Treatment of Acute and Chronic Rhinosinusitis in the United States, 1999-2002 Hadley J. Sharp, BS; David Denman, MD; Susan Puumala, MS; Donald A. Leopold, MDObjective: To generalize the prescribing trends of a sta-
nasal decongestants; corticosteroids; and antitussive, ex-
tistically defined sample of patient visits because of acute
pectorant, and mucolytic agents, respectively. In addi-
or chronic rhinosinusitis in the United States, using re-
tion, corticosteroids are used for the treatment of chronic
ported diagnostic codes from the International Classifi-cation of Diseases, Ninth Revision, Clinical Modification. Conclusions: The use of prescription antibiotics far out- Design: Four-year prospective study.
weighs the predicted incidence of bacterial causes of acuteand chronic rhinosinusitis. Frequency of antibiotic class
Setting: Public use data from the National Ambulatory
used was not congruent with reported antimicrobial effi-
Medical Care Survey and the National Hospital Ambu-
cacy of the respective classes. Despite contradictory effi-
latory Medical Care Survey collected by the National Cen-
cacies reported in the literature, inhaled corticosteroids were
frequently used to treat acute rhinosinusitis. Antibiotics andinhaled nasal corticosteroids are being used more often than
Results: The most frequently recommended medica-
their published efficacies would encourage.
tions for treatment of both acute and chronic rhinosinu-sitis are antibiotic agents, followed by antihistamines;
Arch Otolaryngol Head Neck Surg. 2007;133:260-265RHINOSINUSITISISANIMPOR- recentlyfavoredasadiagnosisbecauseof
the combined nasal and paranasal sinus in-
consistent with the current guidelines and
to avoid confusion, we use the term “rhino-
chronic rhinosinusitis based on time line
sinusitis” throughout this article. Physi-
cian-generated clinical information about
tion added clarity, there is still much con-
patient visits because of rhinosinusitis was
collected. Using reported InternationalClassification of Diseases, Ninth Revision,
stitute rhinosinusitis and within the medi-
Clinical Modification (ICD-9-CM) codes
cal field about how to treat the different
subgroups. Until recently, most studies of
ize the prescribing trends of a statisti-
cally defined sample of visits in the UnitedStates that resulted in a primary diagno-sis of acute or chronic rhinosinusitis. CME course available at www.archoto.com
cial burden for the US health care sys-tem. In 1992, direct medical costs of rhino-
conservative estimates. With direct and in-
Author Affiliations:
ment, these results were difficult to inter-
direct costs calculated, the total expendi-
sive disorders experienced by the US popu-
lation.3 Proof can also be found in the num-
were used to evaluate patient visits to sta-
ber of prescriptions written for antibiotic
tistically selected ambulatory care facili-
ties. Although rhinosinusitis has been more
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133, MAR 2007
2007 American Medical Association. All rights reserved.
scriptions for antibiotics in children and 21% in adults.4
antimicrobial use in the past 4 to 6 weeks.4 This order
Not only cost, but also the effect that rhinosinusitis has
will be compared with the descending order of antimi-
on quality of life, makes it a major medical concern.5 With-
crobial prescribing frequency by physicians in the United
out standard protocols, treatment of this varied disor-
States. The effects of antibiotic therapy on chronic rhino-
der can be inconsistent between providers and among
sinusitis are questionable, but if an acute infection oc-
curs in the inflamed nasal or sinus cavities, use of a short-
In this article the various medical treatments used for
term regimen can provide relief.4 Decongestants are often
chronic and acute rhinosinusitis are tabulated. The cur-
used in treatment plans to increase sinus drainage and
rent classification of rhinosinusitis in adults, from the
ventilation and to thin mucosa and mucous secretions,
Sinus and Allergy Health Partnership (SAHP) and the
and result in decreasing mucous stasis.13
American Rhinologic Society, is as follows: acute rhino-
For acute rhinosinusitis, and especially for acute bac-
sinusitis is manifested with symptoms for up to 4 weeks,
terial rhinosinusitis, there are guidelines for treatment.
