Classification, Diagnosis and Treatment of Sinusitis: Evidence-Based Clinical Practice Guidelines

Abstract

OBJECTIVE: To provide evidence-based recommendations for classification, diagnosis and treatment of acute, chronic and recurrent acute sinusitis in adults and children.DATA SOURCES: Review articles, textbooks, other published guidelines and recommendations of task force members.STUDY SELECTION: One hundred and seventy-one papers addressing one or all of the objectives.DATA EXTRACTION: Relevant data were collated under each objective.DATA SYNTHESIS: Validity of diagnostic and treatment evidence was assessed by using the methodological recommendations of Sackett et al and the canadian Task Force on Periodic Health Examination, respectively. Where there was a paucity of data, consensus of task force members was reached.CONCLUSIONS: Sinusitis is classified as acute, chronic or recurrent acute disease according to duration and frequency of symptoms and response to therapy (expert opinion). Potential risk factors, concomitant diseases and complications are identified (limited evidence). Diagnosis is based on symptoms, history and physical examination. For adults, independentpredictors of acute sinusitis include maxillary toothache, coloured nasal discharge, poor response to nasal decongestants/antihistamines and mucopurulent nasal secretions (good evidence); for children, cough, nasal discharge and fever are common (good evidence). For chronic disease that persists despite adequate therapy and recurrent acutedisease, referral to a specialist for investigative measures (nasal endoscopy, computed tomography) is often necessary to determine predisposing anatomical features. Level I evidence supports the use of antibiotics for the treatment of sinusitis; selection is based on the local pattern of bacterial resistance, relative efficacy, safety and cost. Amoxicillinclavulanate, cefuroxime axetil, cefixime, ciprofloxacin and clarithromycin are approved for the treatment of acute sinusitis in canada. Amoxicillin, amoxicillin-clavulanate and cefuroxime axetil have been shown to be effective in children. Ciprofloxacin, amoxicillin-clavulanate, clarithromycin and erythromycin have been shown to be effective in chronic disease, although no agents have been approved for this indication. Given changing patterns of bacterial resistance, more up-to-date comparative efficacy data are needed.