AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Development of the paranasal sinuses begins in the third week of gestation and continues until early adulthood. Knowledge of developmental milestones is important for the clinician to properly diagnose and treat infectious disorders of the paranasal sinuses.

During the third week of embryonic development, the notochord is formed by the proliferation and medial migration of ectodermal cells. The notochord, which is initially in the caudal region of the embryonic disc, rotates to lie posterior to the primitive foregut after the heart tube and pericardium rotate from the cranial position to lie anteriorly. The paraxial layer of mesenchyme, which lies adjacent to the notochord, differentiates into the somite ridges, intermediate cell mass, and lateral plate mesoderm. The branchial arches develop from these mesodermal structures, the first of which gives rise to the internal nasal structures.

The paranasal sinuses develop in conjunction with the palate from changes in the lateral wall of the nasal cavity. At 40 weeks' gestation, 2 horizontal grooves develop in the mesenchyme of the lateral wall of the nasal cavity. Proliferation of maxilloturbinate mesenchyme between these grooves results in an outpouching of tissue medially into the nasal lumen. This is the precursor of the middle and inferior meatus and the inferior turbinate. Ethmoidoturbinate folds develop superiorly to give rise to the middle and superior turbinates. Once turbinate structures are established, sinus development begins and continues until early adulthood.

The maxillary sinus begins developing in the third month of gestation. It arises as an ectodermal invagination in the middle meatal groove and develops laterally, measuring 7 X 4 X 4 mm at birth. After birth, it continues to grow at a rate of 2 mm vertically and 3 mm anteroposteriorly until early adulthood. The sinus grows rapidly for the first 3 years of life and then grows at a slower rate until age 7 years. A second rapid growth phase takes place from age 7-12 years; growth then slows until early adulthood, when the sinus has reached its final adult proportions. The floor of the sinus is level with the floor of the nose at age 12 years and then descends inferiorly into the alveolus as adult teeth begin to erupt. Articles that detail surgical management of the nose, ethmoid sinuses, frontal sinus, and sphenoid sinuses address development of these structures.

Problem

Many classifications, both clinical and radiologic, have been proposed throughout the literature to define acute sinusitis. Although no consensus on the precise definition exists, acute sinusitis may be defined as a bacterial or viral infection of the sinuses of less than 4 weeks' duration that completely resolves with appropriate treatment. Subacute sinusitis represents a temporal progression of symptoms for 4-12 weeks. Recurrent acute sinusitis is diagnosed when 2-4 episodes of infection occur per year, with at least 8 weeks between episodes. As in acute sinusitis, the sinus mucosa completely normalizes between attacks. Chronic sinusitis is the persistence of insidious symptomatology beyond 12 weeks, with or without acute exacerbations, and is discussed in the eMedicine article Sinusitis, Chronic, Medical Treatment.

Frequency

Sinusitis affects 1 out of every 7 adults in the United States, with over 30 million individuals diagnosed each year. Acute bacterial sinusitis is the fifth most common diagnosis prompting antibiotic administration and accounts for 0.4% of ambulatory diagnoses. The economic burden of acute sinusitis in children is 1.77 billion dollars per year.

Etiology

The sinuses are normally sterile under physiologic conditions. Purulent sinusitis can occur when ciliary clearance of sinus secretions decreases or the sinus ostium becomes obstructed, which leads to retention of secretions, negative sinus pressure, and reduction of oxygen partial pressure. This environment is then suitable for growth of pathogenic organisms.

Factors that predispose the sinuses to obstruction and decreased ciliary function are allergic, nonallergic, and viral insults, which produce inflammation of the nasal and sinus mucosa and result in ciliary dysmotility and sinus obstruction. Approximately 90% of patients who have viral upper respiratory tract infections (URTIs) have sinus involvement, but only 5-10% of these patients have bacterial superinfection requiring antimicrobial treatment.

Microbiology

The bacteria most commonly involved in acute sinusitis are part of the normal nasal flora. These bacteria can become sinus pathogens when they are deposited into the sinuses by sneezing, coughing, or direct invasion under conditions that optimize their growth. The most common bacterial pathogens in acute sinusitis are Streptococcus pneumoniae (30-40%), Haemophilus influenzae (20-30 %), and Moraxella catarrhalis (12-20%). Staphylococcus aureus and Streptococcus pyogenes are isolated in rare cases.

