Sinusitis

Topic Overview

What is sinusitis?

Sinusitis is infection or inflammation of the lining of the sinus cavities. These are hollow spaces in your cheeks and around your eyes. Sinus infections often follow a cold and cause pain and pressure in your head and face.

Sinusitis can be either acute (sudden) or chronic (long-term). With chronic sinusitis, the infection or inflammation does not completely go away for 8 weeks or more.

What causes sinusitis?

Sinusitis can be caused by three things:

• Viruses.
• Bacteria.
• Fungi.

The same viruses that cause the common cold cause most cases of sinusitis.

When the lining of the sinus cavities gets inflamed from a viral infection like a cold, it swells. This is viral sinusitis. The swelling can block the normal drainage of fluid from the sinuses into the nose and throat. If the fluid cannot drain and builds up over time, bacteria or fungi (plural of fungus) may start to grow in it. These bacterial or fungal infections can cause more swelling and pain. They are more likely to last longer, get worse with time, and become chronic.

Nasal allergies or other problems that block the nasal passages and allow fluid to build up in the sinuses can also lead to sinusitis.

See a picture of normal facial sinuses and a picture of a blocked sinus .

What are the symptoms?

The main symptoms of sinusitis are a runny or stuffy nose and pain and pressure in your head and face. You may also have a yellow or green drainage or drip from your nose or down the back of your throat (postnasal discharge). Where you feel the pain and tenderness depends on which sinus is affected.

Other common symptoms of sinusitis may include:

• A headache.
• Bad breath.
• A cough that produces mucus.
• A fever.
• Pain in your teeth.
• A reduced sense of taste or smell.

How is sinusitis diagnosed?

Your doctor can tell if you have sinusitis by asking questions about your past health and doing a physical exam. You probably won't need any other tests.

How is it treated?

Viral sinus infections usually go away on their own within 10 to 14 days. Antibiotics don't work for viral infections. But there are some things you can do at home to help relieve your symptoms:

• Drink plenty of fluids.
• Try over-the-counter pain relievers and decongestant pills to help relieve the pain and pressure in your head and face.
• Put a hot, damp towel or gel pack on your face for 5 to 10 minutes at a time, several times a day.
• Breathe warm, moist air from a steamy shower, a hot bath, or a sink filled with hot water.
• Use saltwater nose drops to help keep the nasal passages open and wash out mucus and bacteria.

Home treatments may help drain mucus from the sinuses and prevent a more serious bacterial or fungal infection.

Bacterial infections can be treated with antibiotics. You will probably feel better in a few days, but some symptoms may last for several weeks. You may need to take the medicine for a longer time if you have chronic sinusitis.

If you have a fungal infection-which is not common-antibiotics won't clear up your sinusitis. With this type of infection, you may need treatment with antifungal medicines, steroid medicines, or surgery.

If you have taken antibiotics and other medicines for a long time but still have sinusitis symptoms, you may need surgery. You may also need surgery if the infection is likely to spread or if you have other problems, such as a growth (polyp) blocking the nasal passage.

Frequently Asked Questions

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	Should I have surgery for sinusitis?

Cause

Sinusitis is most often the result of a viral infection that causes the mucous membrane lining the inside of the nose and the sinuses to become inflamed.

• The mucous membrane swells when it becomes inflamed, blocking the drainage of fluid from the sinuses into the nose and throat.
• Mucus and fluid build up inside the sinuses, causing pressure and pain.
• Bacteria are more likely to grow in sinuses that are unable to drain properly. Bacterial infection in the sinuses often causes more inflammation and pain.

While colds usually trigger this process, any factor that causes the mucous membrane to become inflamed may lead to sinusitis. Many people with nasal allergies (allergic rhinitis), for instance, are likely to have recurring or long-term (chronic) sinus infections. Nasal polyps, foreign objects (usually in children), structural problems in the nose such as a deviated septum, and other conditions can also block the nasal passages, increasing the risk of developing sinusitis.

Fungal infections may also cause sinusitis. This is especially true in people with impaired immune systems. Fungal sinusitis tends to be chronic and more difficult to treat than bacterial sinusitis.

Symptoms

Pain and pressure in the face along with a stuffy or runny nose are the main symptoms of sinusitis. You also may have a yellow or greenish discharge from your nose. Leaning forward or moving your head often increases facial pain and pressure. The location of pain and tenderness may depend on which sinus is affected.

