Acute & Chronic Sinusitis לימודי המשך Ephraim Eviatar Assaf Harofeh Medical Center.
Transcript of Acute & Chronic Sinusitis לימודי המשך Ephraim Eviatar Assaf Harofeh Medical Center.
Acute & Chronic Acute & Chronic SinusitisSinusitis
לימודי המשךלימודי המשך
Ephraim Eviatar
Assaf Harofeh Medical Center
סינוסיטיס היא האבחנה החמישית אשר סינוסיטיס היא האבחנה החמישית אשר אנטיביוטיקה מומלצת עבורה. אנטיביוטיקה מומלצת עבורה.
מכלל הילדים מכלל הילדים 9%9% סינוסיטיס מהווה סינוסיטיס מהווה במבוגרים. במבוגרים.21%21%שקיבלו אנטיביוטיקה ו-שקיבלו אנטיביוטיקה ו-
RhinosinusitisRhinosinusitis
Acute rhinosinusitisAcute rhinosinusitis
Subacute rhinosinusitisSubacute rhinosinusitis
Chronic rhinosinusitisChronic rhinosinusitis
Recurrent ARSRecurrent ARS
Acute rhinosinusitis superimposed on CRS Acute rhinosinusitis superimposed on CRS
Acute rhinosinusitisAcute rhinosinusitis
Acute sinusitis Acute sinusitis 7-21 days7-21 days (7 days viral (7 days viral illness)illness)Spontaneous resolution of ARS -40%Spontaneous resolution of ARS -40%The most common pathogens: strep The most common pathogens: strep pneumonia-30%, pneumonia-30%, non typeabale hemophilus infl.-20%, non typeabale hemophilus infl.-20%, moraxella catarrhalis.(20% in children)moraxella catarrhalis.(20% in children)Staph aureus- 30%Staph aureus- 30%Anaerobes- rareAnaerobes- rare
Recurrent ARSRecurrent ARS
EpisodesEpisodes of bacterial infection of the of bacterial infection of the paranasal sinuses, each lasting less than paranasal sinuses, each lasting less than 30 days and 30 days and separated by intervalsseparated by intervals of at of at least least 1010 daysdays during which the patient is during which the patient is asymptomatic.asymptomatic.
Subacute sinusitisSubacute sinusitis
Subacute Subacute RS:3W-3monthsRS:3W-3months
The same pathogens as in ARS The same pathogens as in ARS
Chronic rhinosinusitisChronic rhinosinusitis
Beyond 3 monthsBeyond 3 months
Bacteria are as in ARS, butBacteria are as in ARS, but
More non-typeable H InfluezaeMore non-typeable H Influezae
More staph aureus, anaerobic bacteria, More staph aureus, anaerobic bacteria, gram- Negative, pseudomonase gram- Negative, pseudomonase aeruginosaaeruginosa
Polymicrobials with resistant organismPolymicrobials with resistant organism
Culture recommendedCulture recommended
Acute bacterial sinusitis Acute bacterial sinusitis superimposed on chronic sinusitissuperimposed on chronic sinusitis
Patients with residual respiratory Patients with residual respiratory symptoms develop new respiratory symptoms develop new respiratory symptoms. When treated with symptoms. When treated with antimicrobials, these new symptoms antimicrobials, these new symptoms resolve, but the underlying residual resolve, but the underlying residual symptoms do not.symptoms do not.
Major & Minor signs and symptoms Major & Minor signs and symptoms in diagnosis of Chronic RSin diagnosis of Chronic RS
Majors:Majors:Facial pain/pressureFacial pain/pressureNasal congestion/fullnessNasal congestion/fullnessN. obstruction/blockageN. obstruction/blockageN. discharge/purulenceN. discharge/purulenceHyposmia/ anosmiaHyposmia/ anosmiaPurulent rhinitisPurulent rhinitisFever (acute sinusitis only)Fever (acute sinusitis only)
MinorsMinors::HeadacheHeadacheFeverFeverHalitosisHalitosisFatigueFatigueDental painDental painCoughCoughEar pain/ Ear pain/
pressure/fullnpressure/fulln
Clinical Diagnosis of rhinosinusitisClinical Diagnosis of rhinosinusitis
2 or more major2 or more major factors factors
1 major & 2 minor1 major & 2 minor factors factors
Or Or Purulence Purulence on examinationon examination
Duration of symptoms Duration of symptoms > 10 days> 10 days or or worsen after worsen after 5-7 days5-7 days
Kinney WC : otolaryngol Head Neck Surg 2002
Predisposing factorsPredisposing factors
URIURI
AllergyAllergy
TraumaTrauma
Dental infectionDental infection
Environmental Pollutants Environmental Pollutants
GERD GERD
Cystic FibrosisCystic Fibrosis
Facial painFacial pain on percussion or palpation, on percussion or palpation, sedimentation ratesedimentation rate and and white blood countwhite blood count have little diagnostic valuehave little diagnostic value. .