Cultures from 66% of patients with acute sinusitis grow at least one pathogenic bacterial species from sinus aspirates while 26-30% of cases have multiple predominant bacterial species. Anaerobic organisms have been found in fewer than 10% of patients with acute bacterial sinusitis despite the ample environment available for their growth. The exception is in sinusitis resulting from a dental source or in patients with chronic sinus disease in which anaerobic organisms are usually isolated.

Gram-negative organisms, including Pseudomonas aeruginosa (15.9%), Escherichia coli (7.6%), Proteus mirabilis (7.2%), Klebsiella pneumoniae, and Enterobacter species, predominate in nosocomial sinusitis, accounting for 60% of cases. Polymicrobial invasion is seen in 25-100% of cultures. The other pathogenic organisms found in nosocomial patients include gram-positive organisms (31%) and fungi (8.5%).

Viruses are the most common triggers of acute sinusitis. Rhinovirus, influenza viruses, and parainfluenza viruses are the primary pathogens in 3-15% of cases of acute sinusitis.

Fungal causes of sinusitis are discussed elsewhere (see Allergic Fungal Sinusitis; Sinusitis, Fungal).

Pathophysiology

Anatomic variations that narrow the ostiomeatal complex, including septal deviation, paradoxical middle turbinates, and Haller cells, make this area more sensitive to obstruction from mucosal inflammation. Mechanical obstruction of the ostiomeatal complex from foreign bodies, polyps, or tumors also can result in acute sinus disease. Systemic diseases that result in decreased mucociliary clearance, including cystic fibrosis and Kartagener syndrome, can be predisposing factors for acute sinusitis in rare cases. Patients with deficiencies in their humoral immune system (eg, agammaglobulinemia, combined variable deficiency, immunoglobulin G [IgG] deficiency, immunoglobulin A [IgA] deficiency) are also at increased risk of developing acute sinusitis.

Nosocomial sinusitis occurs in 18-32% of patients who require prolonged periods of intensive care with nasogastric or nasotracheal intubation. Nasotracheal intubation is the greatest risk factor, although patients with prolonged orotracheal intubation are at greater risk than the general population.

Ciliary function also is reduced in the presence of low pH, anoxia, bacterial toxins, smoking, dehydration, foreign bodies, and drugs such as atropine, antihistamines, and phenylephedrine. Approximately 10% of cases of acute sinusitis result from direct inoculation of the sinus with a large amount of bacteria. Dental abscesses or procedures that result in communication between the oral cavity and sinus can produce sinusitis by this mechanism, as can facial trauma or large inoculations from swimming.

Clinical

Acute sinusitis is a clinical diagnosis; thus, an understanding of its presentation is of paramount importance in differentiating this entity from allergic or vasomotor rhinitis and common URTIs. No specific clinical symptom or sign is sensitive or specific for acute sinusitis, and the overall clinical impression should be used to guide management.

A recent consensus statement published in Otolaryngology - Head and Neck Surgery made strong recommendations that clinicians should distinguish between acute rhinosinusitis caused by bacterial causes and those episodes caused by viral upper respiratory infections and noninfectious conditions.²⁶ The panel suggests that the diagnosis of acute bacterial sinusitis be entertained when (a) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms or (b) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement. In the intensive care setting, acute sinusitis should be suspected in the presence of sepsis of unknown origin.

The diagnosis of acute sinusitis can be difficult to make on clinical grounds because of the similarity of presenting symptoms to those of uncomplicated URTIs. In a primary care setting, diagnosis of acute sinusitis usually is based on the constellation of clinical findings and may be overdiagnosed because of the poor predictive value of history and physical examination findings. A history of purulent secretions, dental pain, poor response to decongestants, or examination findings of colored nasal discharge or abnormal sinus transillumination suggests a diagnosis of acute sinusitis. The presence of 4 or more of these clinical findings greatly increases the probability that the patient has sinusitis.

Anterior rhinoscopic examination with or without a topical decongestant is important to assess the status of the nasal mucosa and the presence and color of nasal discharge. Documentation of predisposing anatomic variations also can be performed during anterior rhinoscopy. Sinus transillumination and palpation are of little predictive value.