• Pain over the cheeks and upper teeth is often caused by maxillary sinus inflammation.
• Pain in the forehead, above the eyebrow, may be caused by frontal sinus inflammation.
• Pain behind the eyes, on top of the head, or in both temples may be caused by sphenoid sinus inflammation.
• Pain around or behind the eyes is caused by ethmoid sinus inflammation.

See a picture of the location of normal facial sinuses .

Other common symptoms of sinusitis include:

• Headache.
• Yellow or greenish discharge from the nose or down the back of the throat.
• Bad breath.
• Stuffy nose.
• Cough that produces mucus.
• Fever.
• Tooth pain.
• Reduced sense of taste or smell.

Acute (sudden) sinusitis is usually caused by a viral infection and often develops rapidly. It usually lasts for 4 weeks or less, and the symptoms often begin to clear up within a week without any treatment. Acute sinusitis caused by a bacterial infection is less likely to clear up on its own and may lead to chronic sinusitis or to complications in which the infection spreads beyond the sinuses. Nasal discharge that contains pus and worsens after 5 days or persists for more than 10 days is usually a strong sign of acute sinusitis caused by a bacterial infection.

Chronic (long-term) sinusitis is usually caused by a bacterial or fungal infection. These infections may be difficult to treat. If chronic sinusitis is not cured after trying two or more different antibiotics, you may want to talk with your health professional about surgery or allergy testing. Chronic sinusitis can lead to permanent changes in the mucous membranes that line the sinuses and may make you more prone to sinus infections.

Symptoms of sinusitis in children include coughing, nasal discharge that lasts more than 7 to 10 days, and complaints of headache and facial pain. Many children age 2 or older with chronic sinusitis may also have allergies and frequent ear infections. Some immunizations, particularly pneumococcal conjugate vaccine (PCV) and Haemophilus influenzae type b (Hib), may help prevent ear and sinus infections.

Other conditions that have symptoms similar to sinusitis may include allergies, toothaches, and colds or other upper respiratory infections. But if you've had a cold that returns or gets worse after 7 days (called double sickening), you probably have a sinus infection rather than a cold or other upper respiratory infection.

What Happens

There are two types of sinusitis: acute (sudden onset) and chronic (long-term). Sinusitis often develops after a cold or viral infection. Most sinus infections improve on their own, but sometimes they develop into a bacterial infection-swelling, inflammation, and mucus production caused by the cold can lead to blockage in the nasal passages, which may encourage the growth of bacteria.

Acute sinusitis, whether viral or bacterial, may develop into chronic inflammation or infections that may last 8 weeks or longer. Chronic sinusitis can lead to permanent changes in the mucous membranes that line the sinuses. As a result of these changes, you may become prone to having more sinus infections that may become more difficult to treat.

Complications of sinusitis (such as an infection of the facial bones called osteomyelitis) are relatively rare. But when complications occur, they may be life-threatening and often require extensive medical or surgical treatment.

What Increases Your Risk

Your risk of developing sinusitis increases if you have recently had a cold, another viral or bacterial infection, or an upper respiratory tract infection. Also, chronic nasal allergies (allergic rhinitis) can lead to sinusitis.

Sometimes a deviated septum, broken nose, or growths such as nasal polyps can make you more susceptible to sinus infections. Problems with nasal structure can prevent the proper flow of mucus from the sinuses into the nose.

Other factors that increase your risk for getting sinus infections include smoking, air pollution, overuse of decongestant sprays, cold weather, rapid air pressure changes (such as from flying or scuba diving), and swimming in contaminated water. In addition, using continuous positive airway pressure (CPAP) to treat sleep apnea may increase the risk of sinusitis.

When To Call a Doctor

Call your health professional if sinusitis does not improve after 2 days of home treatment and you have symptoms such as:

• Pain in the face or upper teeth.
• Pain extending from the bridge of the nose to the lower eyelid.
• Headache that is not relieved by taking acetaminophen or aspirin.

Call your health professional after three or four days of home treatment if you still have symptoms such as:

• Fever of 101 °F (38.3 °C) or higher.
• Nasal discharge that starts out clear and later becomes thick and discolored (yellow or green).
• Repeated nosebleeds.