Purulent secretions by history Purulent secretions in the nasal cavity on examination
Lack of response to decongestants and antihistamines Unilateral maxillary pain
Double-sickening": an upper respiratory infection that initially improves then worsens
The The gold standardgold standard for the diagnosis of for the diagnosis of acute bacterial sinusitis is the acute bacterial sinusitis is the recovery of recovery of bacteriabacteria in high density (>10 in high density (>10 colony-colony-forming units/mL) from the cavity of a forming units/mL) from the cavity of a paranasal paranasal sinussinus
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Rhinosinusitis definitions for patient careRhinosinusitis definitions for patient care
Type of rhinosinusitis
Acute rhinosousitis CRS without polyposis
Pattern of symptoms * Symptoms minimum 10d-28d
*severe disease
*worsening disease
Symptoms >12w
Symptoms for diagnosis *Ant./post purulent discharge
*nasal obstruction
*facial pain-pressure
The following symtoms
*ant/post mucupurulent
*nasal obstruction
*facial pain- Objective documentation Nasal exam:purule
Radiographic evidence
Nasal exam to exclude polyps
CT sinus not essential
Rhinosinusitis definitions for patient careRhinosinusitis definitions for patient care
Type of rhinosinusitis
AFRSCRS with polyposis
Symptoms for diagnosis
Objective documentation
>2 of the symptoms :
*ant/pos mucupurulent d
*nasal obstruction
*decrease sense of smell
>1 of the symptoms:
*ant/pos rhinitis
*nasal obstruction
*facial pain/pressure
Nasal exam.to confirm bilat polyps.
CT is not essential
Nasal exam. Allergic mucin, inflammation &
polyps
*fungal specific IgE
No invasion
CT is not essential
Fungal culture , total IgE
Dose the patient have 2 or more Dose the patient have 2 or more major factorsmajor factors?... ?...
Yes:Yes:
AmoxicillinAmoxicillin
Or BactrimOr Bactrim
No:No:
Treat symptomaticallyTreat symptomatically
Saline irrigationSaline irrigation
Oral decongestant Oral decongestant
Antihistamine (allergy)Antihistamine (allergy)
Reevaluate in 10 daysReevaluate in 10 days
Kinney WC : otolaryngol Head Neck Surg 2002
typetypeorganismorganismdrugsdrugscommentscomments
acuteacuteStrep pneumoniaeStrep pneumoniae
h. Influenzaeh. Influenzae
m. catarrhalism. catarrhalis
Amoxicillin 10 Amoxicillin 10 daysdays
22ndnd generation generation cephalosporin,cephalosporin,
Macrolide, Macrolide, for for
penicillin allergypenicillin allergy
subacutesubacuteIncreased resistant of Increased resistant of bacteriabacteria
22ndnd line drugs line drugs
chronicchronicPolimicrobial, Polimicrobial, psudomonase a, psudomonase a, anaerobes, moreanaerobes, more
resistantresistant
Augmentin, Augmentin, 22ndnd cephalo. cephalo. macrolide, macrolide, clinda,3-4w clinda,3-4w
Culture Culture whenever whenever possiblepossible
Recurrent Recurrent chronicchronic
ResistantResistant , , polimicrobialpolimicrobial
consider 3-4w consider 3-4w profilaxis profilaxis
CultureCulture guidedguided
Suppurative Suppurative complicationscomplications
G(-). Staph G(-). Staph aureusaureus
CefuroximeCefuroxime,,aminoglicozidaminoglicozidee
Surgery if no Surgery if no responceresponce
Severe sinusitis with suspected Severe sinusitis with suspected orbital or orbital or intracranial complicationsintracranial complications –cefuroxime or –cefuroxime or ceftriaxoneceftriaxone
The best in The best in crscrs treat according to treat according to cultureculture
For crs treat 3 weeks, while improvement For crs treat 3 weeks, while improvement within 3-5 dayswithin 3-5 days
3-6 weeks prophylaxis once daily therapy 3-6 weeks prophylaxis once daily therapy for patients with rapid recurrence?? for patients with rapid recurrence??
