The ACEP Clinical Policies Committee regularly reviews guidelines published by other organizations and professional societies. Periodically, new guidelines are identified on topics with particular relevance to the clinical practice of emergency medicine. This article highlights recommendations published by the American Academy of Otolaryngology-Head and Neck Surgery in 2015 for diagnosis and treatment of sinusitis in adults.1
Sinusitis is a huge burden on the health care system. Twelve percent of U.S. adults are diagnosed with sinusitis every year.2 Sinusitis accounts for more primary ambulatory care visits associated with an antibiotic prescription than any other diagnosis and is estimated to cost the health care system more than $3 billion every year.3 Emergency providers are often faced with requests for imaging and treatment for sinusitis, and the twin pressures of wanting the most efficient remedy and patient experience with various treatments may make these encounters difficult for both patients and providers.
Recently, the American Academy of Otolaryngology-Head and Neck Surgery updated their recommendations to help guide physicians and patients on the diagnosis and management of adults presenting with sinusitis.
The guideline was developed through a literature review to include data published since the last version of the guideline in 2007. In all, five guidelines, 42 systematic reviews, and 70 randomized controlled trials were included for consideration. A working group developed a draft, which was open for public comment and multidisciplinary peer review, and a final version was published in April 2015.
In all, 12 statements comprise the guideline with varying levels of evidence supporting each as a strong recommendation, a recommendation, or an option to providers:
- For strong recommendations, benefits clearly exceed harms, and evidence is at a Grade A or B level.
- For recommendations, benefits exceed harm, and the quality of evidence isn’t as high (Grade B or C).
- For Options, either the quality of evidence is suspect (Grade D) or well-done studies (Grade A or B) show little advantage of one approach to another.
The guideline is quite comprehensive, but the following statements are particularly pertinent to EM practice:
Statement 1A: Differential Diagnosis of Acute Rhinosinusitis
“Clinicians should distinguish presumed acute bacterial rhinosinusitis (ABRS) from acute rhinosinusitis (ARS) caused by viral upper respiratory infections and noninfectious conditions. A clinician should diagnose ABRS when (a) symptoms or signs of ARS (i.e. purulent nasal drainage accompanied by nasal obstruction, facial pain-pressure-fullness, or both) persist without evidence of improvement for at least 10 days beyond the onset of upper respiratory symptoms, or (b) symptoms or signs of ARS worsen within 10 days after an initial improvement (double worsening).” (Strong recommendation)