Clinical Intelligence

Neil Foden, Christopher Burgess, Kathryn Shepherd and Robert Almeyda

A guide to the management of acute

rhinosinusitis in primary care
management strategy based on best evidence and recent European guidelines

INTRODUCTION parainfluenza, and influenza with rhinovirus

The terms rhinitis and sinusitis have being the most common. The commonest
been superseded by rhinosinusitis, which organisms in acute bacterial rhinosinusitis
represents the understanding that the two (ABRS) include Streptococcus pneumonia
conditions usually coexist. Rhinosinusitis (41%) and Haemophilus influenza (35%).
can be subdivided into acute and chronic. Other causes include anaerobes, Moraxella,
Acute rhinosinusitis (ARS) presents an Strep spp and Staphylococcus aureus.4
enormous burden in primary care. It is Most cases of ARS are viral. Bacterial
estimated that around 1–2% of visits to a GP rhinosinusitis occurs most commonly
in Europe are for symptoms of ARS.1 secondary to a viral infection. Other risk
ARS is seen across a wide spectrum of factors for ARS include allergies, cigarette
ages, but is less common in the paediatric smoking, and anatomical variation.5
group due to the relative immature Seasonal variations in the incidence of ARS
development of the sinuses in children have also been reported, with cases being
(maxillary and ethmoidal sinuses develop much more likely during the first early
during gestation, whereas the frontal and months of the year.
sphenoid sinuses begin to develop at the
age of 3 years but are not fully developed DEFINITION AND DIAGNOSIS
until late adolescence). A consequence of The European Position Paper on
patients presenting to primary care is the rhinosinusitis and nasal polyps (EPOS 2012)3
associated high pharmacy costs. Ashworth presents an evidence-based approach to
et al found that a prescription for antibiotics the treatment of all types of rhinosinusitis.
was given in 92% of patients with symptoms A definition of ARS in adults for use in
of ARS.2 primary care is:3
This article provides a summary of the
current best evidence for the management Sudden onset of two or more symptoms,
of ARS in primary care and highlights the one of which should be either nasal
recent guidelines provided by the European blockage/obstruction/congestion or nasal
Position Paper on Rhinosinusitis and Nasal discharge (anterior/posterior nasal drip):
Polyps (EPOS2012).3
+/– facial pain/pressure
AETIOLOGY AND PATHOPHYSIOLOGY +/– reduction or loss of smell
N Foden, MBChB (Hons), SpR in
otolaryngology; C Burgess, BM BCh, SpR The paranasal sinuses are lined by
in otolaryngology; R Almeyda, ORL-HNS, pseudostratified ciliated columnar epithelia for <12 weeks;
consultant in otolaryngology, Department Of containing basal cells, columnar cells, and with symptom free intervals if the problem
Otolaryngology, John Radcliffe Hospital, Oxford.
K Shepherd, MBChB (Hons) GP, Manor Health mucus-secreting goblet cells. Secretions is recurrent, with validation by telephone or
Centre, Wirral. aid humidification, olfaction, and filtration. interview.
Address for correspondence Cilia are crucial to mucus clearance. The
Neil Foden, John Radcliffe Hospital, cilia can be damaged by smoking, chronic ARS becomes chronic rhinosinusitis
Otolaryngology, Headley Way, Oxford, OX3 9DU. nasal disease, or genetic predisposition (CRS) when symptoms persist for more
E-mail: [email protected]
such as primary cilia dyskinesia. When the than 3 months. ARS can be considered as
Submitted: 7 February 2013; final acceptance:
15 March 2013.
clearance of mucus from the paranasal recurrent but only if the previous episode
©British Journal of General Practice 2013; sinuses to the meati of the nose is has fully resolved.
63: 611–613. interrupted, mucus trapping can occur with ARS in children is defined as:3
increased risk of infection.
DOI: 10.3399/bjgp13X674620 Viral causes of the common cold include Sudden onset of two or more of the
respiratory syncytial virus (RSV), rhinovirus, symptoms:

