Acute Sinusitis: A Cost-Effective Approach to Diagnosis and
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- L.J. FAGNAN, M.D.,
- Oregon Health Sciences
University
- Portland, Oregon
Acute bacterial sinusitis usually
occurs following an upper respiratory infection that results in
obstruction of the osteomeatal complex, impaired mucociliary clearance
and overproduction of secretions. The diagnosis is based on the
patient's history of a biphasic illness ("double sickening"), purulent
rhinorrhea, maxillary toothache, pain on leaning forward, pain with a
unilateral prominence and a poor response to decongestant therapy.
Radiographs and computed tomographic scans of the sinuses generally
are not useful in making the initial diagnosis. Since sinusitis is
self-limited in 40 to 50 percent of patients, the expensive,
newer-generation antibiotics should not be used as first-line
therapy.
First-line antibiotics such as amoxicillin or trimethoprim-sulfamethoxazole are as effective in the treatment of
sinusitis as the more expensive antibiotics. Little evidence supports
the use of adjunctive treatments such as nasal corticosteroids and
systemic decongestants. Patients with recurrent or chronic sinusitis
require referral to an otolaryngologist for consideration of
functional endoscopic sinus surgery.
Sinusitis is a
common ailment: 16 percent of the U.S. population reports a diagnosis of
sinusitis annually, accounting for 16 million office visits.1
Public interest in sinusitis is exemplified by a 1997 Internet search
using Alta Vista, which found 4,960 matches. Furthermore, sinusitis is a
costly disorder: about $2 billion is spent annually on medications to
treat nasal and sinus problems.1 The
National Ambulatory Medical Care Survey (NAMCS) lists sinusitis as the
fifth most common diagnosis for which an antibiotic is prescribed.2
Sinus Anatomy and
Function
The function of the paranasal sinuses is not clear,
but theories include humidification and warming of inspired air,
lightening of the skull, improvement of vocal resonance, absorption of
shock to the face or skull, and secretion of mucus to assist with air
filtration. The four paranasal sinuses (maxillary, frontal, ethmoid and
sphenoid) develop as outpouchings of the nasal mucosa. They remain
connected to the nasal cavity via narrow ostia with a lumen diameter of
1 to 3 mm (Figure 1). The sinuses are lined with mucoperiosteum,
which is thinner and less richly supplied with blood vessels and glands
than the mucosa of the nasal cavity. Cilia sweep mucus toward the ostia.
The ostia of the frontal, maxillary and anterior ethmoid sinuses open
into the osteomeatal complex, which lies in the middle meatus lateral to
the middle turbinate. The posterior ethmoid and sphenoid sinuses open
into the superior meatus and sphenoethmoid recess. The osteomeatal
complex is important because the frontal, ethmoid and maxillary sinuses
drain through this area.
SOURCE
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