The Many Faces of Rhinosinusitis: Case Challenges

Gordon H. Sun, MD, MS

September 22, 2015

Management of ABRS

Guidelines from the AAO-HNSF,[1] Infectious Diseases Society of America (IDSA),[3] and Canadian Society of Otolaryngology-Head and Neck Surgery (CSO-HNS)[4] all suggest either amoxicillin alone or amoxicillin with clavulanate as first-line antibiotic therapy for ABRS in adults. Use of amoxicillin as first-line therapy is based on the drug's good safety and efficacy profile, low cost, and narrow microbiological spectrum. The 2015 AAO-HNSF guideline[2] recommends amoxicillin with or without clavulanate, a change from the 2007 version[5] in which amoxicillin alone was recommended. Although the IDSA supports the use of amoxicillin with clavulanate over amoxicillin alone, the organization acknowledges that the evidence for this decision is relatively weak, primarily based on in vitro studies and epidemiologic reports of beta-lactamase production among Haemophilus influenzae isolates.[3]

First-line alternatives for adult patients with penicillin allergies include a fluoroquinolone (eg, levofloxacin), a macrolide (eg, azithromycin), doxycycline, or trimethoprim/sulfamethoxazole. There is no consensus among the three sets of guidelines on which of these alternatives for penicillin-allergic patients is optimal.

The frequency and type of antibiotics prescribed for ABRS vary substantially. Bhattacharyya and Kepnes[6] reported a significant increase in the use of amoxicillin as the antibiotic of choice for acute rhinosinusitis in adults after the publication of the 2007 AAO-HNSF clinical practice guideline. Data from the 2006-2010 US National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey Outpatient Department component indicate that the three most commonly prescribed antibiotic classes for acute rhinosinusitis are penicillins/beta-lactams (54.4%), macrolides (28.7%), and quinolones (19.9%).[7] In contrast, a study of acute rhinosinusitis antibiotic prescription patterns in the Kaiser Permanente Southern California system found that amoxicillin and amoxicillin with clavulanate were the two most commonly prescribed antibiotics, but one half of all filled prescriptions were for patients with symptoms of less than 7 days' duration.[8]

Watchful waiting, which involves the deferral of antibiotic treatment for up to 7 days after the diagnosis of ABRS and limits management to symptom relief, is another reasonable option for initial management of ABRS. In another change from the older AAO-HNSF guideline, the 2015 version now recommends either watchful waiting without antibiotics or amoxicillin with or without clavulanate for adults with uncomplicated ABRS.[1] This strategy is no longer limited to patients with "mild" symptoms, but can be offered to anyone with symptoms of any severity. The guideline authors concluded that there was no evidence that patients with "severe" disease were more likely to benefit from antibiotic therapy, owing to the lack of a specific, consistent explanation for what actually constituted severe disease in randomized trials of antibiotics vs watchful waiting for ABRS.

An effective watchful waiting strategy includes a reliable mechanism for follow-up reevaluation if the ABRS fails to improve within 7 days of diagnosis or if it worsens at any time.

It should be noted that other guidelines do not necessarily agree with the AAO-HNSF's stance on watchful waiting. The 2012 IDSA guideline recommends antibiotic therapy without watchful waiting in patients with severe symptoms or signs, defined as high fever (≥102.2°F) and purulent rhinorrhea or facial pain lasting for 3-4 days at the beginning of illness onset.[3]

Clinical Presentation: Third Case—Unending Congestion

A 40-year-old radiology technician with long-standing nasal congestion, rhinorrhea, and reduced sense of smell is being seen by her internist for the first time. The patient told her new physician that her previous provider had said that she had "some kind of sinus problem" but did not know the specific diagnosis. She reported frequent use of oral antibiotics with previous flare-ups of rhinorrhea and congestion, at least three times annually over the past 2-3 years. However, she also felt that her sinus-related symptoms never resolved completely and lingered throughout the entire year.

The patient denied a history of headaches, asthma, or seasonal allergies, and she reported being a nonsmoker. Her most recent course of amoxicillin with clavulanate was completed about 4 months ago.

The internist was preparing the patient for a nasal exam, suspecting a diagnosis of CRS. The patient asked her physician whether CT was absolutely necessary to support the diagnosis, saying that "I work with radiologists all the time, and I know that there are a lot of risks with having too many CT scans." She inquired whether there were other ways of objectively documenting clinical evidence of CRS besides CT.

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