You also need to call a health professional if:

• Cold symptoms last longer than 10 days or worsen after the first 7 days.
• You have mild or chronic pain in the face that lasts longer than a month, has changed, or has not been checked by a doctor.
• You are taking antibiotics for a sinus infection, and you do not feel any better after 3 to 5 days. You may need to try a different antibiotic or add medicine that will reduce swelling (decongestants) to your treatment.

If you are not sure whether you have a cold or a sinus infection, see the topic Facial Problems, Noninjury.

Watchful Waiting

Watchful waiting is appropriate if you have symptoms of an early sinus infection (such as pain and pressure in your head along with a stuffy or runny nose). An early sinus infection can often be treated at home if you are in good health. If you develop symptoms of a sinus infection, start home treatment, such as drinking lots of fluids and breathing steam from a warm shower, and use the guidelines above to decide whether you need to call a health professional.

Who To See

Sinusitis may be diagnosed by any of the following health professionals:

• Family medicine doctor
• Pediatrician
• Internist
• Nurse practitioner
• Physician assistant

Your primary care health professional may refer you to an ear, nose, and throat (ENT) specialist (also called an otolaryngologist) who can provide a more specialized examination of the nasal passages and upper throat. Referral to an ENT specialist may be beneficial for people in whom nasal polyps or other conditions causing blockage of the nasal cavity are suspected. Diagnosis and surgical treatment of chronic or complicated cases of sinusitis may be done by an ENT specialist.

An infectious disease specialist may be needed when sinusitis is caused by something unusual or when rare complications (such as an infection of the facial bones) occur. An allergist may be needed when allergies are suspected to be causing or contributing to sinus problems.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Diagnosis of sinusitis is usually based on your medical history and physical examination. A detailed history of the problem often can be of more value to the diagnosis than a physical exam. If the symptoms and physical findings are typical of sinusitis, further testing is usually not needed.

Additional tests may be done if:

• The diagnosis is not clear.
• Antibiotic treatment has failed to clear up the problem.
• Complications (such as a bone infection) are suspected.
• Surgery is being considered.

Imaging tests may be used when symptoms of sinusitis persist or recur despite treatment, or to look for tumors or other growths when there is bleeding or bloody discharge from the nose. They include:

• Computed tomography (CT) scan of the head and face, which provides a detailed image of sinus structures. A CT scan may help evaluate severe or chronic sinusitis, identify suspected complications of sinusitis, or rule out other conditions. It is not used to diagnose acute sinusitis.
• Sinus X-ray, which may be done to confirm a suspected case of sinusitis. An X-ray produces a picture of dense tissues inside the body. But a CT scan may provide better information.

Less often, other tests may be done by an ear, nose, and throat (ENT) specialist (also called an otolaryngologist) or by an allergist. These tests may include:

• An endoscopic sinus exam (ESM) (nasal endoscopy). An ESM uses a lighted viewing instrument called an endoscope to view structures inside your nose and sinus cavities. ESM is used to evaluate chronic sinusitis.
• A needle puncture and aspiration of sinus contents, followed by nasal culture to identify the bacteria or fungus causing the problem.
• A magnetic resonance imaging (MRI). An MRI may be done if there is reason to believe that an infection has spread beyond the sinuses. It may also be helpful in evaluating growths or tumors inside the nose or sinuses.

Treatment Overview

Sinusitis is treated with medications and home treatment methods, such as applying moist heat to your face. The goals of treatment for sinusitis are to:

• Improve drainage of mucus and reduce swelling in the sinuses.
• Relieve pain and pressure.
• Clear up any infection.
• Prevent the formation of scar tissue, and avoid permanent damage to the tissues lining the nose and sinuses.

Medications may be used to treat sinusitis, especially when it is caused by a bacterial infection. There are varying lengths of treatment with medications-treatment may be as short as three days or last as long as several weeks or more. Medications most often used to treat sinusitis include a combination of:

• Antibiotics, such as amoxicillin, which kill bacteria.
• Decongestants, such as pseudoephedrine hydrochloride, which reduce the swelling of the mucous membranes in the nose.
• Analgesics, such as aspirin, acetaminophen, or ibuprofen, to relieve pain.
• Mucolytics, such as guaifenesin, which thin the mucus.
• Corticosteroids, such as beclomethasone dipropionate or prednisone, which reduce inflammation in the nasal passages. These medications may also be used as an inhaled nasal spray.

