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ACEP Now: Vol 35 – No 10 – October 2016

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Your first patient of the shift is a 40-year-old woman with a fever of 101 degrees Fahrenheit, and has had congestion, facial pain, and thick, yellow nasal discharge for the past three days. You diagnose her with acute sinusitis, and she asks if she needs any testing to confirm the diagnosis or antibiotics to help clear up the infection.

Acute sinusitis or rhinosinusitis (the latter term is preferred since sinus inflammation almost never occurs without nasal mucosal inflammation) affects one in seven adults annually and accounts for $4.3 billion in annual direct health care expenditures.

CT Has No Role in Routine Management

Acute rhinosinusitis is a clinical diagnosis, characterized by nasal discharge, congestion, facial pain or pressure, postnasal drip, olfactory dysfunction, fever, and/or ear pain or pressure. The vast majority of acute sinusitis and rhinosinusitis cases are viral, associated with the common cold, and only 0.5 to 2 percent are acute bacterial rhinosinusitis.¹

Non-contrast computerized tomography (CT) of the sinuses is used to characterize sinus anatomy prior to surgery in patients with chronic refractory sinusitis. In the emergency department setting, CT is the diagnostic modality of choice for complications of bacterial sinusitis, such as intraorbital or intracranial extension, abscess, or osteomyelitis.

There’s no indication for CT in the routine management of acute uncomplicated rhinosinusitis, however. In fact, a prospective study found sinus abnormalities in 37 percent of asymptomatic adults and 87 percent of adults with common cold symptoms (rhinitis only).^2,3 Additional studies have shown poor correlation between abnormalities on CT and symptoms.⁴

Medicare reimbursement (a conservative estimate of cost) for non-contrast CT max/face (or sinus) is $173.85. A recent study in a managed care population found that among ED patients with sinusitis, over 25 percent underwent CT scans, compared to 0.6 percent and 1.4 percent in primary care and urgent care settings, respectively.⁵ Based on 350,000 annual ED visits for sinusitis, a 50 percent reduction in current CT use rates would result in $7.6 million in annual savings.

Antibiotics: Unnecessary and Overprescribed

Nearly all acute rhinosinusitis is viral and associated with organisms that cause the common cold. A 2013 Cochrane review of four randomized, controlled studies found that antibiotics had no effect on persistence of acute purulent rhinosinusitis, and that antibiotics were associated with high rates of side effects when compared to a placebo.⁶

Among the 2 percent of patients with bacterial rhinosinusitis, the majority will improve without antibiotics within 10 to 14 days.⁷ Acute purulent bacterial rhinosinusitis is rare and is characterized by:

• Persistent or worsening symptoms lasting over 10-14 days;
• Fever of greater than 102 degrees Fahrenheit (39 degrees Celsius) for three to four consecutive days (in contrast to a fever in a common cold, which usually lasts 24 to 48 hours);
• Unilateral facial pain; and
• Worsening symptoms after typical viral cold symptoms seem to be improving.

Despite this, 85 percent of ED patients diagnosed with sinusitis receive antibiotics.⁸ Furthermore, there’s wide variation in ED antibiotic prescribing patterns for bacterial sinusitis. Amoxicillin-clavulanate for five to seven days (not 10 to 14 days) is the first-line treatment, while doxycycline or a respiratory fluoroquinolone can be used for penicillin-allergic patients. Due to antibiotic resistance, probably related to previous overuse, amoxicillin is no longer the recommended first-line therapy.

Effective Alternatives for Acute Sinusitis

Nasal corticosteroids have shown evidence of symptom improvement in both viral and bacterial acute rhinosinusitis. Nasal irrigation has been shown to have modest benefit in symptom reduction as well.

Limited use of topical decongestants such as oxymetazoline has shown benefit in treating viral rhinosinusitis. Oral decongestants (phenylephrine, pseudoephedrine) and antihistamines have not been shown to be superior to a placebo in randomized trials and may worsen inflammation by drying mucous membranes.

(click for larger image)
Table 1. Conversation Guide for Acute Sinusitis

So, the next time you diagnose a patient with acute sinusitis, skip the CT and antibiotics and offer a prescription for evidence-based symptomatic therapy instead (see Table 1). Opting for a cost-effective approach to sinusitis can not only improve quality of care and reduce costs, it can actually relieve your patient’s sinus discomfort.

References

1. Fokkens W, Lund V, Mullol J. European Position Paper on Rhinosinusitis and Nasal Polyps Group. EP3OS 2007: European position paper on rhinosinusitis and nasal polyps 2007. A summary for otorhinolaryngologists. Rhinology. 2007 Jun;45(2):97–101.
2. Nazri M, Bux SI, Tengku-Kamalden TF, Ng K-H, Sun Z. Incidental detection of sinus mucosal abnormalities on CT and MRI imaging of the head. Quant Imaging Med Surg. 2013 Apr;3(2):82–8.
3. Gwaltney JM, Phillips CD, Miller RD, Riker DK. Computed Tomographic Study of the Common Cold. N Engl J Med [Internet]. 1994 Jan 6 [cited 2015 May 13];330(1):25–30. Accessed: Aug. 23, 2016.
4. Basu S, Georgalas C, Kumar BN, Desai S. Correlation between symptoms and radiological findings in patients with chronic rhinosinusitis: an evaluation study using the Sinonasal Assessment Questionnaire and Lund-Mackay grading system. Eur Arch Otorhinolaryngol. 2005 Sep;262(9):751–4.
5. Sharp AL, Klau MH, Keschner D, Macy E, Tang T, Shen E, Munoz-Plaza C, Kanter M, Silver MA, Gould MK. Low-value care for acute sinusitis encounters: who‘s choosing wisely? Am J Manag Care. 2015 Jul;21(7):479-85.
6. Kenealy T, Arroll B. Antibiotics for the common cold and acute purulent rhinitis. Cochrane Database Syst Rev. 2013;6:CD000247.
7. Ahovuo-Saloranta A, Rautakorpi U-M, Borisenko OV, Liira H, Williams JW, Mäkelä M. Antibiotics for acute maxillary sinusitis in adults. Cochrane Database Syst Rev. 2014;2:CD000243.
8. Fairlie T, Shapiro DJ, Hersh AL, Hicks LA. National trends in visit rates and antibiotic prescribing for adults with acute sinusitis. Arch Intern Med [Internet]. 2012 Oct 22 [cited 2015 May 12];172(19):1513–4. Accessed: Aug. 23, 2016.