Bacteriology and antibiotics treatment of maxillary sinusitis: a prospective study

INTRODUCTION

Sinusitis is generally triggered by a viral upper respiratory tract infection, with only 2% of cases being complicated by bacterial sinusitis.¹ About 90% of patients in the United States are estimated to receive an antibiotic from their general practitioner, yet in most cases the condition resolves without antibiotics, even if it is bacterial in origin.²

The mainstay of treatment for acute rhinosinusitis is symptomatic relief with analgesics; little evidence supports the use of antihistamines, intranasal steroids, nasal douches, or decongestants.³

Some evidence supports the use of antibiotics, with a 3-5% difference in cure rate compared with placebo, especially in cases where symptoms are severe, persistent (>5 days), or progressive.⁴ Evidence suggests benefit with Amoxicillin or Co-amoxiclav, as well as with Cephalosporins or macrolides. Resolution rates for these drugs are reported to be similar, although Cephalosporins and macrolides may have fewer adverse effects.³

Chronic rhinosinusitis: Oral antibiotics with anaerobic and gram negative cover may be required, although the European Academy of Allergology and Clinical Immunology found limited evidence to support their use. They may be considered in patients who have failed to respond to initial intranasal steroid therapy or in those who have severe symptoms with evidence of persistent nasal sepsis. Symptom relief can be achieved in both acute and chronic rhinosinusitis with the use of topical saline douches and sprays.⁵

Hence in this study, we assessed efficacy of different class of antibiotics in treatment of maxillary sinusitis and treatment response assessed with help of diagnostic endoscopic findings and radiologically by X-ray PNS Water’s view findings.

Objectives

We conducted this study with following main objectives

• 1) To study the bacteriology of maxillary sinusitis.
• 2) To compare efficacy and safety of different antibiotics in the treatment of maxillary sinusitis.

METHODS

100 patients presenting with complaints of maxillary sinusitis to the ENT, OPD, KIMSDU, Karad, Maharashtra, India were selected randomly (more than 12 years of age). All of them were examined clinically and subjected to X-ray PNS (Water’s view) and Diagnostic Nasal Endoscopy [DNE]. Antral lavage was done for all the patients and returning fluid sent for culture and sensitivity. For acute maxillary sinusitis- endoscopic guided middle meatus secretion were collected for microbiological examination, followed by antral puncture which was undertaken with antibiotic coverage.

Statistical analysis

Results were evaluated by statistical analysis using Chi square test and evaluating p value tabulated and compared.

Culture specific appropriate antibiotics were advised orally for 10 days such as

• • Amoxcillin-Clavulinate 625 mg BID.
• • Cefpodoxime proxetil 200 mg BID.
• • Levofloxacin 500 mg OD.
• • Ciprofloxacin-Tinidazole (500:600 mg) BD.

Inclusion criteria

Patients presenting with clinical features (>7 days) related maxillary sinusitis of all age groups and sexes.

Nasal obstruction and nasal discharge, headache, postnasal drip, sinusitis pain, facial pain, anosmia, malaise, fever and cough, purulent secretion in the nasal cavity, discharge in the pharynx and tenderness on sinus tapping.

Exclusion criteria

Exclusion criteria were age less than 12 years, allergy to study medications, pregnancy and breast feeding; previous paranasal surgeries, clinical suspicion of frontal sinusitis or pansinusitis, cases with complications due to spread of the infection to surrounding areas; space occupying lesions in nasal cavities.

RESULTS

Sex incidence

In present study, females were most affected 53%, followed by males- 47%.

Age distribution

Highest age incidence was in the third decade i.e. 20-29 age groups. Least commonly affected were elderly more than 50 years.

Clinical diagnosis

Chronic rhinosinusitis (45%) was the most common diagnosis followed by acute rhinosinusitis (39%).

Symptomatological index

Among the major factors for diagnosis of rhinosinusitis, commonest symptoms noted were nasal discharge (66%), nasal obstruction (48%), followed by and facial pain (39%). Of the minor factors, commonest symptoms were headache (27%) followed by dental pain and halitosis (18% each).

