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Sinusitis, also known as rhinosinusitis, is inflammation of the mucous membranes that line the sinuses resulting in symptoms.[1][7] Common symptoms include thick nasal mucus, a plugged nose, and facial pain.[1][7] Other signs and symptoms may include fever, headaches, a poor sense of smell, sore throat, and a cough.[2][3] The cough is often worse at night.[3] Serious complications are rare.[3] It is defined as acute sinusitis if it lasts less than 4 weeks, and as chronic sinusitis if it lasts for more than 12 weeks.[1]

Sinusitis can be caused by infection, allergies, air pollution, or structural problems in the nose.[2] Most cases are caused by a viral infection.[2] A bacterial infection may be present if symptoms last more than 10 days or if a person worsens after starting to improve.[1] Recurrent episodes are more likely in persons with asthma, cystic fibrosis, and poor immune function.[1] X-rays are not usually needed unless complications are suspected.[1] In chronic cases, confirmatory testing is recommended by either direct visualization or computed tomography.[1]

Some cases may be prevented by hand washing, avoiding smoking, and immunization.[2] Pain killers such as naproxen, nasal steroids, and nasal irrigation may be used to help with symptoms.[1][5] Recommended initial treatment for acute sinusitis is watchful waiting.[1] If symptoms do not improve in 7–10 days or get worse, then an antibiotic may be used or changed.[1] In those in whom antibiotics are used, either amoxicillin or amoxicillin/clavulanate is recommended first line.[1] Surgery may occasionally be used in people with chronic disease.[8]

Sinusitis is a common condition.[1] It affects between about 10 and 30 percent of people each year in the United States and Europe.[1][6] Women are more often affected than men.[9] Chronic sinusitis affects about 12.5% of people.[10] Treatment of sinusitis in the United States results in more than US$11 billion in costs.[1] The unnecessary and ineffective treatment of viral sinusitis with antibiotics is common.[1]

Treatment

Treatments[50]&#

Recommended treatments for most cases of sinusitis include rest and drinking enough water to thin the mucus.[52] Antibiotics are not recommended for most cases.[52][53]

Breathing low-temperature steam such as from a hot shower or gargling can relieve symptoms.[52][54] There is tentative evidence for nasal irrigation in acute sinusitis, for example during upper respiratory infections.[5] Decongestant nasal sprays containing oxymetazoline may provide relief, but these medications should not be used for more than the recommended period. Longer use may cause rebound sinusitis.[55] It is unclear if nasal irrigation, antihistamines, or decongestants work in children with acute sinusitis.[56] There is no clear evidence that plant extracts such as Cyclamen europaeum are effective as an intranasal wash to treat acute sinusitis.[57] Evidence is inconclusive on whether anti-fungal treatments improve symptoms or quality of life.[58]

Antibiotics

Most sinusitis cases are caused by viruses and resolve without antibiotics.[30] However, if symptoms do not resolve within 10 days, amoxicillin is a reasonable antibiotic for first treatment,[30] with amoxicillin/clavulanate being indicated if symptoms do not i

Breathing low-temperature steam such as from a hot shower or gargling can relieve symptoms.[52][54] There is tentative evidence for nasal irrigation in acute sinusitis, for example during upper respiratory infections.[5] Decongestant nasal sprays containing oxymetazoline may provide relief, but these medications should not be used for more than the recommended period. Longer use may cause rebound sinusitis.[55] It is unclear if nasal irrigation, antihistamines, or decongestants work in children with acute sinusitis.[56] There is no clear evidence that plant extracts such as Cyclamen europaeum are effective as an intranasal wash to treat acute sinusitis.[57] Evidence is inconclusive on whether anti-fungal treatments improve symptoms or quality of life.[58]

Most sinusitis cases are caused by viruses and resolve without antibiotics.[30] However, if symptoms do not resolve within 10 days, amoxicillin is a reasonable antibiotic for first treatment,[30] with amoxicillin/clavulanate being indicated if symptoms do not improve after 7 days on amoxicillin alone.[46] A 2012 Cochrane review, however, found only a small benefit between 7 and 14 days, and could not recommend the practice when compared to potential complications and risk of developing resistance.[59][needs update] Antibiotics are specifically not recommended in those with mild / moderate disease during the first week of infection due to risk of adverse effects, antibiotic resistance, and cost.[60]

