ACUTE SINUSITIS
BY ASHOK PATEL, MD

“Dr. Patel, Sara has a sinus infection” Beth, Sara’s mother, stated. “Will you please prescribe an antibiotic? By the way, amoxicillin doesn’t work for her.”

Sara is a 15-year-old pleasant, adolescent girl with moderate asthma. I have asked her and her mother to report to me when she develops a cold because it usually worsens her asthma.

“Before I prescribe an antibiotic for her, I have some questions for you,” I responded.

How do doctors decide if a patient has a sinus infection and needs an antibiotic? The question seems very simple; I thought I could answer the question in my sleep. However, recently I did a presentation on the evaluation of the treatment of sinusitis to a group of doctors and performed extensive research. I had difficulty finding an answer for the simple questions—When does a cold turn into a bacterial sinus infection, and when should a doctor prescribe antibiotics? During my interactions with numerous doctors over the years, I have found that doctors’ practices differ widely regarding diagnosis and treatment of acute sinusitis. In my practice, I have found that sometimes patients who carry the diagnosis of “sinusitis” in reality are having symptoms because of another medical condition. These symptoms should be explored before any treatment is prescribed.

In this column, I share my views on the diagnosis and treatment of acute sinusitis. Your doctor may or may not agree with me.

“I know what you’re going to ask, Dr. Patel,” Beth retorted. “Sarah has yellow nasal discharge.”

“How much and for how long?” I asked.

“A small amount for the last 3 days,” Beth murmured.

Yellow nasal discharge--As soon as a patient’s nasal discharge turns green or yellow, she calls the doctor’s office requesting antibiotics. Yellow or green nasal discharge does not automatically mean that she has a bacterial infection and needs an antibiotic. A change in the color or characteristic of the nasal discharge is not a specific sign of a bacterial infection.

“Sara needs an antibiotic because she complains of sinus pressure!” Beth emphasized.

Sinus pressure--When some patients feel sinus pressure, they think they have a sinus infection and request an antibiotic. With the common cold, a patient can have sinus congestion and sinus pressure.

“I’m not convinced that Sara needs an antibiotic,” I expressed my opinion.

“Why don’t you order sinus x-rays, Dr. Patel?” Beth intervened. “Sinus x-rays will tell you whether she has a sinus infection or not.”

“In my opinion, sinus x-rays are not very helpful in deciding if a patient needs an antibiotic or not,” I replied.

“Why?” Beth quizzed me.

Need for sinus x-ray--Many patients, especially children, used to or still do, undergo numerous sinus x-rays for diagnosis of acute sinusitis. Personally, I do not order sinus x-rays to diagnose acute sinusitis—why? I read a research study, which in my opinion, is not widely known. As a part of the study, the doctors ordered a CT scan of the sinuses for volunteers who were suffering from a common cold. To the doctors’ great surprise, they found severe abnormalities in the CT scan of the sinuses. The bottom line is that a simple cold can cause severe abnormalities on a CT scan and plain sinus x-rays. Why order sinus x-rays if they do not help in differentiating a common cold from bacterial sinus infection?

“My friend, Monica, called her doctor and she got an antibiotic called in, Dr. Patel.” Beth claimed, “Why are you not prescribing Sara an antibiotic?”

I examined Sara. The examination was unremarkable except for a small amount of white mucus in the nostrils.

“Beth, Sara has a viral infection.” I counseled. “She does not need antibiotics.”

“Oh,” Beth mumbled.

Seeing the frustration on Beth’s face, to lighten up the situation I declared, “If all else fails, I recommend that the two of you go to Hawaii for 2 weeks. Lying down on the beach and exposing her sinuses to the warm moist ocean air can help.”

When should a doctor prescribe antibiotics?--After reviewing medical literature extensively, I realized this question does not have a simple answer. A recent and very well-designed study published in a medical journal, Pediatrics, concluded: “Neither amoxicillin nor amoxicillin-clavulanate offers any clinical benefit compared with a placebo for children with clinically diagnosed acute sinusitis.” In simple words, antibiotics were as good as a placebo, a sugar pill.

Another study published in Lancet, a respected medical journal, compared a placebo to an antibiotic in treatment of acute sinusitis and concluded: “Antibiotic treatment did not alter the clinical course of sinusitis, nor the number of relapses in the following year.”

Duration of symptoms--Symptoms of the common cold can last for several days. The younger the child, the longer the symptoms will last. In children less than 1 year old, symptoms of a cold can last up to 9 days. According to one research study, symptoms of the common cold lasted as long as 15 days in 13% of children attending daycare centers.

An expert group of physicians comprised of infectious disease specialists, pediatricians, and allergists concluded: “The diagnosis of bacterial sinusitis is made too frequently…patients with viral illnesses of only a few days’ duration are inappropriately labeled as having bacterial disease.” In the absence of evidence-based data, the group recommended that a physician may consider a course of antibiotics if the patient is “no better or worse after 10 days.” Your doctor will work with you to decide whether you need an antibiotic or not.

So, when you are seeking relief from sinus pressure and congestion, work with your doctor to do the thing that is best for you, which may not always be the old standby antibiotic. By the way, evaluation and treatment of “sinusitis” costs the nation billions of dollars annually—a lot of money, some of which we may be able to save.