Recent studies point out that antibiotics are used much too frequently in patients with sore throat and sinusitis. The two following articles emphasize that most patients get well without them. RTJ

Antibiotics of little benefit in most patients with uncomplicated sinusitis
3-9 PRIMARY-CARE-BASED RANDOMIZED PLACEBO-CONTROLLED TRIAL OF ANTIBIOTIC TREATMENT IN ACUTE MAXILLARY SINUSITIS
Published trials of treatment of acute maxillary sinusitis have been done in selected groups of patients referred to ENT clinics. No effectiveness studies have been done in unselected primary care patients.
This study tested the hypothesis that there would be an improvement associated with the use of amoxicillin in unselected patients.

Conclusion: Antibiotic treatment did not improve the clinical course in these unselected patients.

STUDY

1. Adult patients with suspected acute maxillary sinusitis received radiographs.1 Those with abnormalities (n = 214) were randomized: 1) Amoxicillin 750 mg three times daily for 7 days, or 2) Placebo.
2. All received xylometazoline2 0.1%, steam inhalations, and acetaminophen.

RESULTS

1. At 2 weeks, symptoms had improved substantially or disappeared in 83% of patients receiving amoxicillin and in 77% of patients receiving placebo.
2. Amoxicillin did not influence the clinical course or the frequency of relapses over 1 year. (21% amoxicillin; 17% placebo)
3. Radio graphs had no prognostic value.
4. Adverse effects occurred in 28% of those taking amoxicillin vs 9% of those taking placebo.

DISCUSSION

1. The spontaneous course of acute sinusitis has a good prognosis. No or few symptoms were reported after 2 weeks by about 4 of 5 patients taking placebo.
2. No distinct clinical effect of antibiotic treatment occurred even in patients with a fluid level on X-ray.1
3. No patient developed chronic sinusitis. "This finding raises the question of whether acute maxillary sinusitis is...a preliminary stage of chronic sinusitis. Chronic sinusitis is more likely to be associated with abnormalities of the ethmoid region and with allergy."
4. "We conclude that in newly presenting cases initial treatment should be symptomatic only. However, there may be patients with more severe acute maxillary sinusitis who benefit from antibiotic therapy. The duration of symptoms may be helpful. After 2 to 3 weeks those with symptoms which show no improvement may benefit."

CONCLUSION
Antibiotic treatment did not improve the clinical course of acute maxillary sinusitis presenting to general practice. For these patients an initial radiographic examination is not necessary. Initial management can be limited to symptomatic treatment. Whether antibiotics are necessary in more severe cases warrants further study.
Lancet March 8, 1997; 349: 683-87 Original investigation first author from St. Elizabeth Hospital, Tilburg, Netherlands.

Comment:

1. Should we do X-rays for suspected sinusitis? If those with positive X-rays do not benefit, surely those without will not benefit either.
2. Xylometazoline is a topical vasoconsrictor.

I believe most US primary care physicians would take X-rays, and prescribe antibiotics if the X-ray was positive. I believe most would also prescribe antibiotics for a patient with sinus discomfort even if an X-ray were not ordered. Many patients will demand antibiotics. Again, the "if " prescription, after a concurrence for treatment is reached by careful listening and explanation, will reduce frequency of use. RTJ

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