Endoscopic examination may reveal the origin of the purulent discharge from the middle meatus and may provide information about the nature of ostiomeatal obstruction. Endoscopy also may aid in the etiologic diagnosis of acute sinusitis by allowing careful attainment of purulent secretions from the sinus ostia for culture.

INDICATIONS

Section 3 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Use a surgical means of sinus drainage when appropriate medical therapy has failed to control the infection, resulting in prolonged or slowly resolving symptoms, or when the patient has complications of sinusitis. Another indication for sinus puncture is to provide culture material to guide antibiotic selection when empiric therapy has failed or when antibiotic choice is limited. This is particularly important in patients who are immunocompromised or under intensive care, in whom sinusitis can be a prominent source of sepsis.

RELEVANT ANATOMY

Section 4 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

The paranasal sinuses are air-filled bony cavities extending from the skull base to the alveolar process and laterally from the nasal cavity to the inferomedial aspect of the orbit and the zygoma. They are lined with a pseudostratified columnar epithelium, which is continuous with the lining of the nasal cavity via the ostia. This epithelium contains a number of mucus-producing goblet cells. Branches of the internal and external carotid arteries provide arterial supply to the sinuses, while the venous and lymphatic drainage is through the sinus ostia into the nasal cavity plexi. Venous drainage occurs through valveless vessels corresponding to the arterial supply.

The focal point of sinus drainage is the ostiomeatal complex, which comprises the maxillary, frontal, and anterior ethmoid ostia and is located in the middle meatus. The posterior ethmoid sinuses empty into the superior meatus, and the sphenoid sinuses empty into the sphenoethmoidal recess.

The exact function of the paranasal sinuses is not well understood. Possible roles of the sinuses may involve reducing the weight of the skull, pressure dampening, humidifying and warming inspired air, absorption and heat insulation of the brain, resonance of sound, mechanical rigidity, or increasing olfactory surface area.

The sinus mucosa has less secretory and vasomotor function than the nasal cavity. Cilia are concentrated near the natural sinus ostia and beat toward them. Ostium blockage results in stasis of mucus flow, which can result in development of disease.

The maxillary sinus is a pyramidal cavity, the base of which lies lateral to the nasal cavity. In adults, the dimensions of the sinus are approximately 33 mm in height, 23-25 mm in width, and 34 mm in the anteroposterior axis; the volume is approximately 15 mL. Maxillary sinus size may be asymmetrical within the same individual.

Medial wall

The medial wall of the sinus is composed of a thin plate of maxilla, the inferior turbinate, the uncinate process, the perpendicular plate of the palatine bone, and the lacrimal bone. The ostium is a large opening in the posteromedial aspect of the sinus that is partially covered by the above-mentioned bony structures and by a reduplication of mucosa inferior to the uncinate process. This leaves an opening into the infundibulum of the middle meatus that measures 3-4 mm. The natural ostium usually is found in the posterior third of the infundibulum; 25-30% of individuals have accessory ostia.

Lateral wall

The lateral apex of the sinus extends into the zygomatic process of the maxillary bone or into the zygoma.

Superior wall

The roof of the sinus slopes inferiorly as it passes from base to apex along the floor of the orbit. This orbital surface of the sinus is approximately twice as wide as the floor. The infraorbital nerve forms a groove in the roof of the sinus as it passes anteriorly.

Inferior wall

The floor of the sinus is formed by the alveolar and palatine processes of the maxilla and lies 1-1.2 cm below the level of the floor of the nose in dentulous adults. The maxillary sinus most often is related to the 3 molar teeth. A layer of compact bone usually separates the tooth cavity from the sinus mucosa. This layer of bone may be thin or absent in some individuals, leaving a direct route for dental infections to spread into the sinus. The premolar and canine teeth are not usually a direct relation of the sinus.

Anterior and posterior walls

The anterior and posterior walls of the maxillary sinus are formed by the corresponding surfaces of the maxilla and are directly related to the cheek skin anteriorly and to the infratemporal fossa posteriorly.

Blood supply

The maxillary sinus derives its arterial blood supply from the infraorbital, greater palatine, sphenopalatine, and posterior and anterior superior alveolar branches of the maxillary artery, which penetrate the bone of the sinus. The facial artery gives a smaller contribution to the maxillary sinus blood supply.

