Sinusitis guidelines

These guidelines are a pretty reasonable summary of the contemporaneous understanding of this disease. I would take issue with the proposition that Allergists should be viewed as the “internists of the upper respiratory tract.” They have their turf wars with the Pulmonologists over the lower respiratory tract and I will not comment on those. As an otolarynygologist, I will state unequivocally that it is a mistake to adopt the view that an allergist is capable of making a determination as to when a patient should or should not proceed to surgery. That is a discussion for another day

Secondly, these guidelines skip over the one critical issue: sinusitis is a DIFFICULT diagnosis to make on clinical grounds alone. Sure the patient with greater than 10 days of unilateral mucopurlulent rhinorrhea, focal unilateral facial pain, fever, and cough is a no-brainer, but I submit to you that few patients actually present that way (and I say this not as a specialist but as one who in my earlier days put in a good deal of time as a moonlighting doc-in-a-box at an urgent care center). Most come in with a cardinal complaint of face pain, which they and most generalists reflexively assume is “sinus pain,” and Presto! out come the antibiotics. The majority of these patients I see in consultation for “chronic sinusitis” are suffering from chronic facial pain due to TMJ and/or cervical spine issues. They have absolutely normal sinus CT scans – and I insist that these be taken at a time when the patient is maximally (and typically) symptomatic AND untreated (so as to render moot any quesion of normal scan resulting from successful antibiotic treatment).

The other large cohort of “chronic sinus sufferers” are those with a cardinal complaint of “post-nasal drainage”- a term which should be tossed into the venerable trash can of ill defined medical terms such as “dropsy,” “nerves,” and “liver spots.” This group of patients invariably suffer from supra-esopahageal maifestations of GERD, but both patients and doctors are resistant to this idea because there is generally no complaint of pyrrhosis. (Distrubingly, a significant proportion of these individuals are ALREADY known to have a diagnosis of GERD- but again, because their pyrrhosis sypmtom is controlled, everyone feels the problem is controlled.) Diagnosis = sinusitis. Treatment= out come the antibiotics.

So while these guidelines are nice as far as they go, they do not help the generalist UNDERSTAND and therefore properly diagnose or treat the problem. And therin lies the conundrum: if you can’t make the proper diagnosis, you can’t render the proper treatment.

On behalf of my own specialty community I offer my apologies for our collective failure to educate the generalist and lay community better in this regard. Even our own guidleines largely mirror these; and again they are nothing more than an algorithm of thought processes for those who ALREADY understand the intricacies of the disease.