Sinusitis Referral Guidelines

Diagnosis/Definition

• Sinusitis is defined as an infection of the paranasal sinuses, typically secondary to obstruction of normal sinus outflow.
• The obstruction can be either mucosal (i.e. edema due to allergy, URI, irritants etc) or bony (i.e. anatomical narrowing due to trauma, polyps etc) or a combination of both.
• Treatment is designed to relieve the obstruction and eradicate the infection.
• Chronic sinusitis refers to the persistence of symptoms despite adequate medical therapy for over 12 weeks.

Initial Diagnosis and Management

• History: Pertinent historical data include the duration of symptoms and previous treatment, history of prior episodes, and complaints of nasal obstruction, anosmia, facial or dental pain, rhinorrhea (clear, mucoid or purulent), post nasal drip, and visual changes. Documentation of any facial trauma and allergy history should also be done.
• Physical: Physical findings should note any rhinorrhea, septal deviation, nasal polyps, facial tenderness or asymmetry, post nasal drainage, and turbinate hypertrophy pre and post decongestant treatment.
• Additional studies: Plain film X-rays are discouraged in the acute sinusitis setting because they rarely add useful information. A Landmarx CT scan of the sinuses is indicated after a second 3-week trial of antibiotics with recurrent or unresolved symptoms.
• Initial management: Antibiotics should usually be reserved for select patients who are at higher risk for developing bacterial infections. Because up to 80% of sinusitis cases resolve on their own within 2 weeks, doctors generally wait 7 - 14 days before prescribing antibiotics. The standard first-line antibiotic treatment for acute uncomplicated bacterial sinusitis is a 10 - 14 day course of amoxicillin. Trimethoprim-sulfamethoxazole is an alternative choice. This is supplemented with nasal saline rinses and topical nasal decongestant therapy for 3-5 days. The use of mucolytics (guaifenesin), oral decongestants, antihistamines, and nasal steroids are dictated by the patient’s history.
• For recurrent or unresolved symptoms, a second line antibiotic such as Levaquin 500mg PO daily or Augmentin 875mg PO BID is used for no less than 3 weeks, nasal steroid therapy is instituted, and sometimes oral steroids are started (Prednisone 40mg daily for one week followed by 20mg daily the second week): be cautious with use of steroids in diabetics and the elderly and other at risk patients. A CT scan is obtained after this therapy for recurrent or persistent symptoms. For those patients with a strong allergy history, an allergy evaluation may be indicated. For recurrent sinusitis (3 or more episodes in 6 months) despite maximal medical therapy, a sinus CT scan is indicated.

Indications for Specialty Care Referral

• Sinusitis unresponsive to medical therapy after a 3 week trial of a second line agent and a full course of nasal steroid therapy with evidence of disease on the post-treatment sinus CT scan.
• Recurrent sinusitis - 3 or more episodes in a 6 month period despite adequate medical treatment as outlined above and evidence of disease on the sinus CT scan.
• Patient with known immune compromise or ciliary motility problem.
• Orbital or cranial complications of sinus infections.
• Recurrent nasal polyps unresponsive to medical therapy and evidence of disease on the sinus CT scan.
• Any evidence of tumor noted on exam or CT.