Venous drainage of the sinus is to the internal jugular via the maxillary and anterior facial veins and to the pterygoid plexus through contributions from the maxillary vein. The pterygoid plexus communicates with the dural sinuses, providing a root for the spread of sinus infections intracranially. Lymphatic drainage is to the submandibular lymph nodes.

Nerve supply

Sensory innervation of the maxillary sinus is by the infraorbital nerve, posterolateral nasal nerve, and the anterior, middle, and posterior superior alveolar branches of the second division of the trigeminal nerve. Secretomotor innervation of the sinus mucosa is from the intermediate nucleus of the facial nerve through postsynaptic parasympathetic branches of the pterygopalatine ganglion.

Anatomies of the nose, ethmoid sinuses, sphenoid sinuses, and frontal sinus are discussed in articles detailing their surgical management.

CONTRAINDICATIONS

Section 5 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

No absolute contraindications to maxillary sinus drainage exist; however, prudent evaluation is necessary in patients at high risk of bleeding (eg, low platelet count) or with anatomical variations that increase the risk of injury to adjacent structures (eg, hypoplastic maxillary sinus).

WORKUP

Section 6 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Lab Studies

• Some authors have reported the use of laboratory tests such as erythrocyte sedimentation rate, white blood cell count, and C-reactive protein to help diagnose acute sinusitis. These tests appear to add little to the predictive value of clinical findings in establishing the diagnosis of acute sinusitis.
• Attaining sinus cultures is the only definitive way to confirm the diagnosis of infectious sinusitis. Cultures can be obtained from the middle meatus under endoscopic guidance or via puncture techniques (see Surgical therapy).
• • Because the nose is colonized with multiple nonpathogenic species of bacteria, care must be taken when evaluating culture results.
  • A specific organism is considered pathogenic when more than 104 colony-forming units of the species are grown on culture or when polymorph counts are greater than 5000 cells per milliliter.
  • Carry out sinus puncture in patients in intensive care in whom acute sinusitis is suspected as a cause of sepsis.

Imaging Studies

• Imaging studies are not necessary when the probability of sinusitis is either high or low but may be useful when the diagnosis is in doubt, based upon a thorough history and physical examination.
• Plain radiography of the sinus may demonstrate mucosal thickening, air-fluid levels, and sinus opacification. Limitations of plain radiography include interobserver variability, inability to distinguish infection from polyp or tumor disease, and poor visualization of ethmoid and sphenoid sinuses.
• CT scanning is excessively sensitive, demonstrating sinus air-fluid levels in 87% of individuals with simple URTIs and in 40% of asymptomatic individuals. However, CT scanning is the modality of choice in specific circumstances such as in evaluation of the intensive care patient, when complications are suspected, or in the preoperative evaluation of surgical candidates.
• • CT scanning can provide valuable information regarding the anatomic and mechanical contributions in the development of acute sinusitis.
  • Coronal views with bone windows are the preferred sinus study for evaluating each of the sinuses and the ostiomeatal complex.
• MRI is excellent for evaluating soft tissue disease within the sinuses but is of little value in the diagnostic workup of acute sinusitis.

TREATMENT

Section 7 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Medical therapy

The primary goals in management of acute sinusitis are to eradicate the infection, decrease the severity and duration of symptoms, and prevent complications. Most patients with acute sinusitis are managed in the primary care setting. Further evaluation by an otolaryngologist is recommended when patients experience continued deterioration with appropriate antibiotic therapy, recurrent episodes of sinusitis, persistence of symptoms after 2 courses of antibiotic therapy, comorbid immunodeficiency, nosocomial infection, or complications of sinusitis. The goals of management of acute sinusitis are the provision of adequate drainage and appropriate systemic treatment of the likely bacterial pathogens.

Drainage of the involved sinus can be achieved medically and surgically. Medical means of providing drainage include topical and systemic vasoconstrictors. Oral alpha-adrenergic vasoconstrictors, including pseudoephedrine, phenylpropanolamine (recalled from US market), and phenylephrine, can be used for 10-14 days, allowing for restoration of normal mucociliary function and drainage. They may be contraindicated in patients with cardiovascular disease because they may cause hypertension and tachycardia. They also may be contraindicated in competitive athletes because of rules of competition.