Antimicrobial treatment guidelinesAntimicrobial treatment guidelines
1. mild symptoms, 1. mild symptoms, not receivednot received antibiotics antibiotics within 4-6w.within 4-6w.
2. mild disease, who 2. mild disease, who received received antibiotics antibiotics within 4-6w, within 4-6w,
or with moderate disease regardless of or with moderate disease regardless of recent antibiotic exposure,recent antibiotic exposure,
מטרת הטיפול האנטיביוטי:מטרת הטיפול האנטיביוטי:
לחסל את החיידקים באתר של הזיהום כדי שלהשיב לחסל את החיידקים באתר של הזיהום כדי שלהשיב את הסינוסים לבריאותםאת הסינוסים לבריאותם
לקצר את תקופת המחלה ולשוב לשגרת חיים לקצר את תקופת המחלה ולשוב לשגרת חיים נורמאליתנורמאלית
למנוע סיבוכים קשים, כמו מנינגיטיס.למנוע סיבוכים קשים, כמו מנינגיטיס.
למנוע התפתחות מחלה כרונית למנוע התפתחות מחלה כרונית
According to the guidelines
טיפול במבוגריםטיפול במבוגרים
מגיעה מגיעה האנטיביוטיקה שיעילותה הקלינית המנובאתהאנטיביוטיקה שיעילותה הקלינית המנובאת כמו כמו fluoroquinolonesfluoroquinolones הינם: הינם: 90-92%90-92%ל ל
levofloxacinlevofloxacin -ו- ו moxifloxacinmoxifloxacin.. ceftriaxoneceftriaxone , ,augmentinaugmentin
cefiximecefixime high dose high dose: : 83-88%83-88%יעילות של יעילות של amoxicillin, cefpodoxime proxile, cefuroxime amoxicillin, cefpodoxime proxile, cefuroxime
axetil, cefdinir TMP/SMXaxetil, cefdinir TMP/SMX , , docxycyline, clindamycindocxycyline, clindamycin::77-81%77-81%יעילות של יעילות של
azitromycin, clarithromycin, erythromycinazitromycin, clarithromycin, erythromycin cefaclor,loracarbefcefaclor,loracarbef: : 65-66%65-66% יעילות של יעילות של
According to the guidelines
טיפול בילדיםטיפול בילדים
91-92% 91-92% : ceftriaxone, augmentin: ceftriaxone, augmentin
82-87%82-87%: amoxicillin, cefpodoxime proxetil, : amoxicillin, cefpodoxime proxetil, cefixime, cefuroxime axetil,cefdinir,TMP/SMXcefixime, cefuroxime axetil,cefdinir,TMP/SMX
78-80%78-80%: : clindamycin, cefprozil, azithromycin, clindamycin, cefprozil, azithromycin, clarithromycin, erythromycinclarithromycin, erythromycin
67-68% 67-68% : cefaclor: cefaclor
According to the guidelines
ההמלצות לטיפול התחלתי במבוגרים ההמלצות לטיפול התחלתי במבוגרים עם מחלה קלהעם מחלה קלה
Augmentin, amoxicillin, cefpodoxime proxetil, Augmentin, amoxicillin, cefpodoxime proxetil, cefuroxime axetil, or cefdinircefuroxime axetil, or cefdinir
For b-lactam allergies patients: TMP/SMX, For b-lactam allergies patients: TMP/SMX, doxycilline, azithromycin, doxycilline, azithromycin, clarithromycin,erythromycinclarithromycin,erythromycin
Failure after 72h: reevaluation or switch to Failure after 72h: reevaluation or switch to alternate antimicrobial therapyalternate antimicrobial therapy
According to the guidelines
המלצות לטיפול התחלתי במבוגרים המלצות לטיפול התחלתי במבוגרים עם מחלה קלה שטופלו קודםעם מחלה קלה שטופלו קודם
Respiratory flouroquinolones, augmentin Respiratory flouroquinolones, augmentin (4g/day),ceftriaxone (1-2 g/day 5 days), (4g/day),ceftriaxone (1-2 g/day 5 days), combination of g+ and g-combination of g+ and g-
Failure after 72h: switch to alternate Failure after 72h: switch to alternate antimicrobial therapy, or reevaluation antimicrobial therapy, or reevaluation
CT scan, endoscopy, sinus aspiration and CT scan, endoscopy, sinus aspiration and culture culture
According to the guidelines
המלצות לטיפול התחלתי בילדים עם המלצות לטיפול התחלתי בילדים עם מחלה קלהמחלה קלה
Augmentin (90mg/k/day), amocixillin (90 Augmentin (90mg/k/day), amocixillin (90 mg/k/day), cefpodoxime proxetil, mg/k/day), cefpodoxime proxetil, cefuroxime axetil, or cefdinircefuroxime axetil, or cefdinirType I hypersensitivity to b-lactams Type I hypersensitivity to b-lactams patients: TMP/SMX, azithromycin, patients: TMP/SMX, azithromycin, clarithromycin or erythromycin.clarithromycin or erythromycin.Make differentiate an immediate Make differentiate an immediate hypersensitivity from other side effectshypersensitivity from other side effectsFailure after 72 h Failure after 72 h
