Clinical Review

Sinusitis and its management

BMJ 2007; 334 doi: http://dx.doi.org/10.1136/bmj.39092.679722.BE (Published 15 February 2007) Cite this as: BMJ 2007;334:358
  1. Kim W Ah-See, consultant ENT surgeon,
  2. Andrew S Evans, specialist registrar in ENT
  1. Department of Otolaryngology, Head, and Neck Surgery, Aberdeen Royal Infirmary, Aberdeen AB25 2ZN
  1. kim.ah-see{at}nhs.net

    Sinusitis is one of the most common diagnoses in primary care. It causes substantial morbidity, often resulting in time off work, and is one of the commonest reasons why a general practitioner will prescribe antibiotics.1

    Summary points

    • Rhinosinusitis is a common primary care condition

    • Most cases of acute rhinosinusitis resolve with symptomatic treatment with analgesics

    • Chronic rhinosinusitis may, however, require referral to an ear, nose, and throat specialist for possible endoscopic sinus surgery if medical management fails

    • Patients with acute facial pain or headache but no other nasal symptoms are highly unlikely to have rhinosinusitis

    • Urgent referral is required if complications of rhinosinusitis are suspected—such as orbital sepsis or intracranial sepsis

    Sources and selection criteria

    We searched Medline for recent papers (1996-2006) using “sinusitis”, “rhinosinusitis”, “acute”, “chronic”, “diagnosis”, and “management” as keywords. We also searched the Cochrane Database of systematic reviews using the keywords “sinusitis” and “rhinosinusitis”. In addition, we used a personal archive of references relating to our clinical experience and updates written for Clinical Evidence.

    Causes of sinusitis

    Sinusitis is generally triggered by a viral upper respiratory tract infection, with only 2% of cases being complicated by bacterial sinusitis.2 About 90% of patients in the United States are estimated to receive an antibiotic from their general practitioner, yet in most cases the condition resolves without antibiotics, even if it is bacterial in origin.3 Most general practitioners rely on clinical findings to make the diagnosis. Signs and symptoms of acute bacterial sinusitis and those of a prolonged viral upper respiratory tract infection are closely similar, resulting in frequent misclassification of viral cases as bacterial sinusitis. Boxes 1 and 2 list common and rarer causes of rhinosinusitis.

    Box 1: Common causes of rhinosinusitis

    • • Viral infection

    • • Allergic and non-allergic rhinitis

    • • Anatomical variations

      • Abnormality of the osteomeatal complex

      • Septal deviation

      • Concha bullosa

      • Hypertrophic middle turbinates

    • Cigarette smoking

    • Diabetes mellitus

    • Swimming, …

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