Topical vasoconstrictors, such as oxymetazoline hydrochloride, provide good drainage but should only be used for a maximum of 3-5 days because of the increased risk of rebound congestion, vasodilatation, and rhinitis medicamentosa when used for longer periods.

Mucolytic agents, such as guaifenesin and saline lavage, have the theoretical benefit of thinning mucus secretions and improving drainage. However, they are not commonly used in clinical practice in the treatment of acute sinusitis. Intranasal steroids have not conclusively been demonstrated to be of benefit in patients with acute sinusitis.

Antihistamines are beneficial for reducing ostiomeatal obstruction in patients with allergies and acute sinusitis. They are not recommended for routine use by patients with acute sinusitis and may complicate drainage by thickening and pooling sinonasal secretions.

Treat patients who develop acute sinusitis while in the intensive care unit aggressively to avoid septic complications. Consider removal of nasotracheal and nasogastric tubes, and promote drainage with the above-mentioned modalities.

Surgical therapy

Sinus puncture and irrigation techniques allow for a surgical means of removal of thick purulent sinus secretions. The purpose of surgical drainage is to enhance mucociliary flow and provide material for culture and sensitivity. A surgical means of sinus drainage should be used when appropriate medical therapy has failed to control the infection and prolonged or slowly resolving symptoms result or when complications of sinusitis occur. Another indication for sinus puncture is to obtain culture material to guide antibiotic selection if empiric therapy has failed or antibiotic choice is limited. This is particularly important in patients who are immunocompromised or in intensive care. Sinusitis can be a prominent source of sepsis in these patients.

Preoperative details

In adults sinus puncture can usually be achieved using local anesthesia; however, in children a general anesthetic is usually necessary.

Intraoperative details

Several techniques have been described for drainage of the maxillary sinus. The inferior meatus and canine fossae are optimal drainage sites because of their ease of accessibility and relatively thin well-vascularized bone. Preoperative imaging is necessary to document the presence of acute sinusitis and to guide surgical planning. Place conscious patients in the sitting position to allow for drainage of the sinus contents into a provided basin. Protect the airway and suction the oropharynx during sinus puncture performed on unconscious patients. In patients in the intensive care unit, catheterization of the sinus may be undertaken with puncture to ensure continued adequate drainage.

Inferior meatal puncture

Use topical anesthesia (eg, cocaine, tetracaine, lidocaine 4%) and a local anesthetic/vasoconstrictor (eg, lidocaine 1% with epinephrine 1:100,000) to infiltrate the inferior meatal mucosa.

Placement of a curved trocar through the mucosa and bone 1 cm above the floor of the nose, one third of the way toward the posterior choana with an upward angle, allows for optimal penetration of the sinus. A curved trocar is preferred to the straight type to minimize risk of orbital injury caused by misdirected force. Advance the trocar until the sinus mucosa is penetrated, then remove the introducer.

Aspirate a sterile sample with a 10-mL syringe for Gram stain, culture, and sensitivities.

Irrigation of the sinus with 50-100 mL of isotonic sodium chloride solution allows flow of purulent secretions through the natural ostium. Irrigation should commence only once the position of the trocar is confirmed to be in the antrum by aspiration of air or purulent fluid.

The procedure is complete when secretions passing through the natural ostium are clear. Remove the trocar and have the patient rest for 15 minutes to prevent vasovagal episodes.

Canine fossa puncture

Use topical anesthesia (eg, cocaine, tetracaine, lidocaine 4%) and a local anesthetic/vasoconstrictor (eg, lidocaine 1% with epinephrine 1:100,000) to infiltrate the superior gingivolabial groove at the level of the canine fossa.

Placement of a straight trocar through the mucosa and bone superior to the root of the canine tooth, inferior to the infraorbital foramen, medial to the zygomatic buttress, and lateral to the piriform aperture allows for optimal penetration of the sinus. Advance the trocar until the sinus mucosa is penetrated, and then remove the introducer.

Aspirate a sterile sample with a 10-mL syringe for Gram stain, culture, and sensitivities.

Irrigate the sinus with 50-100 mL of isotonic sodium chloride solution, which allows flow of purulent secretions through the natural ostium. Irrigation should commence only once the position of the trocar is confirmed to be in the antrum by aspiration of air or purulent fluid.

