treatement of Avute sinus & chronic sinus

Although rare, complications of acute sinusitis can occur through direct,
local extension. With antibiotic treatment, complications occur with an estimated frequency of 1 per 10,000 cases. Clinical presentation may include facial edema, cellulitis, orbital, visual, and meningeal involvement.


In these cases, aggressive treatment, which may include surgical intervention, is warranted.
Chronic sinusitis  Unfortunately, clinical criteria to diagnose chronic sinusitis, as well as the
predictive value of these criteria, are sorely lacking. Historically, the diagnosis of chronic sinusitis was based on several clinical symptoms, similar to the presentation of acute sinusitis, although often less dramatic; however, none of these symptoms are specific to sinusitis. In particular, headache, as the sole presenting symptom, is not likely chronic sinusitis. 


On the other hand, nasal endoscopy is useful. Evidence of nasal secretions, nasal polyps, and deformation of the middle meatus have been shown to distinguish patients with extensive sinus disease, as defined by CT image criteria, compared with either the control group or to those with limited disease. 

Plain X-rays are often insufficiently sensitive to diagnose chronic sinusitis and do not provide the anatomic detail required for preoperative evaluation. Although CT is recommended, this alone is still not evidence  enough to make the diagnosis.   

CT should be performed at least 2 weeks after an upper respiratory infection, and more than 4 weeks after treatment of acute bacterial sinusitis, to evaluate underlying chronic disease. 

Therefore  it is recommended that a combination of clinical signs and symptoms, nasal endoscopy, and CT be used to make the diagnosis of chronic sinusitis.


Treatment

Acute sinusitis

The diagnosis of acute sinusitis prompts countless number of antibiotic prescriptions per year. Although the vast majority of cases of acute sinusitis resolve without treatment, antibiotics are prescribed for an estimated 85% to 98% of cases presented to a primary care clinic. 

Antibiotics, compared with placebo, do reduce treatment failures in bacterial sinusitis by almost
one half (from 31% to 16%)[38]. If culture results are unavailable, the antibiotic should target the most common bacterial pathogens. These include S. pneumoniae, H. influenzae, and M. 

catarrhalis.Antibiotic resistance is on the rise and almost half of S. pneumoniaeis now resistant to penicillin, and the majority of both H. influenzaeand M. catarrhalisare B-lactamase positive[39]. The choice of antibiotic should take into account a number of factors, such as geographic prevalence of resistance patterns, predicted efficacy, cost, side effects, and ease of ‘‘use.’’




The American College of Physicians published practice guidelines for the treatment of acute sinusitis[40]. This position publication was endorsed by a number of groups, including the Centers for Disease Control and Prevention, the American Academy of Family Physicians, the American College of Physicians, American Society of Internal Medicine, and the Infectious Disease Society of America. In this publication they give the following practice guidelines:

1. Sinus radiography is not recommended for the diagnosis of uncomplicated sinusitis.
2. Acute bacterial sinusitis does not require antibiotic treatment, especially
if symptoms are mild or moderate.
3. Patients with severe or persistent moderate symptoms and specific findings of bacterial sinusitis should be treated with antibiotics. Narrowspectrum antibiotics  including amoxicillin, doxycycline and trimethoprim-sulfamethoxazole) are reasonable first-line agents.

Amoxicillin is a reasonable first line antibiotic choice for both adults and children, unless there is a high prevalence of B-lactamase producing strains.


The higher dose (90 mg/kg/day) is recommended for children at higher risk of amoxicillin resistance, such as those who attend day care, were recently treated with antibiotics, or are under the age of 2 years. The addition of potassium clavulanate can also counter this antibiotic resistance. The most common side effects include abdominal cramping and diarrhea, which are
quickly reversed upon discontinuation of the drug. Trimethoprim-sulfamethoxazole is an alternative antibiotic in penicillin-allergic individuals; however, up to 20% ofS. pneumoniaemay be resistant to this alternative.

 In a meta-analysis of several randomized trials, folate inhibitors were found to be as effective as the newer, more costly antibiotics [38]; however, even the investigators cede the limitations of their data, so this should be interpreted with caution. In contrast to amoxicillin, doxycycline provides broader antibiotic coverage, including activity against B-lactamase producing strains of H. influenzaeandM. catarrhalis.



First generation cephalosporins, such as cephalexin and cefadroxil, do not provide adequate coverage againstH. influenzaeand should not be used. 

Second generation cephalosporins, such as cefuroxie axetil and cefprozil, as well as third generation cephalosporins, such as cefpodoxime axetil, and cefdinir, are appropriate choices.

 The first ketolide, telithromycin, was initially indicated for acute sinusitis, but this was revoked after reports of severe hepatotoxicity. The fluoroquinolones, including ciprofloxacin, levofloxacin, and moxifloxacin, offer broadspectrum antimicrobial coverage, and are all indicated for acute sinusitis.

 Because of the concern for adverse effect on the development of joints, these should be avoided in children. These medications can also prolong the QT interval, so should be used with caution in patients at risk for arrhythmia. No controlled studies have examined the length of treatment.