Radiographic appearance of Maxillary sinuses (Pre-treatment)

The maxillary antra in 13% cases were radiologically clear, and hazy in 18%, opaque in 15%, air-fluid level in 24% and 30% had mucosal thickening.

Diagnostic nasal endoscopic (DNE) findings

Based on Lund-Kennedy endoscopic scoring system the diagnostic endoscopy of the middle meatus in all cases revealed no middle meatal discharge in 10%, thin secreations in 29%, thick and purulent discharge in 61%.

Results of antral lavage

Of all the sinuses irrigated, 28% returns obtained were clear. Among the abnormal returns, most common type was the purulent returning fluid in 53%, mucoid and mucopurulent in 8% and 11% respectively (Table 4).

Comparison of lavage findings with radiographic appearance of maxillary sinuses

• i. Of the 18 cases having hazy X-rays, 10 yielded abnormal secretions on antral lavage showing accuracy of 56%. Amongst the cases with abnormal returning fluid 5 were purulent in nature, 2 were mucopurulent and 3 were mucoid.
• ii. Out of the 15 X-rays showing opacity, 10 yielded abnormal on lavage showing accuracy of 67%. Amongst these 10, 5 were purulent, 2 were mucoid, 3 were mucopurulent.
• iii. Of the cases having Air-fluid level on X-rays all proof puncture yielded abnormal purulent returning fluid. Thus showing 100% accuracy.
• iv. Out of the total 30 X-rays showing mucosal thickening, 25 yeilded positive lavage showing an accuracy of 83%.
• v. X² value= 59.47, p<0.05. So comparison was statistically significant.

Comparison of lavage findings with diagnostic nasal endoscopic findings

• 1) Out of the total, 10 patients showing NO discharge on DNE, all 10 gave positive lavage (no secretion) showing an accuracy of 100%.
• 2) Of the 29 patients showing thin secretions on DNE, 19 yielded secretions on irrigation. Accuracy was 66%.
• 3) Of the 61 patients on DNE showing thick and purulent, 53 yielded mucopurulent/purulent secretion on irrigation. Accuracy was 92%.

X² value= 72.42, p<0.0001. So comparison was statistically significant.

Bacteriology of maxillary sinusitis

Most common organisms causing acute maxillary sinusitis in this study are- coagulase positive S. aureus (17.77%), S. pnemoniae (7.77%), Enterobactiaceae (7.77%) and H. influenza (5.55%).

Most common organisms causing chronic maxillary sinusitis in this study are- anaerobic Peptostreptococcus (16.66%), S. aureus (11.11%) and Fusobacterium (6.66%).

Overall most common organisms causing maxillary sinusitis in this study are - coagulase positive S. aureus (28.88%), Peptostreptococcus (18.8%), S. pnemoniae (8.8%) and H. influenza (6.6%).

Sensitivity pattern of antibiotics under study

In Table 6, out of 100 cases 10 (10%) yielded no growth on culture, whereas 90% yielded growth of different organisms.

Out of 90 cases Amoxy-Clav was sensitive in 66 (87%), Cefpodoxime in 59 (78%), levofloxacin in 52 (60%) and Ciprofloxacin-Tinidazole in 43 (57%).

All aerobes are sensitive to Amoxy-Clav, Cephalosporin, Levofloxacin except Alpha Hemolytic strepotococci resistant to Levofloxacin, Cephalosporin.

All anaerobes are sensitive to Amoxy-Clav, Ciprofloxacin-Tinidazole, and resistant to Cephalosporin and Levofloxacin.

All patients received different antibiotics for 10 days on the basis of sensitivity pattern.

33 patients received Amoxy-Clav, 22 patients received Cefpodoxime, 19 patients received levofloxacin, 16 patients received Ciprofloxacin-Tinidazole based on highest sensitivity to particular drug.

Antibiotic efficacy was assessed by improvement of clinical features as per Task Force definitions of rhinosinusitis, X-ray PNS Water’s view, and by diagnostic endoscopy.

