Lesson

2 . 6 - Treatment

Combines antibiotics, possibly short-course systemic corticosteroid therapy (0.8 mg/kg/day for 3 days, AFSSAPS), decongestants, and analgesics/antipyretics. NSAIDs are not indicated in acute sinusitis.

Recurring sinusitis calls for etiological therapy.

2 . 6 . 1 - Guidelines for antibiotic therapy

The main bacteria involved in sinusitis are haemophilus influenzae and streptococcus pneumoniae. Many strains exhibit reduced sensitivity or resistance to antibiotics. Given current marketing authorizations and the resistance of bacteria, first-line antibiotic therapy will involve one of the following per os:

–        co-amoxiclav 1g x 3/day or taken 3 times a day for a total of 80 mg/kg/day in children;

–        cephalosporins: second-generation (cefuroxime axetil) or third-generation (cefpodoxime proxetil or cefotiam hexetil);

–        pristinamycin, especially in cases of beta-lactam allergy;

–        telithromycin is an acceptable alternative.

Fluoroquinolones active against pneumococcus (levofloxacin, moxifloxacin) should be reserved for the most severe and seriously complication-prone cases such as frontal or sphenoid sinusitis, or for when first-line antibiotics fail in maxillary sinusitis, after bacteriological or radiological documentation.

Treatment for acute purulent maxillary sinusitis typically lasts 7 to 10 days. Cefuroxime axetil, cefpodoxime axetil, and telithromycin have been shown effective in 5-day treatments, pristinamycin in 4-day treatments (Table I).

Table I : Symptomatology of sinusitis in adults and first-line antibiotic therapy, by topographical location

Location	Symptoms	First-line antibiotic therapy
Maxillary	Pain under one or both eyes, worse when head forward, sometimes throbbing and worst in late afternoon or at night	Amoxicillin/clavulanic acid 2nd and 3rd generation cephalosporins (except cefixime): cefuroxime axetil, cefpodoxime proxetil, cefotiam hexetil, pristinamycin
Frontal	Headache over eyes	Idem or fluoroquinolones active against pneumococcus (levofloxacin, moxifloxacin)
Ethmoid	Pressure at inner corner of eye, palpebral edema, retro-orbital headache	Idem or fluoroquinolones active against pneumococcus (levofloxacin, moxifloxacin)
Sphenoid	Constant retro-orbital headache radiating to crown and similar to intracranial hypertension in terms of location, intensity, and persistence Purulent discharge on the posterior wall of the pharynx (dripping ostium far back) visible with tongue depressed	Idem or fluoroquinolones active against pneumococcus (levofloxacin, moxifloxacin)

2 . 6 . 2 - Indications for antibiotic therapy

– Acute bacterial maxillary sinusitis: Antibiotics are indicated if two of the three major criteria defined above are fulfilled, if first-line symptomatic treatment fails, or if the infection is of dental origin;

– Frontal, ethmoid, or sphenoid sinusitis: Antibiotics are indicated (Table I);

– Clinical signs suggesting complicated sinusitis: Meningism, exophthalmia, palpebral edema, eye motility disorders, or sleep-disturbing pain. Antibiotic therapy is usually initiated in the hospital after bacteriological testing.

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