Sinusitis Management

Diagnosis and Characteristics

Benign lesions typically originating from the sinus floor are usually radiopaque with various sizes, and are often filled with yellow serous fluid, which is pathognomonic, and are generally asymptomatic and detected incidentally on imaging 1
Acute bacterial rhinosinusitis is defined as symptoms lasting between 7-28 days, according to the European Position Paper on Rhinosinusitis (EPOS) 2
Acute maxillary sinusitis is diagnosed when at least two major criteria are present, including unilateral or bilateral infraorbital pain and purulent rhinorrhea, as reported by the Clinical Microbiology and Infection guidelines 3
Plain radiographs have moderate sensitivity (76%) and specificity (79%) compared to sinus puncture, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 4
Coronal CT scan is the gold standard for diagnosis and should include extra cuts through the ostiomeatal complex to clarify disease extent, as recommended by the American College of Radiology 5

The American Academy of Otolaryngology recommends intranasal corticosteroids to reduce inflammation, and nasal saline lavage to improve drainage, with a trial period of 3 months to assess response 6
The American College of Physicians recommends amoxicillin-clavulanate (875/125 mg twice daily for 7-10 days) as the first-line antibiotic treatment for acute bacterial sinusitis, with alternative options including second-generation cephalosporins and third-generation cephalosporins for patients with penicillin allergies 7, 3
For patients with a penicillin allergy, the American College of Physicians recommends doxycycline (100 mg twice daily for 7-10 days) as an alternative treatment, and the European Position Paper on Rhinosinusitis (EPOS) recommends doxycycline for non-severe penicillin allergy 7, 2
Analgesics and antipyretics are recommended for symptom relief, according to the Clinical Microbiology and Infection guidelines 3
Decongestants may provide temporary relief, but evidence is limited, as reported by the Infectious Diseases Society of America 8
Intranasal corticosteroids are recommended as adjunctive therapy for sinusitis, and nasal saline irrigations are recommended to improve mucociliary clearance and prevent crust formation, as suggested by the American Academy of Allergy, Asthma, and Immunology 5

Surgery is indicated for failure of medical management after 3 months, according to the American Academy of Otolaryngology 6
Functional endoscopic sinus surgery (FESS) is recommended for patients with chronic rhinosinusitis (CRS) refractory to medical treatment, with symptoms persisting >12 weeks, by the American Academy of Otolaryngology 9
FESS is also indicated for complications of acute sinusitis, such as orbital or intracranial involvement, and for anatomic abnormalities contributing to sinus obstruction, as suggested by the American College of Allergy, Asthma, and Immunology 5
Surgical intervention should be considered when nasal polyps obstruct sinus drainage despite medical treatment, or when complications are threatened, according to the American Academy of Allergy, Asthma, and Immunology 5

During dental procedures, the American Association of Endodontists recommends deflating the cyst before membrane elevation, and avoiding overfilling the sinus, to prevent obstruction of the natural ostium 1

Patient education about postoperative care, including pain control expectations, need for debridement, ongoing medical management, activity restrictions, and follow-up requirements, is crucial, as stated by the American Academy of Otolaryngology-Head and Neck Surgery 10
Postoperative follow-up should occur between 3-12 months to assess symptom relief, quality of life, complications, adherence to therapy, and need for rescue medications, as suggested by the American Academy of Otolaryngology-Head and Neck Surgery 10

The American Academy of Allergy, Asthma, and Immunology recommends referral to an ENT specialist for patients with recurrent sinusitis (2-3 episodes per year) despite appropriate treatment, or when condition significantly affects quality of life 5
The American Academy of Otolaryngology-Head and Neck Surgery recommends that not all sinusitis requires antibiotics, and viral sinusitis with mild symptoms of short duration should not be treated with antibiotics to avoid promoting resistance 4
The European Society of Clinical Microbiology and Infectious Diseases recommends first-line antibiotic treatment for chronic sinusitis, including amoxicillin-clavulanate, second-generation cephalosporins (cefuroxime-axetil), or third-generation cephalosporins (cefpodoxime-proxetil, cefotiam-hexetil), with fluoroquinolones (levofloxacino, moxifloxacino) reserved for complicated cases or treatment failures 3