Clinical Notes : ENT

123. Acute Sinusitis

Sinusitis

 

Common symptoms and signs

 

  • Adults with acute sinusitis usually present with:

    • nasal blockage or congestion

    • nasal discharge

    • dental or facial pain or pressure

    • reduction or loss of the sense of smell

  • Children (particularly young children) often present with non‑specific symptoms in the upper respiratory tract. Symptoms of acute sinusitis in children may include the following, but these can be present for many upper respiratory tract infections:

    • nasal blockage or congestion

    • discoloured nasal discharge

    • cough during the day or at night

 

Factors that might make a bacterial cause more likely

 

  • It is difficult to distinguish viral and bacterial acute sinusitis. A bacterial cause may be more likely if several of the following are present:

  • symptoms for more than 10 days

  • discoloured or purulent nasal discharge

  • severe localised unilateral pain (particularly pain over teeth and jaw)

  • fever

  • marked deterioration after an initial milder phase

Algorithm for the management of acute sinusitis

 

People presenting with symptoms for around 10 days or less

  • Do not offer an antibiotic prescription

 

  • Give advice about:

    • the usual course of acute sinusitis (2 to 3 weeks)

    • an antibiotic not being needed

    • managing symptoms, including fever, with self-care (see the recommendations on self-care)

    • seeking medical help if symptoms worsen rapidly or significantly, do not improve after 3 weeks, or they become systemically very unwell

  • Reassess if symptoms worsen rapidly or significantly, taking account of:

    • alternative diagnoses such as a dental infection

    • any symptoms or signs suggesting a more serious illness or condition

 
 

People presenting with symptoms for around 10 days or more with no improvement

  • Consider prescribing a high-dose nasal corticosteroid* for 14 days for adults and children aged 12 years and over, being aware that nasal corticosteroids:

    • may improve symptoms but are not likely to affect how long they last

    • could cause systemic effects, particularly in people already taking another corticosteroid

    • may be difficult for people to use correctly

 

  • Consider no antibiotic prescription or a back-up antibiotic prescription (see the recommendations on choice of antibiotic), taking account of:

    • evidence that antibiotics make little difference to how long symptoms last, or the proportion of people with improved symptoms

    • withholding antibiotics is unlikely to lead to complications

    • possible adverse effects, particularly diarrhoea and nausea

    • factors that might make a bacterial cause more likely (see symptoms and signs)

 

  • When a back-up antibiotic prescription is given, give verbal and written advice about:

    • managing symptoms, including fever, with self-care (see the recommendations on self-care)

    • an antibiotic not being needed immediately

    • using the back-up prescription if symptoms do not improve within 7 days or if they worsen rapidly or significantly at any time

    • seeking medical help if symptoms worsen rapidly or significantly despite taking the antibiotic, or the antibiotic has been stopped because it was not tolerated

 

  • Reassess if symptoms worsen rapidly or significantly despite taking treatment, taking account of:

    • alternative diagnoses such as a dental infection

    • any signs or symptoms suggesting a more serious illness or condition

    • previous antibiotic use, which may lead to resistant organisms

 

People presenting at any time who are systemically very unwell, have symptoms and signs of a more serious illness or condition, or are at high risk of complications

  • Offer an immediate antibiotic prescription (see the recommendations on choice of antibiotic) or further appropriate investigation and management in line with the NICE guideline on respiratory tract infections (self-limiting): prescribing antibiotics

 

  • Refer people to hospital if they have symptoms and signs of acute sinusitis associated with any of the following:

    • a severe systemic infection (see the NICE guideline on sepsis)

    • intraorbital or periorbital complications, including periorbital oedema or cellulitis, a displaced eyeball, double vision, ophthalmoplegia, or newly reduced visual acuity

    • intracranial complications, including swelling over the frontal bone, symptoms or signs of meningitis, severe frontal headache, or focal neurological signs.

 

Treating Your Infection

Patient Information leaflet to be used with patients who are experiencing self limiting URTIs

 

Adapted for use in ROI

From : Treat Antibiotics Responsibly, Guidance, Education, Tools (TARGET) 

Royal College of General Practitioners (RCGP UK)

Access

 

Choice of antibiotic

 

Acute sinusitis : Antibiotics for adults aged 18 years and over

 

Acute sinusitis : Antibiotics for children and young people under 18 years

 

Summary tables: infections in primary care

Management and treatment of common infections:

guidance for consultation and adaptation

Access

 

Self-care

 

  • Explain that some people may wish to try nasal saline or nasal decongestants, although there is not enough evidence to show that they help to relieve nasal congestion

 

  • Explain that no evidence was found for using oral decongestants, antihistamines, mucolytics, steam inhalation, or warm face packs

 
NICE.jpg
PHE.png

NICE 2018. 

Sinusitis guideline NG79

April 2018

View/Access

NICE Guideline NG15

​Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use

August 2015

Access

Management and treatment of common infections

Public Health England (PHE)

October 2017

Access

Acute pharyngitis

BMJ Best Practice

January 2019

Access

Slavin RG, Spector SL, Bernstein IL, et al.

The diagnosis and management of sinusitis: a practice parameter update.

J Allergy Clin Immunol. 2005;116(suppl 6):S13-S47

Access

Gendo K.

Evidence-based diagnostic strategies for evaluating suspected allergic rhinitis.

Ann Intern Med. 2004;140:278-289

Access

Thomas M, Yawn BP, Price D, et al.

EPOS primary care guidelines: European position paper on rhinosinusitis and nasal polyps.

Rhinology. 2012 Mar;50(1):1-12.

Access

 

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