with the presence of at least 2 major symptoms, or 1 ma-
Chronic disorders are not so categorical and are much
jor and at least 2 minor symptoms or purulence; and
more complex. This may be why there is no consensus
chronic rhinosinusitis is defined as the duration of symp-
in the medical community about algorithms or proto-
toms for 12 weeks or longer, with the same symptom pro-
cols for treatment. The goal of resolution of chronic rhino-
sinusitis is to resolve predisposing factors, but many treat-
Acute rhinosinusitis is most often thought to be caused
ments effective in acute episodes do not have the same
by an infectious agent. Watchful waiting, lavage with sa-
efficacy in chronic disorders.4 In this article, we exam-
line solution, and use of a decongestant or proper anti-
ine the national trends in treatment and how they com-
microbial agents are the treatments of choice.6 Despite
the 32 million cases of chronic rhinosinusitis occurringannually in the United States, the causes are not so clearas for acute rhinosinusitis.7 It is assumed that the chronic
process is multifactorial and possibly different inchildren than in adults. Repeated acute upper respira-tory tract infections can lead to mucosal swelling,
Public use data from the NAMCS and NHAMCS for 1999 through2002 were combined and used in this analysis. These years were
obstruction of sinus outflow, and, eventually, chronic in-
chosen because data were collected similarly during all 4 years.
fection. A number of conditions predispose to rhino-
The NAMCS and NHAMCS prospectively collect data from a na-
sinusitis, including smoking, swimming, decongestant
tional probability sample of visits for ambulatory medical care to
spray abuse (rhinosinusitis medicamentosa), immuno-
a physician’s office and to hospital outpatient departments and
globulin deficiencies, disorders of mucociliary trans-
emergency departments. These surveys are conducted annually
port, and changes in glandular secretions.8 Allergies, via
by the National Center for Health Statistics.
antigen-antibody reactions and release of vasodilators and
Both surveys use a multistage probability design. The NAMCS
mediators of inflammation, can cause mucosal swelling
uses a 3-stage design that starts with a probability sample of
and obstruction.9 In addition, anatomical factors such as
primary sampling units, then samples physician practices within
septal spurs or deviations, hypertrophic middle turbi-
primary sampling units, and finally samples patient visits withinpractices. Patient visits are randomly selected from a 1-week
nates, and concha bullosa can affect nasal cavity and si-
reporting period. Physicians are identified through member-
nus ostia airflow.10 All of these conditions can lead to an
ship lists from the American Medical Association and the
environment that is suitable for mucous stasis, bacterial
American Osteopathic Association. Only nonfederally em-
or fungal overgrowth, and chronic inflammation.11 Other
ployed physicians are included. Physicians with a specialty of
proposed causes include hormonal effects, and further
anesthesiology, pathology, or radiology are excluded from the
research should elucidate a better understanding of these
survey. The NHAMCS uses a 4-stage design that also starts with
a probability sample of primary sampling units, then samples
With a demonstration of the complexity of acute and
hospitals within primary sampling units; outpatient clinics and
chronic rhinosinusitis, it is understandable why the ap-
emergency services areas within hospitals; and visits in the out-
proach to treatment has remained controversial. Inas-
patient and emergency clinic area. Patient visits are randomlysampled during a 4-week reporting period. Hospitals included
much as viruses frequently cause acute rhinosinusitis,
are noninstitutional general and short-stay hospitals; federal,
many advocate no antibiotic treatment if the symptoms
military, and Veterans Administration hospitals and hospital
are not severe, wane in 5 to 7 days, and resolve in 10 days.6
When antibiotics are used, there are recommendations
Data are collected on a patient record form that includes pa-
from the SAHP12 for calculated clinical efficacy and bac-
tient demographic data and visit information. Visit informa-
teriologic efficacy, as well as when to change therapy. In
tion includes up to 3 reasons for the visit, a primary diagnosis
2000 and again in 2004, the SAHP reported the clinical
and 1 or 2 secondary diagnoses, projected visit payment type,
and bacteriologic efficacy of a number of antimicrobial
and a list of medications ordered, supplied, administered, or
agents, including, in descending order, amoxicillin–
continued at the visit. As many as 6 medications can be listed
clavulanate potassium, amoxicillin, cefpodoxime prox-
on the survey, and each drug is referred to as a drug mention. These medications were assigned therapeutic classifications from
etil, cefuroxime axetil, cefdinir, trimethoprim-
the National Drug Code Directory, 1995 edition. An overall an-
sulfamethoxasole, doxycycline, azithromycin or
tibiotic category was created by combining the following thera-
clarithromycin or erythromycin, and telithromycin. The
peutic classes: penicillins; cephalosporins; erythromycins, lin-
SAHP recommended antibiotic therapy for adults with
cosamides, and macrolides; tetracyclines; sulfonamides and
acute bacterial rhinosinusitis with mild disease and no
trimethoprim; and quinolones and their derivatives.