According to the guidelines
המלצות לטיפול בילדים עם מחלה המלצות לטיפול בילדים עם מחלה קלה (טופלו לאחרונה) או מחלה קלה (טופלו לאחרונה) או מחלה
בינוניתבינוניתAugmentin(90mg/k/day), cefpodoxime Augmentin(90mg/k/day), cefpodoxime proxetil, cefuroxime axetil or cefdinir.proxetil, cefuroxime axetil or cefdinir.Beta lactams allergic patients: TMP/SMX, Beta lactams allergic patients: TMP/SMX, azithromycin, clarithromycin, erythromycinazithromycin, clarithromycin, erythromycinClindamycin for s pneumoniae Clindamycin for s pneumoniae Ceftriaxone (5 days, parenteral), or Ceftriaxone (5 days, parenteral), or combination therapy for G+ and G- combination therapy for G+ and G- Clindamycin or amocixillin and cefiximeClindamycin or amocixillin and cefiximeClindamycin or amoxicillin and rifampinClindamycin or amoxicillin and rifampin
According to the guidelines
New insights into the role of New insights into the role of bacteria in CRSbacteria in CRS
Bacterial Bacterial superantigenssuperantigens--exotoxinsexotoxins that are that are able to activate T lymphocytes able to activate T lymphocytes
Pathogenesis of nasal polyposis- Pathogenesis of nasal polyposis- superantigens from S aureussuperantigens from S aureus
Biofilms-Biofilms-a artificial or damaged a artificial or damaged biologic biologic surfacesurface that formed communicating that formed communicating organization of microorganisms organization of microorganisms surrounded by a glycocalyssurrounded by a glycocalys
Biofilms is relatively impervious to Biofilms is relatively impervious to antibiotics and is never eradicatedantibiotics and is never eradicated
Mechanical debridement- the only way to Mechanical debridement- the only way to resolve biofilms resolve biofilms
Osteitis: the role of the boneOsteitis: the role of the bone
Osteomyelitis can be seen at a distance Osteomyelitis can be seen at a distance from the primary infectionfrom the primary infection
Inflammatory bone changes were noted on Inflammatory bone changes were noted on contralateral side in 52% of the animalscontralateral side in 52% of the animals
The changes in the involved bone can The changes in the involved bone can explain why CRS is relatively resistant to explain why CRS is relatively resistant to medical therapy. medical therapy.
Khalid et al. laryngoscope 2002
Failed CRSFailed CRS
To sinus surgery or systemic steroid/antibioticsTo sinus surgery or systemic steroid/antibiotics
Macrolid therapyMacrolid therapy (long term, low dose) (long term, low dose) effectiveeffective
Cervin A et al: Otolaryngol Head Neck Surg 2002
CRS CRS
78 had criteria to CRS 78 had criteria to CRS
37- CT findings: positive37- CT findings: positive
41- CT findings: negative41- CT findings: negative
35: endoscopy negative & CT negative 35: endoscopy negative & CT negative
20: endoscopy negative & CT positive20: endoscopy negative & CT positive
55: endoscopy negative 55: endoscopy negative
17 endoscopy: positive
6 endoscopy : positive
Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002
Radiology & clinical examRadiology & clinical exam
Correlated with a Sensitivity of 75%Correlated with a Sensitivity of 75%
And specificity of 84% And specificity of 84%
Endoscopy correlated poorly with sinus Endoscopy correlated poorly with sinus disease and not predictive disease and not predictive
Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002
Endoscopy/ct findings/clinicalEndoscopy/ct findings/clinical
Easy to diagnose CRS by endoscopy Easy to diagnose CRS by endoscopy alone when alone when nasal polyps, purulence, or nasal polyps, purulence, or fungusfungus is observed, is observed,
when absent, establishing the diagnosis when absent, establishing the diagnosis may be more difficultmay be more difficult
45%45% of patients with clinical CRS of patients with clinical CRS were were both both endoscopically and radiographically endoscopically and radiographically negative.negative.