The safety outcomes

The safety outcomes of the study were evaluated by total adverse events (Table 7).

DISCUSSION

This study was conducted in the department of Otorhinolaryngology, KIMSDU, Karad, Maharashtra, India during the period- November 2011 to May 2013.

100 cases diagnosed clinically as maxillary sinusitis were subjected to radiological examination (Water’s view PNS) and diagnostic nasal endoscopy [DNE].

Out of these 100 cases, 87 had abnormal X-rays findings and 90 had abnormal findings at DNE. Antral lavage was done in all cases. The findings were noted, tabulated, compared.

The results of the present study are compared with the previous studies.

Comparison of sex incidence

As per Revonta et al, McNeil et al and Arruda et al the incidence of maxillary sinusitis was seen more in females, while as per Kurien et al it was more in males.^6,8,11,15 In present study females were more commonly affected.

Age distribution

Highest age incidence was in the third decade i.e. 20-29 age groups. Least commonly affected were elderly more than 50 years.

Age incidence

According to Vourinen et al, Axelsson et al, Kurien et al, and also the present study, highest incidence was seen in the 20-29 age group (3rd decade).^7,10,15 While as per McNeil et al, maximum age incidence was in 4^th decade.⁸

Symptomatological index

Of the major factors for diagnosis of rhinosinusitis, most common complaint in this study was nasal discharge (66%), nasal obstruction (48%), followed by and facial pain (39%).

Among the minor factors, most common symptom was headache (27%) followed by dental pain and halitosis each (18%)

Radiological appearance of maxillary antra

Sen et al studied 200 abnormal X-rays.¹³ They categorized X-ray findings as slight haziness (n=47), haziness (n=122), opacity (n=20) and mucosal thickening (n=13).

In McNeil et al’s study, most common radiographic finding was mucosal thickening (n=25) followed by opacity and haziness.⁸ While in Arruda et al study, maximum showed clear antra (n=42).¹¹ In the studies by Kurien et al and Sen et al, the commonest finding was haziness.^13,15 In the present study most common radiographic finding was mucosal thickening (30%) followed by air fluid level (24%) and haziness (18%).

Antral lavage findings

In the study by Kurien et al, commonest return was Purulent in nature.¹⁵ While in Sen et al study and also in the present study most commonly it was clear returning fluid.¹³

Radiological appearance with antral wash findings

Opaque X-rays show a high reliability for predicting lavage effluent as found in the studies of Evans et al (94%), Kurien et al (100%), Ezeanolue et al (96%), Vourinen et al (86%), McNeil et al (81%), Sen et al (80%) and Elwamy et al (75%).^8,10,12-16 Similar observation was made in the present study (80%) also.

Air-fluid level in radiograph also showed a good positive predictive value as shown in studies of Elwamy et al (100%), Ezeanolue et al (87.5%), Kurien et al (73.7%) and Vourinen et al (73.6%).^10,14-16 Same result was obtained in the present study (100%) also.

When X-ray showed haziness, only McNeil et al’s study reported a high percentage of positive lavage i.e. 87%.⁸ Less reliability was shown in studies of Sen et al (49%), Kurien et al (40%), Ezeanolue et al (29.4%) and Samy Elwamy et al (12.5%).^13-16 The present study (56%) also showed comparable findings.

In the case of mucosal thickening in X-ray, only Elwamy et al found a good predictability of 62.5%.¹⁶ While low predictability was shown in the studies of McNeil et al (37%), Ezeanolue et al (36.7%), Vourinen (36.4%), Evans et al (26%) and Hinde (16%).^8-10,12,14 The present study showed a predictability of 83%.

