Sinusitis in Athletes

Anatomy

The sinuses are air pockets within the skull that include the maxillary sinuses, located within the cheek bones; the ethmoid sinuses, located behind the bridge of the nose; the frontal sinuses, located above the eyes in the center of the eyebrows; and the sphenoid sinus, located behind the ethmoid sinuses and behind the eyes. When the mucus-clearing cilia of the epithelial tissue that lines the sinuses cannot function due to swelling and inflammation, mucus is trapped, and an excellent growth medium for bacteria is provided, resulting in symptoms usually correlating with the location of each sinus. Because the epithelial lining of the sinuses and nasal passage is the same as that seen in much of the respiratory system, sinusitis can also cause problems anywhere in the respiratory tract.

Diagnosis

Although bacteria and viruses account for a majority of cases, allergens, smoke, pollution, and cold air can also cause rhinosinusitis. A careful history can usually elicit the likelihood of the latter diagnoses. Sinusitis is a self-limiting condition 80% to 90% of the time. To avoid unnecessary antibiotic use and expensive testing, clinical prediction rules have been developed on the basis of meta-analyses of numerous studies. According to the Cochrane Database and the Agency for Health Care Research and Quality (AHRQ), the most significant clinical predictors for the diagnosis of sinusitis, regardless of symptom duration, and therefore for the consideration for antibiotics, are unilateral purulence, predominantly unilateral facial pain, bilateral purulence, and the presence of pus in the nasal cavity. When other minor symptoms such as fever, headache, anosmia, facial congestion, fatigue, cough, and dental or ear pain have been present for more than 7 days, antibiotics should also be considered. The use of sinus radiographs and limited computed tomography (CT) scans of the sinuses for the diagnosis of sinusitis should be reserved for recalcitrant cases lasting more than 30 days and/or two antibiotic treatment failures.

Asthma and allergy sufferers can have an allergic rhinosinusitis with symptoms mimicking those of acute sinusitis. If any of the acute sinusitis clinical predictors become evident, then antibiotics should be prescribed. Migraines can often be mistakenly attributed to sinusitis when the main complaint is either sinus pain or headache in the absence of other symptoms. A careful history and [Page 1319]physical exam should screen out the athletes with sinusitis.

Treatment

The Sanford Guide to Antimicrobial Therapy and most primary care and otolaryngology organizations recommend mucolytics, analgesics, decongestants, and sinus irrigation in the early stages of infection. With athletes who may undergo drug testing, providers should be aware of current banned substances such as pseudoephedrine. A list of these can be found on the U.S. Olympic Committee (USOC) and sports governing board websites. In most cases of uncomplicated acute sinusitis, amoxicillin for 7 to 10 days provides adequate coverage. There is no evidence that nonpenicillin-based antibiotics offer any additional benefit over penicillins. In penicillin-allergic patients, sulfa drugs, macrolides such as azithromycin and clarithromycin, cephalosporins, and quinolones are good substitutes, but providers should be aware of the potential tendinopathic side effect of quinolones. In more serious cases or treatment failures, amoxicillin-clavulanic acid for 14 to 21 days is recommended. In athletes diagnosed with sinus infections who have comorbid asthma and allergic rhinitis, nasal steroids may enhance mucociliary clearance and reduce nasal congestion. Aggressive long-term treatment in these athletes with nasal steroids, nonsedating antihistamines, nasal irrigation with saline, and/or leukotriene inhibitors can reduce the frequency of sinus infections and improve lung volumes, fatigue, and overall athletic performance.

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