What findings distinguish acute bacterial sinusitis?
Recommendations from others
A recommendation from the Agency for Health Care Policy and Research suggests using symptomatic treatment initially when the prevalence of acute bacterial rhinosinusitis in patients with upper respiratory infection is <25%, and using clinical criteria (see Table) for acute bacterial rhinosinusitis diagnosis when prevalence is higher.5
The Centers for Disease Control and Prevention recommends reserving the diagnosis of acute bacterial rhinosinusitis for patients with symptoms lasting ≥7 days with maxillary pain or tenderness in the face or teeth (especially unilateral) and purulent nasal secretions.8
An otolaryngology guideline recommends considering acute bacterial rhinosinusitis when viral upper respiratory infection persists beyond 10 days or worsens after 5 to 7 days with similar symptoms.9 The 7-to-10-day specification is based on the natural history of rhinovirus infections (SOR: C).
A Canadian Medical Association evidence-based review recommended a score based on Williams’ 5 independent predictor symptoms:
- fewer than 2 symptoms rule out acute bacterial rhinosinusitis (PPV, <40%)
- 4 or more symptoms rule in acute bacterial rhinosinusitis (PPV, 81%) (level of evidence [LOE]: 4)
- 2 or 3 symptoms (PPV, 40%–63%) may benefit from radiography (SOR: C).10
Jacob M. Reider, MD
Department of Family and Community Medicine, Albany Medical College, Albany, NY
This summary emphasizes inconsistencies in the literature and the limited predictive value of clinical findings when diagnosing sinusitis. But there is a way to sidestep this problem. When a patient presents complaining of “sinusitis,” I ask about their expectations for the visit and their understanding of their symptoms’ possible causes, and then I often show the patient a picture of sinus anatomy. By demonstrating that the osteomeatal complex is small, and focusing on obstruction rather than infection, I am able to avoid any confrontation about antibiotics entirely. Then I can recommend irrigation, hydration, and analgesia. For patients whose symptoms persist beyond 10 to 14 days, and for whom these initial interventions have failed, a trial of antibiotics may be indicated.
