AUTHOR AND EDITOR INFORMATION

Section 1 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

INTRODUCTION

Section 2 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Background

Sinusitis is the inflammation/infection of 1 or more paranasal sinuses and occurs with obstruction of the normal drainage mechanism. It is traditionally subdivided into acute (symptoms lasting <3 wk), subacute (symptoms lasting 3 wk to 3 mo), and chronic (symptoms lasting > 3 mo).

Pathophysiology

The paranasal sinuses, a part of the upper respiratory tract, are in direct communication with the nasopharynx. The sinuses are normally sterile. Because of the proximity to nasopharyngeal flora, obstruction can cause bacterial infection.

Diseases that obstruct drainage can result in a reduced ability of the paranasal sinuses to function normally. The sinus ostia may become occluded, leading to mucosal congestion. The mucociliary transport system becomes impaired, leading to more stagnation of secretion and epithelial damage, followed by decreased oxygen tension and subsequent bacterial growth.

Frequency

United States

An estimated more than 30 million patients in the United States have sinus disease. Upper respiratory infections (URIs) are one of the most common presentations in the ED. A viral infection associated with the common cold is the most frequent etiology of acute sinusitis. Only a small percentage (as low as 2%) of viral sinusitis cases are complicated by bacterial sinusitis. The challenge is to differentiate a simple URI and allergic rhinitis from sinusitis. Medical treatment is expensive, with an estimated $5 billion spent annually; another $60 billion is spent on surgical treatment each year.

Mortality/Morbidity

Sinusitis is rarely life threatening, but the close proximity of the paranasal sinuses to the central nervous system, the multiple fascial plains of the neck, and the associated venous and lymphatic channels can lead to serious complications.

Age

An estimated 5-10% of URIs in children are related to sinusitis, while up to 10% of URIs in adults are related to sinusitis. Sinusitis is rare in children younger than 1 year because the sinuses are poorly developed before that age.

CLINICAL

Section 3 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

History

• Presentation of sinusitis is often nonspecific.
• Patients may present with a persistent cold.
• Most complaints are related to the involved sinus.
• Common complaints are nasal congestion, purulent drainage, and facial pain with headache.
• Pain is often exacerbated by leaning forward or any head movement.
• Patients may complain of retro-orbital pain if the ethmoid sinus is involved.
• Some patients complain of dental pain or alteration in smell.
• In pediatric patients, most URIs last 5-7 days.
• • By 10 days, the URI almost always improves.
  • Most rhinoviral infections improve within 7-10 days so the complaint of persistent or worsening symptoms may indicate a developing bacterial sinusitis.
  • Pediatric patients may complain of a daytime cough and persistent nasal discharge.
  • Complaints of facial pain and headache are rare in children.

Physical

• Purulent secretions in the middle meatus (highly predictive of maxillary sinusitis) may be seen using a nasal speculum and a directed light.
• Fever is seen in fewer than 2% of individuals with sinusitis.
• Facial tenderness to palpation is present.
• Complete opacification of sinus on transillumination is present.
• Partial opacification is a nonspecific finding, and it is not as reliable.

Causes

Acute sinusitis is usually bacterial in origin. A URI or severe allergic rhinitis leading to obstruction of the ostia and stasis of drainage often precedes it.

• Haemophilus influenzae and Streptococcus pneumoniae are the organisms most commonly found in adults. In chronic sinusitis, the infecting organisms are variable, and a higher incidence of anaerobic organisms is seen (eg, Bacteroides, Peptostreptococcus, and Fusobacterium species).
• In children, similar organisms are seen, with the addition of Moraxella catarrhalis. In older children and young adults, Staphylococcus aureus is an occasional finding.
• In systemically impaired hosts, Candida, Aspergillus, and Phycomycetes may be the cause. Risk factors include the following: diabetes mellitus, cancer, hepatic disease, renal failure, burns, extreme malnutrition, and immunosuppressive diseases.

DIFFERENTIALS

Section 4 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Other Problems to be Considered

Dental infections
Periapical abscess
Upper respiratory tract infection

WORKUP

Section 5 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Imaging Studies

• Sinus radiography: False-negative results occur in 40% of cases; mucosal thickening or air fluid levels may be seen.
• A-mode ultrasonography has very little advantage over plain radiography.
• Computerized tomography (CT): This very expensive imaging study is used extensively by otolaryngology (ENT) specialists and in the evaluation of chronic sinusitis. In some institutions, CT scanning is preferred as the initial study of choice. It is extremely sensitive, although it may tend to overdiagnose the disease. CT scans cannot distinguish between viral and bacterial infections.
• Magnetic resonance imaging (MRI) can be used to demonstrate intracranial spread but is not as good as CT scanning in aiding in the diagnosis of acute sinusitis.
• Radiographs or CT scanning is not mandatory in the diagnosis. Uncomplicated sinusitis is often diagnosed clinically, with studies reserved for complicated cases or patients who are nonresponsive to the usual therapies.