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133, MAR 2007
2007 American Medical Association. All rights reserved. Table 1. ICD-9-CM Codes Used to Evaluate Frequency of Chronic and Acute Rhinosinusitis Visits in the United States, 1999-2002* Chronic Rhinosinusitis Acute Rhinosinusitis ICD-9-CM Code No. of Visits in Database ICD-9-CM Code No. of Visits in Database
Abbreviation: ICD-9-CM, International Classification of Diseases, Ninth Revision, Clinical Modification. *Of the codes included, any one listed as the primary diagnosis qualified the visit for the respective category of diagnosis, chronic or acute rhinosinusitis. Table 2. Medication Classes With Frequency per Visit* Medication Class† Chronic Rhinosinusitis Acute Rhinosinusitis
Erythromycins, lincosamides, and macrolides
Antitussives, expectorants, and mucolytics
Abbreviation: NE, not reliably estimable because of fewer than 30 observations or a relative standard error greater than 30%. *Data are given as number of visits (95% confidence interval). †Up to 6 medications could be listed per visit. Medication classes of interest that met the requirement of 30 subjects and less than 30% relative standard error
for either chronic or acute rhinosinusitis are given in Table 3. STUDY SAMPLE SELECTION
than 30 visits in the database or if their relative standard errorwas greater than 30%.14
In this study, we selected only those visits that resulted in aprimary diagnosis of chronic or acute rhinosinusitis. As manyas 3 diagnoses could be listed at each visit. The first diagnosis
was considered primary and the other diagnoses were consid-ered secondary.
If a visit included 1 of the ICD-9-CM codes given in Table 1
Extrapolations of data from the NAMCS and NHAMCS
for the primary diagnosis, it was selected as a visit because of
show that in 1999 through 2002 in the United States
chronic or acute rhinosinusitis. We excluded those visits with
there were an estimated 14 277 026 visits annually
a diagnosis of both chronic and acute rhinosinusitis because
because of chronic rhinosinusitis and an estimated
there were fewer than 30 such visits in the database.
3 116 142 visits annually because of acute rhinosinusi-tis. These visits represented 1.39% (95% CI, 1.26-1.52)
STATISTICAL ANALYSIS
and 0.30% (95% CI, 0.22-0.38), respectively, of all vis-its for ambulatory care.
Sample weights from the National Center for Health Statistics
Antibiotic agents were mentioned in visits because of
were used for each visit in both the NAMCS and NHAMCS data
both acute and chronic rhinosinusitis. Penicillins were
to obtain unbiased national estimates based on various patient
the most frequently recommended class of antibiotics
characteristics and to adjust for nonresponse. Standard errors
mentioned (Table 2), and in this group, most men-
were calculated using an ultimate cluster variance estimationdesign using Survey Data Analysis software (SUDAAN, ver-
tions were specifically for amoxicillin or amoxicillin–
sion 8.0; Research Triangle Institute, Cary, NC). This ac-
clavulanate potassium (Table 3). The grouping of eryth-
counts for the multistage sampling design to estimate unbi-
romycin, lincosamides, and macrolides was the second
ased standard errors and 95% confidence intervals (CIs).
most frequent class of antibiotics mentioned at visits be-
Estimates were considered unreliable if they were based on fewer
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133, MAR 2007
2007 American Medical Association. All rights reserved.
Among other drug classes, inhaled or nasal cortico-
steroidal agents and antihistamines were mentioned in
Table 3. Frequency of Amoxicillin vs
visits because of both acute and chronic rhinosinusitis. Amoxicillin–Clavulanate Potassium for Treatment of Both Chronic and Acute Rhinosinusitis*
Additional drug class uses are given in Table 2. Medication† Chronic Rhinosinusitis Acute Rhinosinusitis
The use of prescription antibiotics to treat acute rhino-sinusitis far outweighs the predicted incidence of bacte-
*Data are given as number of visits (95% confidence interval).
rial causes. The literature repeatedly shows that viruses are
†Some visits listed both medications. While this is unlikely accurate and
by far the most frequent cause of acute rhinosinusitis. How-
more likely a mistake in reporting, the data must be evaluated.