DNE findings

In present study thin secretions found in 29% and thick mucopurulent in 61%. The study conducted by Kumar et al found mucopurulent discharge in 63.04% whereas Shahizon et al found mucopurulent discharge in 24%.^17,18

Bacteriology of maxillary sinusitis

According to Brook most common organisms causing acute maxillary sinusitis are S. pnuemoniae (31%), H. influnzae (21%), M. catarrhalis (8%), Enterobactiaceae (7%) and S. aureus (4%) and chronic maxillary sinusitis caused mainly by anaerobes Peptostreptococcus spp (56%), P. acne (19%), Fusobacterium spp (17%), Prevotella, Porphyronas and B. fragilis (47%) and S. pyogens (6%).¹⁹

Most common organisms causing acute maxillary sinusitis in this study are- coagulase positive S. aureus (17.77%), S. pnemoniae (7.77%), Enterobactiaceae (7.77%) and H. influenza (5.55%).

Most common organisms causing chronic maxillary sinusitis in this study are- anaerobic Peptostreptococcus (16.66%), S. aureus (11.11%) and Fusobacterium (6.66%).

Overall most common organisms causing maxillary sinusitis in this study are coagulase positive S. aureus (28.88%), Peptostreptococcus (18.8%), S. pnemoniae (8.8%), and H. influenza (6.6%).

In present study aerobes (48%) are most common organisms responsible for acute maxillary sinusitis, whereas as anaerobes (29%) are more responsible for causing chronic maxillary sinusitis.

Efficacy of each antibiotics by clinical cure rate

According to Kapan 100% clinical cure rate seen with Amoxy-Clav, 87.3% by Adeglass study and 74.5% by Luterman study, whereas in present study clinical cure rate of 96% seen with Amoxy-Clav.²⁰

According to Stefansson 89% clinical cure rate seen with Cefpodoxime, 88.4% by Shiegert study and 92.2% by Namyslowski study, whereas in present study clinical cure rate of 92% seen with Cefpodoxime.²⁰

According to Adeglass 88.4% clinical cure rate seen with levofloxacin, 93.9% by Lesko study and 91.2% by Joreoncharsri study, whereas in present study clinical cure rate of 89% seen with Levofloxacin.²⁰

According to Klapan 100% clinical cure rate seen with Ciprofloxacin-TZ, 87.3% by Adeglass study and 74.5% by Luterman study, whereas in present study clinical cure rate of 76% seen with Ciprofloxacin-Tinidazole.²⁰

The safety

The safety outcomes of the study were total adverse events.²⁰ Adverse effects were negligible and tolerable in all individuals.

Diarrhoea (6%) is most common adverse effect of Amoxicillin-Clavulinic acid seen in this study, similarly diarrheoa (11.6%) noted by Adeglass and (14%) noted by Sher studies.²⁰

Diarrhoea (6%) is most common adverse effect of Cefpodoxime seen in this study, similarly diarrheoa (6%) noted by Siegert and (6.2%) noted by Burke studies.²⁰

Diarrhoea (5%) is most common adverse effect of Levofloxacin seen in this study, similarly diarrheoa (9%) noted by Adelglass and (1.3%) noted by Adelglass studies.²⁰

Nausea/vomiting (12%) are most common adverse effect followed by metallic taste (6%) seen with ciprofloxacin-tinidazole in this study. Change in taste sensation (2.5%) most common adverse effect noted by Weiss 1999 study whereas Clifford noted overall GI side effects in 20.6%.²⁰

CONCLUSION

According to our study, most common organisms causing acute maxillary sinusitis in this study are S. aureus (coagulase +), S. pnemoniae and Enterobacteriacae.

Most common organisms isolated are anaerobic Peptostreptococcus, coagulase positive S. aureus and Fusobacterium in chronic rhinosinusitis. Efficacy of Amoxicillin-Clavulinic acid was 96% clinically, 94% based on results on DNE findings and 87% by radiological success rate which is statistical more significant than other class of antibiotics. So, Amoxicillin Clavulinic acid can be considered as first line of drug for treating bacterial rhinosinusitis.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