TREATMENT

Section 6 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Emergency Department Care

Differentiate from other causes of nasal congestion. Treatment is aimed at blocking the inflammatory reactions that cause the symptoms, while antibiotics should be given to eliminate the infection in acute bacterial sinusitis.

• Allergic rhinitis: Symptoms often are seasonal and may include the following: clear watery anterior and posterior nasal discharge, sneezing, and itchy eyes and nose.
• Viral URI: Dry mucosa of nose and throat, malaise and myalgias, and occasional fever and chills may be present.
• While in the ED, patients may obtain significant immediate relief with the administration of a nasal decongestant.
• Warm compresses to the face give symptomatic relief.
• Treatment to suppress the full development of symptoms, especially nasal fluid production, early on in viral rhinosinusitis includes first generation antihistamines, decongestants, and nonsteroidal anti-inflammatory drugs (NSAIDs).

Consultations

ENT consultation should be obtained in all patients with suspected CNS invasion or fungal infections. Consider referral to an ENT specialist for patients with subacute or chronic sinusitis.

MEDICATION

Section 7 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

The goal of uncomplicated sinusitis is to relieve obstruction. Antihistamines should be avoided, as they thicken secretions.

Drug Category: Nasal decongestants

These agents are used to loosen secretions for clearance.

Drug Category: Antibiotics

Empiric coverage for H influenzae and S pneumoniae; in addition to M catarrhalis in children.

FOLLOW-UP

Section 8 of 9  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

Further Inpatient Care

• Any patient showing evidence of extension of infection into the CNS should be admitted and evaluated by an ENT physician.

Further Outpatient Care

• Prescribe antibiotic of choice and nasal decongestant. If an over-the-counter nasal spray (eg, Afrin) is used, warn the patient to use it no longer than 3 days to avoid any rebound phenomenon.
• Instruct patients to drink a lot of fluids. Use of a humidifier or vaporizer helps in keeping secretions moist and loose.
• Warm compresses to the face provide relief of pain. Pain medication may be prescribed, nonnarcotic or narcotic, at the discretion of the emergency physician.
• Instruct patients to return to the ED or see their personal physician if high fever, visual symptoms, vomiting, lethargy, or any symptom indicating possible extension beyond the sinus cavities develops.

Complications

• Chronic sinusitis
• Osteomyelitis
• Orbital cellulitis
• Intracranial extension resulting in septic cavernous thrombosis

Prognosis

• The prognosis is generally good with appropriate treatment.

REFERENCES

Section 9 of 9

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• References

• American Academy of Pediatrics. Clinical practice guideline: management of sinusitis. Pediatrics. Sep 2001;108(3):798-808. [Medline].
• Benninger MS, Sedory Holzer SE, Lau J. Diagnosis and treatment of uncomplicated acute bacterial rhinosinusitis: summary of the Agency for Health Care Policy and Research evidence-based report. Otolaryngol Head Neck Surg. Jan 2000;122(1):1-7. [Medline].
• Brook I. Microbiology and management of sinusitis. J Otolaryngol. Aug 1996;25(4):249-56. [Medline].
• Chow JM. The diagnosis and management of sinusitis. Compr Ther. 1995;21(2):74-9. [Medline].
• Duncavage JA. Management of sinusitis. Compr Ther. Apr 1996;22(4):211-6. [Medline].
• Osguthorpe JD, Hadley JA. Rhinosinusitis. Current concepts in evaluation and management. Med Clin North Am. Jan 1999;83(1):27-41, vii-viii. [Medline].
• Piccirillo JF. Clinical practice. Acute bacterial sinusitis. N Engl J Med. Aug 26 2004;351(9):902-10. [Medline].
• Snow V, Mottur-Pilson C, Gonzales R. Principles of appropriate antibiotic use for treatment of acute bronchitis in adults. Ann Intern Med. Mar 20 2001;134(6):518-20. [Medline].
• Williams JW, Simel DL. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA. Sep 8 1993;270(10):1242-6. [Medline].

Article Last Updated: Aug 8, 2007