‡Includes amoxicillin, Amoxil (SmithKline Beecham Pharmaceuticals,
ever, in practice, physicians ordered, supplied, adminis-
Philadelphia, Pa), Polymox (Apothecon, a Bristol-Myers Squibb Co, Shawnee
tered, or continued at least 1 prescription antibiotic in
Mission, Kan), and Trimox (Apothecon).
82.74% of visits because of acute rhinosinusitis. With eti-
§Includes Augmentin, Augmentin 125, Augmentin 250, Augmentin 500, and
ologies less understood for chronic rhinosinusitis, a com-
Augmentin ES (all produced by SmithKline Beecham Pharmaceuticals).
parison cannot be made between research and practice. However, with inflammation the most likely cause, the useof at least 1 antibiotic in 69.95% of visits because of chronic
tertain the secondary efficacy of these drugs. Perhaps these
rhinosinusitis is a surprising number.
physicians were treating a secondary infection or using
Penicillins, mainly amoxicillin and amoxicillin–
the anti-inflammatory effects of antibiotic treatments.
clavulanate potassium, were the most commonly used
While keeping the goals of treatment in mind, there are
medication class for both chronic and acute rhinosinu-
concerns about the overuse of antibiotics and the resul-
sitis. A penicillin drug was mentioned in 30.35% of all
tant problems, including drug resistance and increas-
visits with a primary diagnosis of chronic rhinosinusitis
ingly virulent bacteria. When two thirds of patients with
and in 27.18% visits with a primary diagnosis of acute
sinus symptoms expect or receive an antibiotic and as
rhinosinusitis. This is intuitive, inasmuch as recent stud-
many as one fifth of antibiotic prescriptions for adults
ies have shown penicillins to be highly effective against
are written for a drug to treat rhinosinusitis, these dis-
the bacteria in nasal and sinus areas. Amoxicillin–
orders hold special pertinence on the topic.
clavulanate potassium (875/125 mg twice a day for 14
Inhaled or nasal corticosteroids were mentioned in
days) has a 95% clinical response rate in acute bacterial
15.05% of visits because of acute rhinosinusitis. Pre-
rhinosinusitis and acute exacerbations of chronic rhino-
scribed in a significant number of visits, it is important
to discuss what has previously been reported about the
Penicillins are mentioned more often in visits be-
role of corticosteroids in rhinosinusitis. Dolor et al17
cause of chronic rhinosinusitis compared with acute
showed that the concomitant use of cefuroxime and in-
rhinosinusitis. When the SAHP published antimicrobial
tranasal fluticasone for 21 days had a higher clinical suc-
guidelines for acute bacterial rhinosinusitis in 2004, they
cess rate than use of cefuroxime with placebo (93.5% and
discussed all antimicrobial agents with -lactam activ-
73.9%, respectively; P = .009). Lack of objective criteria
ity en bloc. This class topped the list of efficacious agents,
for measuring improvement, data based on patient re-
and, when subdivided, amoxicillin–clavulanate potas-
ports of improvement, and funding of the study by the
sium had the highest calculated clinical efficacy in both
manufacturer of fluticasone all proved limitations of
the groups that had or had not recently received antimi-
that publication. In a different double-blind, placebo-
controlled trial,2 the use of flunisolide as an adjunct to
The group including erythromycins, lincosamides, and
amoxicillin–clavunate potassium therapy was studied. De-
macrolides was second in frequency of antibiotic men-
spite use of flunisolide vs placebo 3 times daily for 3 weeks,
tions in visits because of acute rhinosinusitis. A men-
many patients continued to have symptoms and recur-
tion in 24.32% of visits puts the use of this class of an-
rences were common in both groups.2 As our data show
tibiotics ahead of cephalosporins, sulfonamides and
and as many practicing clinicians can report, the use of
trimethoprim, and tetracyclines, in that order. The Acute
inhaled corticosteroids as adjunctive treatment in acute
Bacterial Rhinosinusitis protocol issued by the SAHP in
rhinosinusitis is not rare but is of undetermined benefit.
