Acute Rhinosinusitis
NICE guideline [NG79] Sinusitis (acute): antimicrobial prescribing. Published: Oct 2017.
Background Information
Definition
Rhinosinusitis is a symptomatic inflammation of the mucosal lining of the paranasal sinuses and nasal cavity.
Acute vs chronic rhinosinusitis:
- Acute rhinosinusitis: symptoms that completely resolve within 12 weeks
- Chronic rhinosinusitis: symptoms lasting 12 weeks or longer
Guidelines
Management
Approach:
- 1st line: conservative management
- If no improvement after ≥10 days (or worsening): further management (intranasal steroids or antibiotics)
Step 1: Conservative Management
Do not offer antibiotics. Offer the following for symptomatic relief:
- Advise that the usual course of acute sinusitis is 2-3 weeks
- Paracetamol or ibuprofen for pain or fever
- Patients may try nasal saline or nasal decongestants but the evidence is not strong
Step 2: Further Management
Consider the following (if there is no improvement of symptoms after ≥10 days OR a worsening of symptoms)
- Intranasal corticosteroids for 14 days
- Antibiotic therapy (back-up) for 5 days
- 1st line: phenoxymethylpenicillin (penicillin V)
- Penicillin allergic: clarithromycin / erythromycin (if pregnant)
- If systemically unwell / features of more serious illness / high risk of complications: co-amoxiclav
The following features are suggestive of bacterial infection (vs viral) in acute sinusitis:
- Persistent symptoms for ≥ 10 days
- Discoloured or purulent nasal discharge
- Severe localised pain (often unilateral, esp. pain over teeth and jaw)
- Fever > 38°C.
- Marked deterioration after an initial milder phase (double sickening)