Stankiewicz and Chow. Otolaryngol head neck surg 2002Stankiewicz and Chow. Otolaryngol head neck surg 2002
Endoscopy/ct findings/clinicalEndoscopy/ct findings/clinical
Negative endoscopyNegative endoscopy alone is insufficient to alone is insufficient to rule out sinusitis.rule out sinusitis.
26% of patients who were negative on 26% of patients who were negative on endoscopy had positive CT – this would endoscopy had positive CT – this would suggest that if endoscopy is negative suggest that if endoscopy is negative most of the time the ct will be also most of the time the ct will be also negative, even with a positive history.negative, even with a positive history.
Stankiewicz & Chow: Otolaryngol Head Neck Surg 2002
בילדיםבילדים
) יופיע ) יופיע URIURI הסיכון שזיהום חיידקי (בעקבות הסיכון שזיהום חיידקי (בעקבות ימים ימים 1010גדול יותר אם המחלה נמשכת מעל גדול יותר אם המחלה נמשכת מעל
אבחנה תעשה בילדים ומבוגרים עם אבחנה תעשה בילדים ומבוגרים עם שלא השתפרו שלא השתפרו VIRAL URIVIRAL URIסימפטומים של סימפטומים של
ימים. ימים. 5-75-7 ימים או הוחמרו אחרי ימים או הוחמרו אחרי 1010אחרי אחרי The The diagnosisdiagnosis of acute bacterial sinusitis is of acute bacterial sinusitis is based on based on clinical criteriaclinical criteria in children who in children who present with present with upper respiratory symptomsupper respiratory symptoms that are either that are either persistent or severepersistent or severe
Guidelines of American Academy of Pediatrics
בילדיםבילדים
Persistent symptomsPersistent symptoms are those that last are those that last longer than longer than 10 to 1410 to 14, but less than , but less than 3030, , daysdays. Such symptoms include . Such symptoms include nasalnasal or or postnasal dischargepostnasal discharge (of any quality), (of any quality), daytime daytime coughcough (which may be worse at (which may be worse at night), or both.night), or both.
Guidelines of American Academy of Pediatrics
בילדיםבילדים
Severe symptomsSevere symptoms include a temperature include a temperature of at least 102°F of at least 102°F (39oC(39oC) and ) and purulent purulent nasal dischargenasal discharge present concurrently for at present concurrently for at least least 3 to 43 to 4 consecutive consecutive days days in a child in a child who seems ill. The child who seems who seems ill. The child who seems toxictoxic should be should be hospitalizedhospitalized and is not and is not considered in this algorithm.considered in this algorithm.
Guidelines of American Academy of Pediatrics
childrenchildren
יש קושי לפעמים להבדיל בילדים בין מחלה וירלית של
דרכי נשימה עליונים ואדנואידיטיס מסינוסיטיס
חריפה
רק נזלת מוגלתית וסמיכה מקורה בסינוסים עצמם, והאף משמש כצינור, בעוד שנזלת מוקואדית,
וירלית מערבת את האף בילבד.
