Sinusitis
                                =========
þ Augmentin is useless for acute (48h) sinusitis:
 - In the Basel Sinusitis Study, researchers randomly assigned 252 adults with
   a 48-hour history of purulent nasal discharge and maxillary or frontal pain
   to a combination product containing 875 mg amoxicillin and 125 mg
   clavulanic acid or placebo twice daily for 6 days. All patients also
   received acetaminophen and a decongestant.
 - There was no difference in the time to cure, the primary outcome, between
   active treatment and placebo, the team reports in the August 11/25 issue of
   the journal Archives of Internal Medicine (Reuters)
   Arch Intern Med 2003;163:1793-1798

þ Sinusitis Diagnosis

        Symptom         Sensitivity     Specificity
        ====================================================
        Purulent Nasal
        Discharge       62-72%          52-67%

        Cough           70%             44%

        Sneezing        70%             34%

        Maxillary
        Toothache                       83-93%

        Preceding URI   85%             28%

        Pain on Bending
        Forward         66%             59%

        Sinus
        Tenderness      48-50%          62-65%

þ Combined likelihood ratio for sinusitis:

Of the following 5:
 - maxillary toothache;
 - purulent nasal secretion;
 - poor response to decongestants;
 - transillumination (normal bilaterally vs. any abnormality);
 - history of colored nasal discharge.

Number of       Likelihood
Signs/Sx        Ratio
-----------------------------------------------
 >=4:           6.4
 3              2.6
 2              1.1
 1              0.5
 0              0.1

[Williams JW, Simel DL.  Does this patient have sinusitis?  Diagnosing acute
sinusitis by history and physical examination. JAMA 1993;270(10):1242-6.]

þ Sinusitis organisms and drugs
 - more staph than other URIs, but not as much as sometimes thought.
 - Ceftin better than Ceclor for sinusitis.
 - Cipro:  weak on pneumococcus, not great for strep, so-so for staph.

þ Duration of Sinusitis Antibiotics
 - 3 days of Bactrim+Afrin as good as 10 days. [Williams JW, Holleman DR,
   Samsa GP, Simel DL. Ramdomized controlled trial of 3 vs 10 days of
   trimethoprim/sulfamethoxazole for acute maxillary sinusitis. JAMA
   1995;273:1015-1021.]  Not a great study.

þ Do we need to treat sinusitis with antibiotics at all?
 - No(?)
   [van Buchem FL, Knotterys JA, Schrijnermaerkers VJJ, Peeters MF.
   Primary-care-based randomised placebo-controlled trial of antibiotic
   treatment in acute maxillary sinusitis. Lancet 1997;349:683-7.]
   [Stalman W, van Essen GA, van der Graaf Y, de Melker RA. Maxillary
   sinusitis in adults: an evaluation of placebo-controlled double-blind
   trials. Family Practice 1997;14(2):124-9.]

þ ENT treats for 3-6 weeks.
- two strong studies suggest antibiotics help.

þ Azithromycin is good.

þ Steroids for Sinusitis?
 - currently being studied.
 -