January 2004 listed efficacies of these classes in an or-
In chronic rhinosinusitis, even more intranasal and oral
der different from that reported in our studies. In the SAHP
corticosteroid use was reported. Inasmuch as many con-
data, the erythromycin, lincosamides, and macrolides
sider chronic rhinosinusitis both an infectious and an in-
group had the lowest calculated clinical efficacy and bac-
flammatory disease, it is understandable that clinicians are,
teriologic efficacy, behind the cephalosporins and the
in many cases, attempting to treat both. Two studies used
sulfonamides and trimethoprim. This higher than ex-
to evaluate treatment approaches in chronic rhinosinusi-
pected ranking in clinical practice could be owing to an
tis have been published. One focused on symptomatic im-
anti-inflammatory benefit that macrolides possess.16 Based
provement only, while a more recent study coupled symp-
on the number of visits with an antibiotic mention
tomatic and radiographic changes due to medical treatment.
(69.95% for chronic rhinosinusitis and 82.74% for acute
In the earlier study, McNally et al18 showed that treatment
rhinosinusitis) and the suspected low number of rhino-
with antibiotics, decongestants, and intranasal steroids can
sinusitis episodes caused by a bacterium, one must en-
decrease symptoms of chronic rhinosinusitis. In that study,
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133, MAR 2007
2007 American Medical Association. All rights reserved.
however, patients were not followed up for occurrence of
tion antibiotic drugs are being used far more than bac-
relapse.16 In a 2002 retrospective study, chronic rhinosinu-
terial causes studies would indicate. Within the class of
sitis was treated with an antibiotic (most commonly, trova-
antibiotics, the penicillins are, appropriately, at the top
floxacin, amoxicillin–clavulanate potassium, levofloxa-
of the prescription list for both acute and chronic rhino-
cin, or metronidazole), oral prednisone for 10 days,
sinusitis. Questionable is the frequent use of the class that
intranasal steroids, and nasal irrigation with saline solu-
includes erythromycins, lincosamides, and macrolides,
tion.19 Statistically significant improvement in both symp-
with other classes having higher antibacterial efficacy. Na-
toms and findings at computed tomography from base-
sal and inhaled corticosteroids are prescribed more fre-
line to the end of the study were demonstrated.19 However,
quently to treat acute rhinosinusitis than published stud-
neither of these studies included a concurrent control group.
ies imply is necessary. Despite current theories of causes
Based on current understanding of the pathogenesis of
of chronic rhinosinusitis, the use of corticosteroids re-
chronic rhinosinusitis and these findings, it is understand-
mains low in this setting. An area where our findings fit
able why some physicians prescribe corticosteroids to treat
nicely with current information is use of antihista-
mines, which roughly matched the prevalence of their
Allergic rhinosinusitis is a common disease that affects
major indication, allergic rhinosinusitis.
approximately 20% of the US population.20 Because corti-
A limitation of this study is that the databases used
costeroids are effective in the treatment of this disorder,
only data for medications ordered, supplied, adminis-
higher numbers of drug mentions for this chronic class
tered, or continued by attending physicians. Because these
might be expected. Inasmuch as a patient could have acute
data were not based on patient responses, the use of over-
or chronic sinus complications from allergies, it further
the-counter medicines or home remedies was not re-
clouds the assumptions about use of corticosteroids to treat
corded. We wonder whether the percentages of medica-
tions used would be much smaller when compared with
The use of antihistamines demonstrated by our data
the number of patients who use hot packs to relieve the
seems logical; 20.93% of visits because of chronic rhino-
symptoms of chronic rhinosinusitis or whether physi-
sinusitis and 25.26% of visits because of acute rhinosinu-
cians recommend irrigation with saline solution and
sitis is near the prevalence of allergic rhinosinusitis in the
steam, as often as antihistamine prescriptions.