The procedure is complete when the secretions passing through the natural ostium are clear. Remove the trocar and have the patient rest for 15 minutes to prevent vasovagal episodes.

Endoscopic techniques

Endoscopic techniques of sinus drainage may be useful if multiple sinuses are infected or to decompress the orbit in patients with complications. Using a 0° or 30° telescope, the nasal cavities are inspected bilaterally.

The condition of the mucosa, turbinates, septum, and airway are noted, as is the presence of purulent secretions. On the side of the maxillary sinus infection, the middle turbinate and uncinate process are infiltrated with 1-2% lidocaine with 1:100,000 epinephrine. The nose is then packed with 0.25-inch gauze for 5 minutes, allowing time for optimal decongestion.

Using a freer elevator or a backbiting instrument, the uncinate process is removed, exposing the maxillary sinus ostium. The maxillary sinus is entered using a curved suction, and secretions are sent for culture. The ostium is opened widely to allow for optimal sinus drainage. If the patient has concurrent ethmoid disease, an ethmoidectomy is performed. Further discussion of the techniques and complications of endoscopic sinus surgery are described in other eMedicine articles (see Sinusitis, Frontal, Acute, Surgical Treatment).

COMPLICATIONS

Section 8 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Complications of nonendoscopic drainage procedures can be minor or severe. The most common complication is failure to enter the sinus because of improper positioning of the trocar, incomplete penetration of the sinus mucosa, or presence of a hypoplastic antrum. Epistaxis may occur because of laceration of the nasal mucosa or preexisting coagulopathies necessitating packing. Severe complications include orbital injury, air embolism, and death secondary to injection of air into the sinus.

OUTCOME AND PROGNOSIS

Section 9 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Complications of bacterial sinusitis can be local, orbital, intracranial, or systemic.

Local

Mucoceles are chronic epithelial cysts that develop in sinuses in the presence of an obstructed sinus ostium or minor salivary gland duct. They have the potential for progressive concentric expansion, potentially leading to bony erosion and extension beyond the sinus. Maxillary sinus mucoceles usually are found incidentally on sinus radiography and are of little significance in the absence of symptomatology or infection. Surgical treatment is not usually necessary, and these lesions often regress spontaneously over time. Conversely, frontoethmoidal and sphenoethmoidal mucoceles tend to be symptomatic and have a high potential for bony erosion. Frontoethmoidal mucoceles should be completely removed and the sinus obliterated. Sphenoethmoid mucoceles should be widely opened into the nasal cavity.

Osteomyelitis is a potential local complication most commonly occurring with frontal sinusitis. Osteomyelitis of the frontal bone is called Pott puffy tumor and manifests as a subperiosteal abscess with local edema anterior to the frontal sinus. This lesion can advance to form a fistula to the upper lid with sequestration of necrotic bone. This rare local complication of frontal sinusitis should be managed with a combination or systemic antibiotics, surgical drainage of affected sinuses, and debridement of necrotic bone.

Orbital

Orbital complications are the most common complications encountered with acute bacterial sinusitis. Infection can spread directly through the thin bone separating the ethmoid or frontal sinuses from the orbit or by thrombophlebitis of the ethmoid veins. Base diagnosis on an accurate physical examination, including ophthalmologic evaluation and appropriate radiologic studies. CT scanning is the most sensitive study to aid in diagnosing an orbital abscess, although ultrasonography has been found to be 90% effective for use in diagnosing anterior abscesses.

The Chandler classification includes physical examination and radiographic findings and provides a reasonable framework to guide management.

• Group I - Inflammatory edema (preseptal cellulitis) with normal visual acuity and extraocular movement
• Group II - Orbital cellulitis with diffuse orbital edema but no discrete abscess
• Group III - Subperiosteal abscess beneath the periosteum of the lamina papyracea resulting in downward and lateral globe displacement
• Group IV - Orbital abscess with chemosis, ophthalmoplegia, and decreased visual acuity
• Group V - Cavernous sinus thrombosis with rapidly progressive bilateral chemosis, ophthalmoplegia, retinal engorgement, and loss of visual acuity, along with possible meningeal signs and high fever

Obtain medical management, including sinus drainage and intravenous antibiotics, for any degree of orbital complication. Use of decongestant and antibiotic therapy is discussed in Treatment.

