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A systematic biomedical literature review was conducted in April 2005. The search was limited to English language articles and human subjects, and included PubMed, the Cochrane Database, and the National Guideline Clearinghouse. The current consensus documents for otitis media with effusion, and for diagnosis and management of acute otitis media can be found at the American Academy of Pediatrics website: Acute rhinosinusitis consensus statements can be found at the National Guideline Clearinghouse website:


Sinusitis and otitis media (OM) are two of the most common presenting conditions in primary care practice. They are frequent causes of missed school and work days, and they cost the United States health care system billions of dollars in office visits, surgeries, and medications. They have a profound impact on quality of life, work productivity, and school performance.1–4


Caring for patients with sinusitis and OM has changed dramatically in the past few years. The vast body of literature on sinusitis and OM suffers from widely divergent opinions regarding pathophysiology, diagnosis, and treatment. As a result of poor standardization of definitions, measures of severity, and improper clinical research design, frequently cited studies often directly contradict each other. Further, inappropriate antibiotic use leading to rising bacterial resistance to antimicrobials and growing health care costs are compelling trends that are impacting treatment approaches to these common illnesses. For these reasons, recent evidence-based reference guidelines, systematic reviews, and multidisciplinary consensus statements have been invaluable in providing guidance to clinicians.


The upper airway is a complex system with numerous functions. It includes the nose, the sinuses and pharyngeal structures, the eustachian tubes, and the outer, middle, and inner ears (Fig. 38-1). The paranasal sinuses, consisting of the maxillary, ethmoidal, sphenoidal, and frontal sinuses are connected to the nasal passage and ultimately the pharyngeal structures. These sinuses are thought to aid the nose in providing heat and humidification to inhaled air, while also decreasing the weight of the bony skull and increasing resonance for speech. The osteomeatal complex, a narrow orifice connecting the maxillary sinuses to the nasal passage, is a critical component of sinus function. Cilia lining the walls of the sinuses provide regular clearance of mucus and debris.5

Figure 38-1.
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Anatomy of the upper airway. (Reproduced with permission from Mckinley M, O’Loughlin VD. Human Anatomy, 2nd ed. NY: McGraw-Hill; 2008:749.)


Healthy sinuses may produce up to 2 liters of mucus per day that goes unnoticed. Mucus thickens in response to inflammatory signals and becomes noticeable in its altered state. The infiltrate and degradation products associated with inflammation can alter the color of mucus even in the absence of true infection.


The space known as the middle ear begins at the nasopharyngeal orifice of the eustachian tube and extends to the air cells of the mastoid, petrosa, and ...

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