Inhaled antibiotics are a fairly new treatment choice for chronic sinusitis. Initial studies show that since inhaled antibiotics make direct contact with the mucous membranes, they may be effective when other treatments have failed.¹

It is possible to develop "double sickening" while being treated for acute or chronic sinusitis. At first, you may begin to feel better from antibiotics and home treatment, but then your symptoms become worse and additional treatment may be needed.

For acute sinusitis

Short-term (acute) sinusitis usually lasts less than 4 weeks. Up to two-thirds of people with acute sinusitis improve on their own without antibiotic treatment.² Sinus infections are commonly caused by viral infections, which do not respond to antibiotics. Antibiotics may cause bothersome side effects (such as diarrhea or upset stomach) and also may contribute to your becoming resistant to antibiotics in the future. Talking with your health professional will help you determine whether treatment with antibiotics is needed for your acute sinus infection.

After one or two bouts of sinusitis, you may be able to recognize the early symptoms of a sinus infection. Using steam to relieve nasal congestion at the first sign of a sinus infection may relieve your symptoms and prevent the need for antibiotics. For more information, see the Home Treatment section of this topic.

Most people recover completely when treated with an antibiotic for acute sinusitis that is caused by a bacterial infection. The number of days you take antibiotics depends on the antibiotic and the severity of the infection. When you are prescribed an antibiotic, be sure to take it until it is gone, even if you feel better. It is important to always take an antibiotic exactly as your health professional tells you, or the infection may not go away completely.

If symptoms get worse during antibiotic treatment, contact your health professional. You may need to take the antibiotic longer, or you may need to try a different antibiotic.

If you had a sinus infection that lasted a long time, it may take weeks or months for the mucous membranes that line your nose and sinuses to fully recover, and some minor symptoms may continue after the bacteria have been killed. During this time, there is an increased chance that the infection may return. Longer treatment with antibiotics may be needed.

Decongestants and medications that thin mucus may also be used. Do not give cough and cold medicines to a child younger than 2 unless your child's doctor has told you to. If your child's doctor tells you to give a medicine, be sure to follow what he or she tells you to do.

For chronic sinusitis

Sinusitis that lasts 8 weeks or longer is called chronic sinusitis. It is more difficult to treat and responds more slowly to antibiotics than acute sinusitis.

Antibiotic therapy is usually recommended for chronic sinusitis and may require a longer course of treatment. You may need to try more than one antibiotic. A corticosteroid nasal spray that reduces inflammation and swelling of the lining of the nasal passages may also be used during treatment.

In some people, a sinus infection may be caused by a fungus or a bacterium other than those normally associated with sinusitis. People who have an impaired immune system are at risk for these unusual infections. It also may include people who must use an oral or inhaled corticosteroid medication (such as prednisone). Fungal sinusitis, which accounts for a significant number of chronic sinusitis cases, does not respond to antibiotic treatment and may need treatment with antifungal medications, corticosteroids, or surgery.

Surgery may be required if you have taken antibiotics for an extended period of time but still have symptoms or when complications (such as infection of facial bones) are likely. For more information, see:

Should I have surgery for sinusitis?

What To Think About

Sinusitis may be difficult to diagnose because it often causes the same symptoms as a cold or other viral illness, especially in its early stages. It can be particularly difficult to identify sinusitis in children. If your child or you have frequent sinus infections, learn what signs to watch for, and begin home treatment immediately.

Symptoms of chronic sinusitis are often vague and may not respond well to treatment. It may take time and patience to find a successful treatment.

Prevention

There are several ways you may reduce your chance of getting sinusitis:

• Treat stuffiness (nasal congestion) caused by colds or allergies promptly. This can help you prevent a bacterial infection from developing in your sinuses.
• Avoid contact with people who have colds and other viral upper respiratory infections. If you do have contact with people who have these infections, wash your hands often, especially after being in contact with those who are infected.
• Avoid cigarette, cigar, and pipe smoke in your home and workplace. Smoke causes and further irritates inflamed membranes in your nose and sinuses.
• If you have allergies, avoid the things that trigger your allergy attacks. Consider talking to your health professional about allergy shots (immunotherapy). For more information, see the topic Allergic Rhinitis.
• Avoid breathing dry air. Consider using a humidifier at home and work to increase the moisture in the air.