יש דמיון רב בין דלקת אוזן חריפה לסינוסיטיס חריפה בילדים מבחינת פטוגנסיס ומיקרוביולוגיה
בגלל הקשר לנאסופארינקס
ARS in childrenARS in children
DiagnosisDiagnosis in children based on in children based on clinical clinical criteriacriteria
RadiologyRadiology is only for is only for complicationscomplications, , persistent persistent oror recurrent recurrent sinusitis sinusitis
For prevention there is For prevention there is no prophylacticno prophylactic antimicrobial treatment, ancillary antimicrobial treatment, ancillary therapies, complementary/alternative therapies, complementary/alternative medicinemedicine
Guidelines of American Academy of Pediatrics
Surgical managementSurgical management of crs in of crs in childrenchildren
5-8 events of colds/year5-8 events of colds/year
5%-13% will complicate by acute RS5%-13% will complicate by acute RS
Most of children with RS respond to Most of children with RS respond to medical treatmentmedical treatment
Today surgery consist of sinus lavage, Today surgery consist of sinus lavage, ESS, adenoidectomyESS, adenoidectomy
Goal of surgeryGoal of surgery
Surgery is for Surgery is for control of symptomscontrol of symptoms, , better better quality of lifequality of life and and to prevent complicationsto prevent complicationsIndications to surgery are not uniform Indications to surgery are not uniform between OL and Pbetween OL and P““cure”-the goalcure”-the goal for surgery, but is not the for surgery, but is not the likely end pointlikely end pointReversible mucosal disease may be Reversible mucosal disease may be possible in the long run, but is unlikely to possible in the long run, but is unlikely to be realized in the short term be realized in the short term
Maximal medical managementMaximal medical management
RefluxReflux
MacrolidsMacrolids
AntileukotriensAntileukotriens
Irrigations-nasal spraysIrrigations-nasal sprays
Alternative medical approachesAlternative medical approaches
Surgical management childrenSurgical management children
BiomaterialsBiomaterials
Subperiosteal abscessSubperiosteal abscess
The surgical site in childrenThe surgical site in children
There is strong evidence to support the There is strong evidence to support the fact that thefact that the OMC OMC area is the area is the primary siteprimary site of involvement of inflammatory sinuses of involvement of inflammatory sinuses disease. disease.
Surgical management in childrenSurgical management in children
Role of adenoidectomyRole of adenoidectomy::1. reservoir for pathogenic bacteria1. reservoir for pathogenic bacteria2. interfere with nasal mucociliary 2. interfere with nasal mucociliary clearanceclearance3.better drainage3.better drainageOverall successOverall success of adenoidectomy- of adenoidectomy-5050%%Studies show reduction in the number of Studies show reduction in the number of bacterial pathogens in the nasopharynx bacterial pathogens in the nasopharynx after adenoidectomyafter adenoidectomy
Fear of surgeryFear of surgery??
Surgery may cause Surgery may cause growth retardation of growth retardation of the midfacethe midface
Bothwell et al. showed no difference in Bothwell et al. showed no difference in facial growth of children with CRS who facial growth of children with CRS who operated compare with children who operated compare with children who refused surgery.refused surgery.
SurgerySurgery
Children who fail medical therapy benefit Children who fail medical therapy benefit from surgeryfrom surgery
AdenoidectomyAdenoidectomy recommended recommended initially initially for for children 6 years of age (no asthma, low children 6 years of age (no asthma, low CT score)CT score)
ESS and adenoidectomyESS and adenoidectomy for children older for children older than 6 (asthma and high CT score)than 6 (asthma and high CT score)
Ramadan. Laryngoscope.2004Ramadan. Laryngoscope.2004
Results of surgery childrenResults of surgery children
Older childrenOlder children do better than youngest do better than youngest
Old children (>6 y/o)- Old children (>6 y/o)- successes ratesuccesses rate is is 89%89% , but younger children (>6 y/o)- , but younger children (>6 y/o)- successes rate is only 73%successes rate is only 73%
>3 y/o>3 y/o who were operated have who were operated have 75%75% chance chance to be reoperateto be reoperate
Antibiotic therapyAntibiotic therapy
Amoxicillin -1Amoxicillin -1stst choice choice In children give high dose In children give high dose 60mg/kg/day 60mg/kg/day To consider 2To consider 2ndnd generation cephalosporin, or generation cephalosporin, or erythromycin with sulfonamide ,or high dose erythromycin with sulfonamide ,or high dose penicillin in areas with a high incidence of penicillin in areas with a high incidence of bacterial antibiotic resistance.bacterial antibiotic resistance.Based on studies showing a 20% incidence of Based on studies showing a 20% incidence of viable bacteria through maxillary sinus tap after viable bacteria through maxillary sinus tap after 7 days of antibiotic therapy, most authors 7 days of antibiotic therapy, most authors recommend recommend 10 days of therapy10 days of therapy in the manage in the manage of acute sinusitisof acute sinusitis