Surgical drainage of both the infected sinuses and the orbit is advocated for Chandler classifications III-V if orbital cellulitis progresses or fails to improve despite medical therapy or if loss of visual acuity occurs. Surgical procedures also are discussed in Treatment.

Intracranial

Intracranial complications may occur because of direct extension through the posterior frontal sinus wall or through retrograde thrombophlebitis of the ophthalmic veins. Subdural abscess is the most common intracranial complication, although cerebral abscesses and infarction can occur, resulting in seizures, focal neurologic deficits, and coma. Manage intracranial complications of sinusitis surgically; drain both the affected sinus and the cranial abscess.

Systemic

Sinusitis can result in sepsis and multisystem organ failure by seeding the blood and various organ systems. Reports of bacteremia, thoracic empyema, and nosocomial pneumonia have been documented in patients in intensive care units who have acute sinusitis; the mortality rate in this group can reach 11%.

FUTURE AND CONTROVERSIES

Section 10 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Some authors who advocate use of only symptomatic therapies in uncomplicated cases have questioned use of antibiotics in patients with acute sinusitis. Moreover, because only 5-10% of URTIs are complicated by purulent sinusitis, the decision to use antibiotics should be made judiciously. In cases of suspected or documented bacterial sinusitis, the second principle of treatment is to provide adequate systemic treatment of the likely bacterial pathogens (ie, S pneumoniae, H influenzae, M catarrhalis).

The physician should be aware of the probability of bacterial resistance within the community. Approximately 44% of H influenzae and almost all of M catarrhalis strains have beta-lactamase–mediated resistance to penicillin-based antimicrobials in children. As many as 64% of S pneumoniae strains are penicillin-resistant because of altered penicillin-binding proteins. Multiple drug–resistant S pneumoniae strains are also found in substantial numbers of children in daycare settings.

Initial selection of appropriate antibiotic therapy should be based on the likely causative organisms for the given clinical scenario and the probability of resistant strains within a community. The course of treatment usually lasts 14 days. First-line therapy at most centers is amoxicillin. Patients who are allergic to penicillin usually receive a macrolide antibiotic because of the low cost, ease of administration, and low toxicity of this class of drugs. Amoxicillin should be given at double the usual dose (80-90 mg/kg/d), especially in areas with known S pneumoniae resistance.

Patients who live in communities with a high incidence of resistant organisms, those who fail to respond within 48-72 hours of commencement of therapy, or those whose symptoms persist beyond 10-14 days should be considered for second-line antibiotic therapy. The most commonly used second-line therapies include amoxicillin clavulanate, second- or third-generation cephalosporins (eg, cefuroxime, cefpodoxime, cefdinir), macrolides (eg, azithromycin, clarithromycin), fluoroquinolones (eg, ciprofloxacin, levofloxacin), and clindamycin. In patients with dental causes of sinusitis or in those with foul-smelling discharge, obtain anaerobic coverage using clindamycin or amoxicillin with metronidazole.

Patients with nosocomial acute sinusitis require adequate intravenous coverage for gram-negative organisms. Aminoglycoside antibiotics are usually the drugs of choice for treatment of such patients because of their excellent gram-negative coverage and sinus penetration. Antibiotic selection usually is based on the culture results of maxillary secretions.

In addition to surgical management, manage complications of acute sinusitis with a course of intravenous antibiotics. Third-generation cephalosporins (eg, cefotaxime, ceftriaxone) in combination with vancomycin provide adequate intracranial penetration, making them a good first-line choice.

The dosage, route, and spectrum of activity of commonly used systemic antibiotics are discussed in the eMedicine article Sinusitis, Acute, Medical Treatment.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

Media file 1:  Surgical treatment of acute maxillary sinusitis. The left orbital subperiosteal abscess is displacing the medial rectus muscle.
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Media type:  CT

Media file 2:  Surgical treatment of acute maxillary sinusitis. The left ethmoidal mucocele is complicating chronic sinusitis: note the proptosis of the left eye.
	View Full Size Image
Media type:  CT

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome and Prognosis
• Future and Controversies
• Multimedia
• References

