Sinusitis
General Management
Few cases of acute bacterial sinusitis are outside of the treatment capabilities of
the primary care physician. Remember that the majority of cases of acute sinusitis
occurring in healthy individuals usually follow viral upper respiratory tract infections.
With mucosal swelling and altered ciliary function, mucous effusions collect in the
sinuses and become secondarily infected. Primary pathogens include Streptococcus
pneumoniae, H. Influenzae, Staph, M. Catarrhalis, and anaerobes. Selection of a
Beta-lactamase resistant antibiotic increases the coverage for these organisms.
Adjunctive medical treatment modalities include humidification of inspired air, saline
nose spray, saline nasal douches, topical and oral decongestants, and in the case of
allergic individuals, antihistamines and nasal steroid sprays. Resolution is the rule
rather than the exception. Keep in mind that x-ray findings persist beyond the period of
acute symptoms and reversal of x-ray findings alone can not always be used to determine a
treatment endpoint.
In a patient with recurrent or refractory sinusitis it is important to rule out polyps,
a dental abscess, allergy, or septal deviation and turbinate hypertrophy. Refer to an
otolaryngologist for definitive treatment.
Difficult cases
-
Antibiotic resistant cases of acute maxillary sinusitis with opacity and air fluid
levels may require irrigation and aspiration of the sinus for relief (much like an abscess
anywhere else). Referral to an otolaryngologist is recommended in this case.
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Symptomatic frontal or sphenoid sinusitis persisting beyond 48-hours from initiation of
oral antibiotic therapy represents a challenge. Because of the propensity for intracranial
spread and complications, aggressive therapy is mandatory. Aggressive topical nasal
decongestion with pledgets of cocaine HCL (mixture of 1:1 phenylephrine 1% and Xylocaine
4%), humidity, saline douches, oral decongestants, and IV antibiotics constitutes complete
medical therapy. Failure of clinical response after 72 hours of IV antibiotics and medical
adjunctive therapy (persistent headache, tenderness to palpation, or any hints of CNS
irritation) requires consultation and referral for surgical trephination.
Reference
-
DeWeese and Saunders, Textbook of Otolaryngology
Reviewed by CAPT David H. Thompson,
MC, USN, Department of Otolaryngology,
National Naval Medical Center, Bethesda, MD (1998).
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Preface
· Administrative Section
· Clinical Section
The
General Medical Officer Manual , NAVMEDPUB 5134, January 1, 2000
Bureau
of Medicine and Surgery, Department of the Navy, 2300 E Street NW, Washington, D.C.,
20372-5300
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