Fluoroquinolones, and a newer macrolide antibiotic such as clarithromycin or a Fluoroquinolones, and a newer macrolide antibiotic such as clarithromycin or a tetracycline like doxycycline, are used in those who have severe allergies to penicillins.[61] Because of increasing resistance to amoxicillin the 2012 guideline of the Infectious Diseases Society of America recommends amoxicillin-clavulanate as the initial treatment of choice for bacterial sinusitis.[62] The guidelines also recommend against other commonly used antibiotics, including azithromycin, clarithromycin, and trimethoprim/sulfamethoxazole, because of growing antibiotic resistance. The FDA recommends against the use of fluoroquinolones when other options are available due to higher risks of serious side effects.[63]

A short-course (3–7 days) of antibiotics seems to be just as effective as the typical longer-course (10–14 days) of antibiotics for those with clinically diagnosed acute bacterial sinusitis without any other severe disease or complicating factors.[64] The IDSA guideline suggest five to seven days of antibiotics is long enough to treat a bacterial infection without encouraging resistance. The guidelines still recommend children receive antibiotic treatment for ten days to two weeks.[62]

For unconfirmed acute sinusitis, nasal sprays using corticosteroids have not been found to be better than a placebo either alone or in combination with antibiotics.[65] For cases confirmed by radiology or nasal endoscopy, treatment with intranasal corticosteroids alone or in combination with antibiotics is supported.[66] The benefit, however, is small.[67]

For confirmed chronic rhinosinusitis, there is limited evidence that intranasal steroids improve symptoms and insufficient evidence that one type of steroid is more effective.[68][68][69]

There is only limited evidence to support short treatment with corticosteroids by mouth for chronic rhinosinusitis with nasal polyps.[70][71][72] There is limited evidence to support corticosteroids by mouth in combination with antibiotics for acute sinusitis; it has only short-term effect improving the symptoms.[73][74]

For chronic or recurring sinusitis, referral to an otolaryngologist may be indicated, and treatment options may include nasal surgery. Surgery should only be considered for those people who do not benefit with medication.[71][75] It is unclear how benefits of surgery compare to medical treatments in those with nasal polyps as this has been poorly studied.[76][77]

Maxillary antral washout involves puncturing the sinus and flushing with saline to clear the mucus. A 1996 study of people with chronic sinusitis found that washout confers n

Maxillary antral washout involves puncturing the sinus and flushing with saline to clear the mucus. A 1996 study of people with chronic sinusitis found that washout confers no additional benefits over antibiotics alone.[78]

A number of surgical approaches can be used to access the sinuses and these have generally shifted from external/extranasal approaches to intranasal endoscopic ones. The benefit of functional endoscopic sinus surgery (FESS) is its ability to allow for a more targeted approach to the affected sinuses, reducing tissue disruption, and minimizing post-operative complications.[79] The use of drug eluting stents such as propel mometasone furoate implant may help in recovery after surgery.[80]

Another recently developed treatment is balloon sinuplasty. This method, similar to balloon angioplasty used to "unclog" arteries of the heart, utilizes balloons in an attempt to expand the openings of the sinuses in a less invasive manner.[34] The effectiveness of the functional endoscopic balloon dilation approach compared to conventional FESS is not known.[34]

For persistent symptoms and disease in people who have failed medical and the functional endoscopic approaches, older techniques can be used to address the inflammation of the maxillary sinus, such as the Caldwell-luc antrostomy. This surgery involves an incision in the upper gum, opening in the anterior wall of the antrum, removal of the entire diseased maxillary sinus mucosa and drainage is allowed into inferior or middle meatus by creating a large window in the lateral nasal wall.[81]

Sinusitis is a common condition, with between 24 and 31 million cases occurring in the United States annually.[82][83] Chronic sinusitis affects approximately 12.5% of people.[10]

Research

Based on

Based on recent theories on the role that fungus may play in the development of chronic sinusitis, antifungal treatments have been used, on a trial basis. These trials have had mixed results.[30]

See also