitis? Citations de Ferranti SD et al, Are amoxycillin and folate inhibitors as effective as other antibiotics for acute sinusitis? A meta-analysis, BMJ 1998 Sep 5;317(7159):632-7 - From PubMed   Receiving a prescription for an antibiotic for a URI was not associated with increased patient satisfaction. Better to spend time explaining the nature of a particular illness and the physician's choice of treatment.  Caveats Age group: Adults Type/size: RCT of 113 Outcome measure: Patient satisfaction Diagnostic criteria unclear Citations Antibiotic use and patient satisfaction: Review of Hamm RM et al, Antibiotics and respiratory infections: Are patients more satisfied when expectations are met? J Fam Pract 1996;43:56-62 - Reviewed by POEMS/JFP   Similarly: Mangione-Smith R et al, The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior, Pediatrics 1999 Apr;103(4 Pt 1):711-8 - From PubMed  Similarly: Himmel W et al, Are patients more satisfied when they receive a prescription? The effect of patient expectations in general practice. Scand J Prim Health Care 1997 Sep;15(3):118-22 - From PubMed  Other Therapies     Decongestants, along with antimicrobial therapy, are useful in treating acute sinusitis (level III evidence).  Antihistamines are contraindicated in the management of acute sinusitis (level III evidence).  Glucocorticosteroids have not been shown to be of any notable benefit in treating acute sinusitis (level III evidence).  Irrigation of the nasal cavity may provide symptomatic relief (level III evidence).   Caveats Age group studied: Unknown Type/size: Hierarchical evaluation of the strength of evidence in the medical literature and consensus of experts. Emphasis was placed on randomized, placebo-controlled clinical trials (level I evidence) and well-designed controlled trials without randomization (level II evidence) when available. Opinions of respected authorities based on clinical experience, descriptive studies and reports of expert committees (level III evidence) were assigned a lower weight.  Population characteristics: Unknown Outcome measure: Unknown Citations A practical guide for the diagnosis and treatment of acute sinusitis - Reviewed by the CMA-CPG Database      Monitoring  No evidence is cited.     Prognosis    No evidence is cited.        Prevention   No evidence is cited.       Patient Education  The following patient education materials are consistent with the available evidence.  How to Help Your Sinus Problems - from the AAFP Sinusitis - from the NIAID You, Your Family and Antibiotics: The Untold Story - From the AAFP Rev. 8/28/99

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