Broad antibiotic coverage of common aerobes and anaerobes is necessary but should be limited to patients with acute pain, especially unilateral maxillary tooth, facial, or sinus pain, and purulent discharge, particularly if the symptoms initially improved and then worsen. This cluster of symptoms is more suggestive of bacterial rather than viral acute sinusitis. It should be noted that the majority of acute bacterial sinusitis cases resolve in 7 to 10 days without antibiotics, similarly to the viral form. For acute bacterial sinus infections, amoxicillin (500 mg three times a day) or trimethoprim/sulfamethoxazole (1 tablet twice a day) remains the treatment of choice. Amoxicillin is inexpensive, penetrates the sinus tissues well, and can be changed to another antibiotic if symptoms have not improved in 48 to 72 hours. If these give only a minimal or no response after 7 days, consider broader spectrum antibiotics. If beta-lactam resistance is likely, amoxicillin/clavulanic acid (875 mg twice daily) or azithromycin (5-day course once a day) may be used. Other second-line drugs include cefuroxime (250 mg twice daily), ciproﬂoxacin (500 mg twice daily), clarithromycin (500 mg twice daily), levoﬂoxacin (500 mg once a day), and loracarbef (400 mg twice daily). The usual treatment course is 10 to 14 days, and patients should be informed that relapses might occur if the full course of treatment is not completed.
Chronic sinusitis may result from repeated infections with inadequate drainage. The interval between infections becomes increasingly shorter until there are no remissions. Presenting symptoms are recurrent pain in the malar area or chronic postnasal drip. In the preantibiotic era, chronic sinusitis was the result of repeated acute sinusitis with incomplete resolution, whereas allergy is currently a more common cause. Injury of surface ciliated epithelium results in impaired removal of mucus. A vicious cycle ensues of incomplete resolution of infection, followed by reinfection, and ending with the emergence of opportunistic organisms. Allergies have become an important factor in chronic sinusitis. The swelling and edema of the mucosa in conjunction with hypersecretion of mucus leads to ductal obstruction and infection. Chronic sinusitis is associated with chronic cough and laryngitis with intermittent acute infections. Treatment is directed at the underlying etiology: either allergy control or aggressive management of infections. Resistant cases require computed tomography and endoscopic surgery for polyp removal. Nasoantral window formation is a radical surgery that is occasionally necessary.
No clinical criteria can reliably identify those patients who might benefit from treatment with antibiotics. It is reasonable to treat women with presumed bacterial sinusitis if they have high fever, systemic toxicity, immune deficiency, or possible orbital or intracranial involvement (6). Although very rare, untreated sinus infections may have dire consequences, such as orbital cellulitis, leading to orbital abscess, subperiosteal abscess formation of the facial bones, cavernous sinus thrombosis, and acute meningitis. Brain and dural abscesses are rare; when they occur, it usually is the result of direct spread from a sinus. A patient complaining of abnormal vision such as diplopia, changes in mental status, and periorbital edema should prompt a referral to emergency room for evaluation of intracranial or orbital extension. Computed tomography scanning is the most accurate diagnostic tool. The use of aggressive surgical approaches with broad-spectrum antibiotics is necessary for adequate drainage.