Home Treatment

Home treatment may relieve symptoms of pain and pressure associated with short-term (acute) sinusitis. Home treatment may improve drainage of mucus from the sinuses and prevent the need for antibiotics. There is no scientific evidence to support the use of home treatments in sinusitis, but you may find one or more of them helpful.

• Drink plenty of fluids to help keep your mucus thin.
• Apply moist heat (using a hot, damp towel or gel pack) to your face for 5 to 10 minutes, several times a day.
• Breathe warm, moist air from a steamy shower, a hot bath, or a sink filled with hot water. Avoid extremely cool, dry air. Consider using a humidifier to increase the moisture in the air in your home.
• Use saltwater nasal washes (saline lavage or irrigation) to help keep the nasal passages open and wash out mucus and bacteria. You can purchase saline nose drops at a pharmacy or make your own saline solution at home. It may also help to gargle with warm salt water by using one teaspoon of salt per pint of water.
• Use nonprescription medications such as pain relievers and decongestants (for example, nasal spray) to relieve symptoms. Do not give cough and cold medicines to a child younger than 2 unless your child's doctor has told you to. If your child's doctor tells you to give a medicine, be sure to follow what he or she tells you to do. Be careful when using some nasal-spray decongestants. They usually should not be used for more than about 3 days. Longer use can lead to further swelling of the sinus membranes after the medicine wears off (called rebound congestion), which makes pressure and swelling worse. You may end up dependent on the medicine if you start using more and more of it to get rid of the pressure and swelling.
• If you need to blow your nose, do it gently. Forceful blowing may force thick mucus back into your sinuses and block them. Keep both nostrils open when blowing your nose.

If you have chronic sinusitis, you'll probably need to continue the above home treatment measures for a long period of time to keep your sinuses clear.

Medications

Medications may be needed when symptoms of sinusitis are severe or do not improve. The goals of treatment with medication are to:

• Treat the infection, which is usually caused by bacteria if your symptoms have lasted more than 7 to 10 days.
• Relieve pressure and pain caused by poor sinus drainage.
• Reduce inflammation of the nose and sinuses caused by allergies.

Antibiotic treatment is successful in most cases of short-term (acute) sinusitis when it is caused by bacteria. You should notice improvement within 3 to 4 days after you begin taking an antibiotic. The number of days you take antibiotics depends on the antibiotic and the severity of the infection. It takes weeks and sometimes months for the mucous membranes that line the sinuses to fully heal after an infection, so some minor symptoms may continue during this time. You are more likely to develop another sinus infection while the membrane is still healing.

Chronic sinusitis may last 8 weeks or longer and usually requires 3 to 4 weeks of antibiotic treatment. Symptoms may persist or return despite adequate antibiotic treatment. A different antibiotic may be needed to treat the infection. Referral to an ear, nose, and throat (ENT) specialist (also called an otolaryngologist) may be needed if symptoms of sinusitis do not go away despite long-term antibiotic treatment.

Medication Choices

Medications are used and sometimes combined to treat sinusitis.

• Antibiotics kill bacteria. A few examples of antibiotics used are amoxicillin (Amoxil and Trimox) and cefdinir (Omnicef).
• Decongestants reduce the swelling of the mucous membranes in the nose. Some examples may include oxymetazoline hydrochloride (Afrin) and phenylephrine hydrochloride (Neo-Synephrine).
• Analgesics, such as aspirin, acetaminophen, or ibuprofen, are used to relieve pain.
• Corticosteroids, such as beclomethasone dipropionate monhydrate (Beconase AQ) or prednisone, reduce inflammation in the nasal passages and may be given as an inhaled nasal spray.
• Mucolytics, such as guaifenesin (Robitussin), are used to thin the mucus.

What To Think About

If you are taking antibiotics for a sinus infection, do not stop taking the antibiotics early just because you feel better. Take the entire course of antibiotics. The infection may not go away if you do not take all of the antibiotics prescribed by your health professional.

More powerful antibiotics may be needed to kill bacteria that persist if there is no improvement after trying a first-line antibiotic. Stronger antibiotics can be very costly and may have more side effects.

Fungal sinusitis, which accounts for a significant number of chronic sinusitis cases, does not respond to antibiotic treatment. It may need treatment with antifungal medications, corticosteroids, and surgery.