population. Antihistamines are clearly indicated in the treat-
The use of antibiotics and corticosteroids, inhaled and
ment of allergy-related disease. Some of the older, gener-
oral, needs more investigation in the treating of rhino-
ally over-the-counter antihistamines are considered detri-
sinusitis. Current theories and contradicting evidence in
mental to the nose and sinus mucosa because their
the literature makes the findings of our study all the more
cholinergic effects cause dryness of the mucous secre-
compelling. Could their use be more efficacious than
tions and resolution of infections can be slowed.22 Most of
proved? Can it be assumed that practicing physicians in
the antihistamines in this study were prescription drugs,
the United States base their decisions on experienced suc-
and these newer antihistamines have fewer adverse effects
cess? Evidence-based medicine means incorporating the
and cause much less drying than their predecessors, which
best evidence into treatment decisions. With limited or
no literature addressing the efficacy of each drug class
Decongestants were mentioned in as many as a fourth
with the separate diagnoses, evidence-based medicine
of visits because of rhinosinusitis, and more often acute
would indicate that it is appropriate to use personal or
rhinosinusitis than chronic rhinosinusitis. The high use
of this class of drugs (evaluated separately from antihis-
The vast use of these agents makes the statement that
tamine combination agents) is understandable consid-
they seem to be effective in reducing symptoms or pre-
ering the efficacy reports in the literature. In reviewing
venting relapse, or they would have been abandoned. An-
5 studies, Arroll24 reports a reduction in nasal airway re-
other important possibility is that many patients have self-
sistance in patients using these drugs compared with pla-
limited disease that will resolve regardless of treatment,
cebo. The same study stated that mucolytic agents were
and their physicians could be prescribing what they think
less reported but that such treatment decreased symp-
will work. With time, many infectious processes are re-
tom scores when compared with placebo.24 The conclu-
solved by the patient’s immune system. To attribute ef-
sions of this review rely on primary studies of variable
ficacy or curative credit to a drug class based solely on
quality. The reviewers were clear about the lack of effi-
resolution of symptoms without comparison with non-
cacy except in the high-quality studies in which global
treated control subjects, physicians could be oversatis-
improvement in symptoms was noted. With limited quan-
fied with their own prescribing habits.
tifiable data and supportive anecdotal evidence, the high
Many physicians might use an ICD-9-CM code to en-
use of decongestant and mucolytic agents is logical. Fur-
sure that a patient’s insurance will pay for a particular
ther, both decongestant and mucolytic agents are avail-
medication and not necessarily because the code is for
able over the counter; thus, it can be assumed that us-
the disease they believe they are treating. The coding could
age is even higher than reflected by physician reports.
be questioned if the physician, nurse, or billing clerk maysimply be in the habit of using a few ICD-9-CM codes,regardless of the actual findings or symptoms. Fol-
low-up studies might reveal how these trends change.
In evaluating the trends of rhinosinusitis treatment in the
Submitted for Publication: April 25, 2006; final revision
United States, many points became apparent. Prescrip-
received September 22, 2006; accepted October 29, 2006.
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133, MAR 2007
2007 American Medical Association. All rights reserved. Correspondence: Hadley J. Sharp, BS, Department of
9. Hinni ML, McCaffrey TV, Kasperbauer JL. Early mucosal changes in experimen-
Otolaryngology–Head and Neck Surgery, University of
tal sinusitis. Otolaryngol Head Neck Surg. 1992;107:537-548.
10. Stammberger H. Endoscopic endonasal surgery: concepts in treatment of re-
Nebraska Medical Center, 5226 B St, Omaha, NE 68106
curring rhinosinusitis, part I: anatomic and pathophysiologic considerations. Oto-laryngol Head Neck Surg. 1986;94:143-147. Author Contributions: Ms Sharp had full access to all
11. Benninger MS, Anon J, Mabry RL. The medical management of rhinosinusitis.
the data in the study and takes responsibility for the in-
Otolaryngol Head Neck Surg. 1997;117(3, pt 2):S41-S49.
tegrity of the data and the accuracy of the data analysis.
12. Sinus and Allergy Health Partnership. Antimicrobial treatment guidelines for acute
bacterial rhinosinusitis. Otolaryngol Head Neck Surg. 2000;123:5-31. Study concept and design: Sharp, Denman, and Leopold.
13. Taccariello M, Parikh A, Darby Y, Scadding G. Nasal douching as a valuable ad-
Acquisition of data: Sharp, Puumala, and Leopold. Analy-
junct in the management of chronic rhinosinusitis. Rhinology. 1999;37:
sis and interpretation of data: Sharp, Puumala, and Leopold. Drafting of the manuscript: Sharp and Puumala. Critical
14. Reliability of survey estimates—2005 Centers for Disease Control and Preven-
revision of the manuscript for important intellectual con-
tion: National Center for Health Statistics. http://www.cdc.gov/nchs/about/major/ahcd/reliabilityhtm. Accessed May 10, 2005. tent: Sharp, Denman, Puumala, and Leopold. Statistical
15. Namyslowski G, Misiolek M, Czecior E, et al. Comparison of the efficacy and tol-
analysis: Puumala. Administrative, technical, and mate-
erability of amoxycillin/clavulanic acid 875 mg b.i.d. with cefuroxime 500 mg bid
rial support: Sharp and Leopold. Study supervision: Sharp
in the treatment of chronic and acute exacerbation of chronic sinusitis in adults. J Chemother. 2002;14:508-517. Financial Disclosure: None reported.
