Use of antibiotics for sinusitis is recommended only in cases caused by bacteria
There is a current trend from national and international guidelines to replace the classic term sinusitis with rhinosinusitis because of the difficulty of establishing precise limits for the inflammatory processes that affect the mucosa of the nose and paranasal sinuses. The sinuses or paranasal sinuses are aerated cavities located in the anterior region of the skull that communicate with the nasal cavity through ventilation and drainage ostia (orifices). The paranasal sinuses are named according to the bone in which they are: frontal sinus (on the forehead), jaws (cheek region), ethmoidal (near the eyes) and sphenoidal (only visualized internally).
Rhinosinusitis is defined as an inflammatory process of the mucosa of the nose and paranasal sinuses in which nasal clogging occurs, anterior nasal secretion (that is going to exit through the nose) or posterior (the one that is lodged in the posterior pharynx), pain or pressure facial and or reduction or loss of smell. General symptoms such as malaise and fever (not always present), irritation of the pharynx, larynx and trachea, sore throat, dysphonia and cough may occur. There are findings in nasal endoscopy: polyps (small benign growths of inflamed tissue in the mucosal layer of the nose or paranasal sinuses that protrude into them), mucopurulent (greenish-yellow) secretion, and edema. In computed tomography, there may be alterations in the ostiomeatal complex mucosa (common final drainage pathway of the frontal, anterior ethmoidal and maxillary sinuses) or paranasal sinuses.
Rhinosinusitis may be related to allergy, polyps and infectious viral, bacterial and fungal. The viral type is the most common. It is believed that an adult can present 2 to 5 colds per year and a child 6 to 10 episodes per year. From these viral episodes 0.5 to 10% evolve to bacterial infection.
The goal of rhinosinusitis treatment is to eradicate the bacterium from the site of infection, decrease the duration of symptoms, prevent complications and avoid chronification. The treatment of bacterial rhinosinusitis should be performed with antibiotics, based on the frequency of the presence of bacteria that may be different in acute and chronic rhinosinusitis. The treatment period in acute rhinosinusitis is 10 to 14 days. Patients who have not used antibiotics in the last four to six weeks will use standard spectrum antibiotics. For those who have used antibiotics in the last four to six weeks or who have moderate to severe disease, broader antibiotics should be given.
In chronic rhinosinusitis antibiotic treatment should be continued for a period of three to six weeks based the most prevalent agents. Use of low doses of specific antibiotics for long periods can be considered. Surgical treatment for such cases may be indicated. Short-term corticosteroids are used in both acute and chronic rhinosinusitis. Topical corticosteroids may be indicated as adjunctive treatment for chronic rhinosinusitis. Nasal wash with saline solutions without preservative is important for both types of frame. Topical or systemic decongestants may be used in the short term for acute cases. In chronic rhinosinusitis, environmental control, reduction of exposure to cigarette smoke, and cessation of smoking should be directed.
If the antibiotic is prescribed unnecessarily, if there is guidance of a gastric protection, there will be no harm to the patient. But if this occurs several times the patient may become resistant to these bacteria. More importantly, perhaps in this case with a specialist doctor who can distinguish between viral and bacterial process, and in the case of chronic or recurrent rhinosinusitis, investigate various causes to establish an accurate diagnosis.How is it suspected that a picture is viral or bacterial?
Classically clear and watery coryza occurs in viral or allergic processes and as the coryza becomes mucopurulent or purulent (greenish yellow) it is thought to be a bacterial process. In practice this is not always true because purulent secretion also occurs in viral infections. There is no specific and unique symptom for the differential diagnosis between viral and bacterial infections of the paranasal sinuses.
The suspicion of bacterial rhinosinusitis following a viral condition should be considered when the manifestations remain after 10 days or worsen after 5 days.
Nasal obstruction and nasal congestion are more common symptoms in acute rhinosinusitis, in the chronic conditions they do not appear as much and when this occurs they are related to allergic rhinitis and deviated nasal septum. They appear in viral and bacterial infections.
Face pain may be present in viral or bacterial rhinosinusitis, in viral cases headache is diffuse and intense, bacterial is "by weight" and worsens with head tilt forward. There may be tooth pain in the chewing. Facial pain is uncommon in chronic rhinosinusitis, may suggest exacerbation. Symptoms that point to bacterial rhinosinusitis in a conclusive way: drainage of posterior mucopurulent secretion, edema surrounding the eyes, halitosis, hyperemia (redness) of the posterior region of the oropharynx, facial palpation pain .
The clinical history and otorhinolaryngological examination are usually sufficient to establish the diagnosis. The conventional radiological study of the paranasal sinuses and rhinopharynx is an increasingly less used technique because it does not accurately assess the extent of inflammation. The imaging examination of choice to confirm the diagnosis and check the extent of the disease is computed tomography. It should be used for chronic cases and difficult to respond to clinical treatment. Magnetic resonance imaging should be used when there is suspicion of neoplasm or for fungal sinusitis. Nasal endoscopy is very useful for identifying deviations of the septum, polyps, visualization of the nasal mucosa and the aspect of the secretion, and material for bacteriology can be removed. Puncture of the maxillary sinus with removal of material to identify the bacteria is not a routine method, since it is very invasive. The request for a profile for evaluation of immunological deficiencies for patients with chronic and recurrent rhinosinusitis is fundamental. There are tests that can be performed when mucociliary transport is suspected.
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