Surgery

Surgery is used only when treatment with medications has failed to control sinusitis. When certain rare complications develop, such as when the infection spreads to the bone or inside the brain, surgery may be needed in addition to antibiotics.

The goal of surgery is to make drainage of the sinuses better, usually by removing the blockage and draining the mucus. This may mean removing:

• Infected, swollen, or damaged tissue.
• Bone, to create a wider opening for drainage of mucus from the sinuses.
• Growths (polyps) inside the nose or sinuses.
• A foreign object that is blocking a nasal or sinus passage. This usually occurs in children.

Surgery may be the only means of getting a badly blocked, infected sinus to drain properly. But surgery does not always completely eliminate sinusitis. Some people may need a second operation.

Surgery is most successful when used along with medication and home treatment to prevent future sinusitis. A second surgery and future sinusitis may be avoided if antibiotics are taken to prevent reinfection.

For more information on when surgery is a good choice, see:

Should I have surgery for sinusitis?

Surgery Choices

Endoscopic surgery is preferred over traditional surgery for most cases of chronic sinusitis that require surgery. It is less invasive, less expensive, and has a lower rate of complications.

Endoscopic surgery may be done to remove small amounts of bone or other material blocking the sinus openings or to remove growths (polyps). Normally, a thin, lighted tool called an endoscope is inserted through the nose so the doctor can see and remove whatever is blocking the sinuses.

Traditional surgery may be done when complications of sinusitis-such as the development of pus in a sinus, infection of the facial bones, or brain abscess-have occurred. In this type of surgery, the doctor makes an opening into the sinus from inside the mouth or through the skin of the face.

What To Think About

There are few clear-cut reasons for sinus surgery, and very few people require it. The decision to operate depends on the success of prior treatment. Situations that may support the need for surgery include:

• Failure of treatment to improve symptoms after 2 or more antibiotics have been tried for 4 to 6 weeks (or 2 to 3 months in children).
• Persistence of symptoms due to thickened mucous membranes, growths inside the nose (nasal polyps), or other problems that cause a blockage.
• A CT scan that shows evidence of long-term (chronic) sinus infection or a blocked drainage opening for a sinus.
• A sinus infection that is caused by a fungus.
• The development of a serious complication of sinusitis. Such complications are rare, but usually involve the spread of the infection beyond the sinuses. The facial bones can become infected (osteomyelitis), or the lining of the brain can become infected (meningitis). Also, the infection can spread outside the sinus and create a pocket of pus (abscess) in an eye socket, the brain, facial bones, or the soft tissues of the face.

The extent of the blockage and other problems determine how extensive your surgery will need to be. Surgery may be limited to removal of infected tissue or small growths (polyps) inside the nose. More extensive surgery involves removing pieces of bone to create a wider opening to allow a sinus to drain.

Sinus surgery is always performed by an ear, nose, and throat (ENT) specialist (also called an otolaryngologist).

Other Treatment

There is no other medical treatment for sinusitis at this time.

Other Places To Get Help

Organizations

Related Information

• Allergic Rhinitis
• Respiratory Problems, Age 11 and Younger
• Respiratory Problems, Age 12 and Older
• Sore Throat

References

Citations

1. Wahl KJ, Otsuji A (2003). New medical management techniques for acute exacerbations of chronic rhinosinusitis. Current Opinion in Otolaryngology and Head and Neck Surgery, 11(1): 27-32.

2. Ah-See, K (2008). Sinusitis (acute), search date August 2007. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.

Other Works Consulted

• Joint Task Force on Practice Parameters in Allergy, Asthma, and Immunology (1998). Diagnosis and management of rhinitis: Complete guidelines of the Joint Task Force on Practice Parameters in Allergy, Asthma, and Immunology. Annals of Allergy, Asthma, and Immunology, 81(5, Part 2): 478-518.

• Lane AP, Kennedy DW (2003). Sinusitis and polyposis. In JB Snow Jr et al., eds., Ballenger's Otorhinolaryngology Head and Neck Surgery, 16th ed., pp. 760-787. Hamilton, ON: BC Decker.

• Subcommittee on Management of Sinusitis and Committee on Quality Improvement, American Academy of Pediatrics (2001). Clinical practice guideline: Management of sinusitis. Pediatrics, 108(3): 798-808.

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