16. Amsden GW. Anti-inflammatory effects of macrolides: an underappreciated ben-
efit in the treatment of community-acquired respiratory tract infections and chronicinflammatory pulmonary conditions? J Antimicrob Chemother. 2005;55:10-21.
17. Dolor RJ, Witsell DL, Hellkamp AS, et al; Ceftin and Flonase for Sinusitis (CAFFS)
Investigators. Comparison of cefuroxime with or without intranasal fluticasone
1. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg.
for the treatment of rhinosinusitis: the CAFFS Trial, a randomized controlled trial
[published correction appears in JAMA. 2004;292:1686]. JAMA. 2001;286:
2. Meltzer EO, Orgel HA, Backhaus JW, et al. Intranasal flunisolide spray as an ad-
junct to oral antibiotic therapy for sinusitis. J Allergy Clin Immunol. 1993;92:
18. McNally PA, White MV, Kaliner MA. Sinusitis in an allergist’s office: analysis of
200 consecutive cases. Allergy Asthma Proc. 1997;18:169-175.
3. Benson V, Marano MA. Current estimates from the National Health Interview Sur-
19. Subramanian HN, Schechtman KB, Hamilos DL. A retrospective analysis of treat-
vey, 1992. Vital Health Stat. 1994;10:1-269.
ment outcomes and time to relapse after intensive medical treatment for chronic
4. Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute
sinusitis. Am J Rhinol. 2002;16:303-312.
bacterial rhinosinusitis [published correction appears in Otolaryngol Head Neck
20. Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing defini-
Surg. 2004;130:794-796]. Otolaryngol Head Neck Surg. 2004;130:1-45.
tions for clinical research and patient care. Otolaryngol Head Neck Surg. 2004;
5. Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking
otolaryngologic care. Otolaryngol Head Neck Surg. 1995;113:104-109.
21. Becker J. Allergic rhinitis. http://wwwemedicinecom. Accessed April 15, 2006.
6. Snow V, Mottur-Pilson C, Hickner JM. Principles of appropriate antibiotic use
22. Spector SL, Bernstein IL, Li JT, et al. Parameters for the diagnosis and manage-
for acute sinusitis in adults. Ann Intern Med. 2001;134:495-497.
ment of sinusitis. J Allergy Clin Immunol. 1998;102(6, pt 2):S107-S144.
7. Melen I. Chronic sinusitis: clinical and pathophysiological aspects. Acta Oto-
23. Storms WW, Bodman SF, Nathan RA, et al. SCH 434: a new antihistamine/
laryngol Suppl. 1994;515:45-48.
decongestant for seasonal allergic rhinitis. J Allergy Clin Immunol. 1989;83:
8. Benninger MS, Schmidt JL, Crissman JD, Gottlieb C. Mucociliary function fol-
lowing sinus mucosal regeneration. Otolaryngol Head Neck Surg. 1991;105:
24. Arroll B. Non-antibiotic treatments for upper-respiratory tract infections (com-
mon cold). Respir Med. 2005;99:1477-1484.
(REPRINTED) ARCH OTOLARYNGOL HEAD NECK SURG/ VOL 133, MAR 2007
2007 American Medical Association. All rights reserved.
hp photosmart hp photosmart 945 digital camera with hp instant share™ The HP Photosmart 945 is a precision 8x optical zoom digital camera delivering superior image quality. With 56x total zoom and 5 MP resolution, it lets you capture incredible detail. Intuitive and enhanced manual controls provide extra creativity. For creative individuals and families who want a 5 MP digital cam
Mecanismos de hemostasia y coagulación para el manejo odontológico El odontólogo y el cirujano bucal, en su práctica diaria, activan de forma inadvertida los mecanismos de hemostasia y coagulación cuando se produce la ruptura de un vaso sanguíneo durante los procedimientos quirúrgicos o no quirúrgicos. Dra. M. Benito Urdaneta, Dra. M. Benito Urdaneta, Dra. C. Bernardoni Socorro, Dra