The double worsening pattern in sinusitis occurs when a patient seems to be recovering and then relapses, he said. When double worsening occurs, the otolaryngologist should be suspicious of a bacterial infection even if 10 days have not elapsed. Dr. Rosenfeld said that these clinical observations are sufficient for diagnosing bacterial sinusitis, and that nasal endoscopy and imaging studies are not necessary.
Explore This IssueOctober 2008
Dr. Anon agreed with Dr. Rosenfeld about the standard for suspecting bacterial sinusitis. However, he has a different approach for the use of diagnostic technology. Nasal endoscopy and cultures, if we see drainage in the middle meatus or superior meatus, are also tools in our armamentarium, he said.
In his research, Dr. Anon has found plain film X-rays, while lacking the sensitivity of computed tomography (CT), to be a benefit, in that the physician can confirm the presence or absence of disease within the maxillary and frontal sinuses.
Faster Healing versus Risk of Adverse Events
Drs. Anon and Rosenfeld agreed that the answer to the third question, whether to treat with antibiotics, is not answered as simply as the first two. The difference in their perspectives reflects the sea change that is occurring regarding antibiotic treatment of sinusitis.
Some physicians question the need for antibiotics in acute sinusitis, Dr. Anon said. He noted that one of the problems is in the way patients are selected for placebo-controlled trials, an issue that has been addressed recently in the literature.2
Most clinical studies will include patients with viral disease, which is self-resolving. Also, 60 percent of bacteriological sinus disease will self-resolve, he said.
Noting that the goal of an antibiotic is to get rid of bacterial disease, he said that otolaryngologists can use the acute otitis media literature as a model for sinusitis. The literature on otitis media is more plentiful because of the ease of obtaining cultures from an ear rather than from the sinus. In the otitis media setting, the literature shows that patients with a bacterial infection have better outcomes with effective antibiotics than without.
In his practice, Dr. Anon chooses the antibiotic with the best pharmacokinetics and pharmacodynamics for the sinuses. His treatment choices include amoxicillin clavunate with additional amoxicillin as a first-line approach. For penicillin-allergic patients, he uses levofloxacin or moxifloxacin. His own research shows that, in particular, levofloxacin is an effective alternative treatment for bacterial sinusitis.3
We have shown in several studies that levofloxacin will sterilize Haemophilus influenzae with one 750-mg dose, he said. Streptococcus pneumoniae requires about three days of treatment before the organism has been eradicated.