REFERENCES

1. 1. Agency for Health Care Policy and Research. Diagnosis and treatment of acute bacterial rhinosinusitis. Evid Rep Technol Assess (Summ). 1999;9:1-5.
2. 2. Scheid DC, Hamm RM. Acute bacterial rhinosinusitis in adults: part I. Evaluation. J Am Fam Phys. 2004;70:1685-92.
3. 3. Ah-See KW. Sinusitis (acute). Clinical Evidence. Available at: www.clinicalevidence.org/ceweb/conditions/ent/0511/0511_contribdetails.jspwww.clinicalevidence.org/ceweb/conditions/ent/0511/0511_contribdetails.jsp. Accessed on 3 March 2017.
4. 4. Williams Jr JW, Aguilar C, Cornell J, Chiquette E. Dolor RJ, Makela M, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. 2003;(2):CD000243.
5. 5. Fokkens W, Lund V, Bachert C, Clement P, Helllings P, Holmstrom M, et al. EAACI position paper on rhinosinusitis and nasal polyps executive summary. Allergy. 2005;60:583-601.
6. 6. Revonta M, Sounpaa J. Diagnosis of subacute maxillary sinusitis in children. J Laryngol Otol. 1981;95:133-40.
7. 7. Axelsson AA, Grebelius N, Chidekel N, Jensen C. The correlation between the radiological examination and the irrigation findings in maxillary sinusitis. Acta Otolaryngol. 1970;69:302-6.
8. 8. McNeil RA (Belfast). Comparison of findings on transillumination, X-ray and lavage of maxillary sinus. J Laryngol Otol. 1963;77:1009-13.
9. 9. Raymond T Hinde. A review of the diagnostic problem in one hundred cases of chronic maxillary sinusitis. J Laryngol Otol, Nov 1950;64:687-92.
10. 10. Vourinen P, Kauppila A, Pulkkinerr K. Comparison of results of roentgen examination and antral puncture and irrigation. J Laryngol Otol. 1962;76:359-64.
11. 11. Arruda LK, Mimica IM, Solé D, Weckx LL, Schoettler J, Heiner DC, et al. Abnormal Maxi llary sinus radiographs in children. Do they represent bacterial infect ion? Paediatrics. 1990;85(4):553-8.
12. 12. Evans FO, Sydnor JB, Moore WEC, Moore GR, Manwaring JL, Brill AH, et al. Sinusitis of maxillary antrum. New England J Med. 1975;293:735-9.
13. 13. Sen MK, Samaddar RR. A correlation between the findings of X-ray PNS and antral washout. Indian J Otolaryngol Head Neck Surg. 1993;45(2):70-2.
14. 14. Ezeanolue BC, Aneke EC, Nwagbo DF. Correlation of plain radiological diagnostic features with antral la vage results in chronic maxillary sinusitis. West African J Med. 2000;19(1):16-8.
15. 15. Kurien M, Raman R, Job A. Roentgen Examination of Maxillary Sinus, Antral Puncture and Irrigation – A Comparative study. Sing Med J. 1989;30:565-7.
16. 16. Elwamy S, Abdell-Kreim A, Tulaii M. Relevance of Conventional Waters view in evaluating chronic bacterial maxillary sinusitis. J Laryngol Otol. 1985;99:1233-44.
17. 17. Patel AK, Patel A, Sing B, Sharma MK. The study of functional endoscopic sinus surgery in patients of sinus headache. Int J Biology Medical Res. 2012;3(3):1924-30.
18. 18. Shahizon AM, Suraya A, Rozmnan Z, Aini AA, Gendeh BS. Correlation of Computed Tomography and Nasal Endoscopic Findings in Chronic Rhinosinusitis. Med J Malaysia. 2008;63(3):211-5.
19. 19. Brook I. Microbiology and antimicrobial management of sinusitis. Otolaryngol Clin North Am. 2004;37:253–66.
20. 20. Update on Acute Bacterial Rhinosinusitis, 2005. AHRQ Publication No. 05-E020-2005. Available at: https://archive.ahrq.gov/downloads/pub/evidence/pdf/rhinoupdate/rhinoup.pdf. Accessed on 10 July 2016.