Treatment Guidelines

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The treatment of choice of acute rhinosinusitis is antibiotic therapy. The most frequently used antibiotics for non-complicated rhinosinusitis are amoxicillin-clavulanate and second generation cephalosporins for at least 10 days. If the patient does not improve within 72 h, an alternative antibiotic should be used. In the very rare event medical therapy fails, microendoscopic surgery, based on a preoperative CT, is indicated. This may encompass a very limited dissection aimed at restoring the ventilation of the involved paranasal sinus(es), by removing only those bony structures (i.e., unci-nate process, ethmoid bulla, pneumatized middle turbinate) which impair the outflow of secretions. There is no need to perform any stripping of mucosa, which will revert to a normal status within a short period.

Most orbital complications respond to intravenous broad-spectrum antibiotics within 48-72 h. According to Younis et al. (2002a), surgery is required when at least one of the following five circumstances is present:

• CT evidence of abscess formation

• 20/60 (or worse) visual acuity on initial evaluation

• Severe orbital complications (i.e., blindness or an afferent pupillary reflex on initial evaluation)

• Progression of orbital signs and symptoms despite therapy

• Lack of improvement within 48 h despite maximum medical therapy

While in the past orbital complications have been routinely treated through external procedures, in the last decades microendoscopic surgery has emerged as the surgical modality of choice for acute rhinosinusitis with an orbital complication, particularly in case of subperiosteal or intraorbital abscesses with a medial location (Lusk 1992; Noordzij et al. 2002; Sobol et al. 2002). Surgical steps include uncinectomy, anterior and posterior ethmoidotomy, followed by subtotal removal of the lamina papyracea to drain the abscess. Conversely, abscesses located laterally in the orbit require an external approach. For cavernous sinus thrombophlebitis, other than intravenous broad-spectrum antibiotics, steroids, and drainage of the sinona-sal area infected (generally the sphenoid or the ethmoid sinus), anticoagulants may be indicated (Amran et al. 2002).

Treatment of intracranial complications consists of broad-spectrum intravenous antibiotics crossing the blood-brain barrier. Surgical treatment is indicated if no improvement is noted within 48 h, provided the patient's neurologic condition is stable. Microendoscopic surgery may be employed, apart from the patients who have obvious CT signs of osteomyelitis of the frontal bone. In this circumstance, a coronal approach with wide resection of diseased bone is mandatory. When the posterior wall of the frontal sinus is also involved and needs to be removed, cranialization is required.

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