Evidence-Based Sinusitis

Sinusitis is one of the most common reasons people go to the doctor, causing an estimated 20 million doctor visits in the U.S. each year. The illness also accounts for a vast number of antibiotic prescriptions—nearly 1 in 5 (Cochrane Database Syst Rev. 2008;2:CD000243).

The American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) Foundation set the standard in developing a clinical practice guideline for sinusitis in 2007. At the time, the only materials available from otolaryngology were consensus documents and literature reviews, said Rich Rosenfeld, MD, MPH, professor and chair of otolaryngology at SUNY Downstate Medical Center in Brooklyn, N.Y., and lead author of the AAO guidelines. “There were not really any validated, trustworthy guidelines.”

Now, five years later, the Infectious Diseases Society of America (IDSA) has drawn up its own set of guidelines. “The IDSA has been putting out clinical practice guidelines for some time, but there had never been one on sinusitis,” said Tony Chow, MD, professor emeritus in the division of infectious diseases at the University of British Columbia and Vancouver Hospital and lead author of the IDSA guidelines. “It’s a controversial area and also an area for overuse of antibiotics.”

Both groups recruited multidisciplinary teams that followed established protocols for reviewing the literature systematically and developing actionable statements.

The main difference is the focus: The IDSA guidelines are for acute bacterial sinusitis in children and adults, whereas the AAO guidelines cover adult patients with either acute or chronic sinusitis. Other variations arise out of differing interpretations of randomized clinical trials.

The good news is that the two sets of guidelines are largely in agreement for acute adult sinusitis. Where they do diverge, the gap is not wide enough to be polarizing. In many cases, shared decision making by doctors and their patients may override the subtle differences in guideline advice.

Here’s a closer look at the two sets of guidelines, the evidence upon which they are based and the differing perspectives of infectious disease scientists versus ear, nose and throat doctors. With a better understanding of the whys behind the guidelines, practitioners will be in a better position to align their own practice in an informed way.

Diagnosis

The first key to appropriate treatment is identifying the causes of sinusitis. Both sets of guidelines tackle how to diagnose bacterial sinusitis and differentiate it from the far more common viral cases. Basically, if symptoms of purulent nasal drainage, nasal obstruction and facial pain/pressure persist for at least 10 days, or if symptoms worsen after an initial improvement (double sickening), then doctors can presume bacterial involvement.