Antibiotics in Acute Maxillary Sinusitis?

ABSTRACT & COMMENTARY

Synopsis: In radiologically documented acute maxillary sinusitis patients, antibiotics utilized in a randomized placebo-controlled trial in primary care patients showed no efficacy over placebo.

Source: van Buchem FL, et al. Lancet 1997;349:683-687.

The authors conducted an interesting study on a very common diagnosis in primary care practice—acute maxillary sinusitis. It is often difficult to tell the difference between this and the common cold with rhinosinusitis, with only history and physical exam at your disposal. Thus, van Buchem and colleagues used radiologic positive maxillary sinusitis patients treated in a randomized fashion between amoxicillin or placebo. A total of 214 patients were randomized (108 to antibiotics and 106 to placebo). In one- and two-week periods, the ear, nose, and throat specialists re-saw the patients. The statisticians then attacked the data. By comparing all those patients with abnormal radiographic evidence of acute maxillary sinusitis and deciding whether antibiotics helped, they found that, at the two-week point, 83% of the patients treated with antibiotics had greatly decreased their symptoms. This was then compared to 77% of the patients treated with placebo. It did not bear out clinical significance. A variety of other statistical manipulations never showed any clinical significance. Drug compliance was good, and there were no complications.

By analyzing the original 500 patients who were screened for the study, they found that only 20% ended up being randomized. They felt amoxicillin was a good drug for treatment of sinusitis. In their discussion, they questioned whether acute maxillary sinusitis is indeed the first stage of chronic sinusitis. They do come out in favor of radiologic definition of sinusitis given the fact that rhinitis can mimic it when all you have is history and physical to rely on.

COMMENT BY LEN SCARPINATO, DO

In 1989 alone, sinusitis was the cause of 16 million visits to primary health care practitioners in the United States. This study done in the Netherlands may have some impact on the way they practiced.

I don't know any practicing clinician who hasn't considered sinusitis, tapped on the face, seen some purulent nasal discharge and ordered sinus x-rays. Most probably, they also simultaneously wrote an antibiotic course. This study questions whether the radiologic definition of sinusitis and the subsequent antibiotic use is of any benefit, especially since placebo patients did just as well as antibiotic patients. Despite side effects to antibiotics being minimal in the outpatient setting, cost is an issue. When added together, the antibiotic and x-ray cost must be multiplied over the 16 million visits mentioned above. This could conceivably cost a lot of money.

van Buchem et al's study puts into question both the age-old antibiotic use for sinusitis and/or the use of radiologic films to define it. It comes on the heels of a growing body of British literature supporting non-use of antibiotics in acute otitis media. CT scan was not looked into, which would increase the cost significantly. Discussing radiologic findings with my radiologist, I've been told that the CT scan is the definitive test, but I don't know any practitioner who would order a CT scan for acute sinusitis.

We may be entering an era in which symptomatic treatment of acute sinusitis would be the norm, and we may have to reserve antibiotics for chronic sinusitis. The problem is that many primary care physicians feel that chronic sinusitis needs to be treated by a drainage procedure and, therefore, referral to your ear, nose, and throat doctor. This study throws all this into question and begs for more questions to be answered. In the meantime, I am going to cut down on the antibiotic use in acute sinusitis and treat symptomatically.