British Journal of General Practice, November 2013 611

 1. nasal blockage/obstruction/congestion in patients with ARS found that 15 patients
2. or discoloured nasal discharge would need to be treated with antibiotics
before a benefit would be seen in a single
3. or cough (day and night time)
case.6 The number needed to treat (NNT)
was lower at 8 for those with a finding
This diagnosis is open and makes of purulent discharge in the pharynx.
differentiation from the common cold The review could not find a justification
difficult. for the use of antibiotics in ARS, even in
A common cold (acute viral rhinosinusitis) those patients with symptoms for more
has duration of symptoms of <10 days. than 7–10 days. This highlights a pitfall in
Acute post-viral rhinosinusitis is seen identifying patients with a bacterial cause
when symptoms worsen after 5 days or who would benefit from antibiotics. It is
symptoms are persistent beyond 10 days difficult to directly compare studies where
but <12 weeks duration. Finally, acute there is no consistent choice or dose of
bacterial rhinosinusitis (ABRS) would be antibiotic. A Cochrane Review found only a
indicated by the presence of at least 3 of: small benefit in patients treated for ARS with
symptoms longer than 7 days in primary
1. discoloured discharge (unilateral care but 80% of patients not treated recover
predominance); within 2 weeks anyway.7 A Dutch study
2. severe local pain (unilateral reported an incidence of complications
predominance); of 3 per million per population annually
3. fever, that is, >38°C; and the prescribing of antibiotics does not
appear to reduce the rate of complications
4. elevated inflammatory markers (CRP);
from ARS.8 A Cochrane Review did not find
and
any deleterious results in patients with
5. ‘double sickening’ whereby the patient’s upper respiratory tract infections (URTIs) in
condition deteriorates. whom antimicrobial therapy was delayed.9
Therefore, patients should not be
The majority of patients presenting with prescribed antibiotics routinely or a delayed
symptoms of ARS will have a common cold. antibiotic prescribing strategy could be
This is followed by post-viral rhinosinusitis employed. Antibiotics should be reserved
and only a very small proportion of patients for patients who are systemically unwell;
will have ABRS and therefore will be symptoms are persistent beyond 10 days,
amenable to management with antibiotics. a worsening of symptoms after 5 days, or
There is no role for imaging for suspected in those with severe symptoms after this
ARS in primary care.3 time period (clinically, severe local pain,
fever, discoloured discharge, or double
COMPLICATIONS OF ACUTE sickening).3 If antibiotics are prescribed
RHINOSINUSITIS after weighing up the risks and benefits,
Although relatively rare, the sequelae amoxicillin, doxycycline, or clarithromycin
of complications can be devastating. for 7 days can be considered, with
Complications can be divided into co-amoxiclav as a backup if no improvement
intracranial, bony (osseous), and orbital is seen within the first 48 hours.
with the latter being most common. If patients require antibiotics and still
Orbital complications range from show no signs of improvement, then
preseptal cellulitis to orbital abscess and referral to ENT is required.
cavernous sinus thrombosis. Intracranial
complications usually result in encephalitis Steroids
Box 1. Red flag signs in ARS or abscess. Osteomyelitis can result from Intranasal corticosteroids (INCS) form the
warranting urgent referral to infection of the bone. Finally, an episode of mainstay of treatment in rhinosinusitis.
ENT ARS can become chronic if no resolution Meltzer et al conducted a large trial of 981
Red flags occurs. patients.10 They found INCS as monotherapy
• Frontal swelling in ARS provided a significant improvement
• Severe frontal headache (worse than MANAGEMENT in symptoms compared to placebo
patient has experienced before)
• Neurological signs The management guidelines of ARS by (P<0.001) and amoxicillin (P = 0.002). The
• Signs of meningitis on clinical examination GPs have been summed up by EPOS same author found INCS to increase the
• Reduced level of consciousness 2012.3 Referral for ARS to ENT should be number of ‘minimal-symptom’ days in
• Reduced visual acuity immediate for any of the ‘red flag’ signs in patients suffering ARS.11 A Cochrane Review
• Double vision (diplopia)
• Periorbital oedema/erythema (cellulitis) Box 1. also supported the use of INCS, either
• Displaced globe as monotherapy or adjuvant to antibiotics
• Opthalmoplegia Antibiotics (when indicated) but these studies also
Young et al ’s meta-analysis of antibiotic use relied on the confirmation of diagnosis

612 British Journal of General Practice, November 2013

 by radiology or nasendoscopy,12 which There is little evidence to date to
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consultation rates for acute respiratory infection
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