1. AHCPR Evidence Report. Diagnosis and treatment of acute bacterial rhinosinusitis. Rockville, MD. Agency for Health Care Policy and Research. 1999.
2. Bishai WR. Issues in the management of bacterial sinusitis. Otolaryngol Head Neck Surg. Dec 2002;127(6 Suppl):S3-9. [Medline].
3. Brooks I, Gooch WM, Jenkins SG. Medical management of acute bacterial sinusitis. Recommendations of a clinical advisory committee on pediatric and adult sinusitis. Ann Otol Rhinol Laryngol Suppl. May 2000;182:2-20. [Medline].
4. Conrad DA, Jenson HB. Management of acute bacterial rhinosinusitis. Curr Opin Pediatr. Feb 2002;14(1):86-90. [Medline].
5. Eibling DE. Maxillary sinus: irrigation techniques. In: Myers EN, ed. Operative Otolaryngology: Head and Neck Surgery. Philadelphia, Pa:. WB Saunders;1997:81-85.
6. Frenkiel S. Embryology of the nose and sinuses. In: Tewfik TL, Der Kaloustian, eds. Congenital Anomalies of the Ear, Nose, and Sinuses. New York, NY:. Oxford University Press;1997:183-187.
7. Graney DO, Rice DH. Anatomy. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology-Head & Neck Surgery. 3rd ed. St. Louis, Mo:. Mosby;1998:1059-1064.
8. International Rhinosinusitus Advisory Board. Infectious rhinosinusitis in adults: classification, etiology and management. International Rhinosinusitis Advisory Board. Ear Nose Throat J. Dec 1997;76(12 Suppl):1-22. [Medline].
9. Johnson JT, Ferguson BJ. Infection. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology-Head & Neck Surgery. St. Louis, Mo:. Mosby;1998:1107-1118.
10. Kaliner MA, Osguthorpe JD, Fireman P, et al. Sinusitis: bench to bedside. Current findings, future directions [published erratum appears in Otolaryngol Head Neck Surg 1997 Sep;117(3 Pt 1):187]. Otolaryngol Head Neck Surg. Jun 1997;116(6 Pt 2):S1-20. [Medline].
11. Laine K, Maatta T, Varonen H, Makela M. Diagnosing acute maxillary sinusitis in primary care: a comparison of ultrasound, clinical examination and radiography. Rhinology. Mar 1998;36(1):2-6. [Medline].
12. Low DE, Desrosiers M, McSherry J, et al. A practical guide for the diagnosis and treatment of acute sinusitis. CMAJ. Mar 15 1997;156 Suppl 6:S1-14. [Medline].
13. Manning SC. Medical management of infectious and inflammatory disease. In: Cummings CW, Fredrickson JM, Harker LA, et al, eds. Otolaryngology-Head & Neck Surgery. 3rd ed. St. Louis, Mo:. Mosby;1998:1135-1144.
14. McCaig LF, Hughes JM. Trends in antimicrobial drug prescribing among office-based physicians in the United States. JAMA. Jan 18 1995;273(3):214-9. [Medline].
15. Poole MD. A focus on acute sinusitis in adults: changes in disease management. Am J Med. May 3 1999;106(5A):38S-47S; discussion 48S-52S. [Medline].
16. Ray NF, Baraniuk JN, Thamer M. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol. Mar 1999;103(3 Pt 1):408-14. [Medline].
17. Rhys-Evans PH. Anatomy of the nose and paranasal sinuses. In: Kerr AG, Groves J, eds. Scott-Brown's Otolaryngology. London, England:. Butterworths;1987:138-161.
18. Savolainen S, Jousimies-Somer H, Karjalainen J, Ylikoski J. Do simple laboratory tests help in etiologic diagnosis in acute maxillary sinusitis?. Acta Otolaryngol Suppl. 1997;529:144-7. [Medline].
19. Slack CL, Dahn KA, Abzug MJ. Antibiotic-resistant bacteria in pediatric chronic sinusitis. Pediatr Infect Dis J. Mar 2001;20(3):247-50. [Medline].
20. Talmor M, Li P, Barie PS. Acute paranasal sinusitis in critically ill patients: guidelines for prevention, diagnosis, and treatment. Clin Infect Dis. Dec 1997;25(6):1441-6. [Medline].
21. Taylor JA, Weber W, Standish L. Efficacy and safety of echinacea in treating upper respiratory tract infections in children: a randomized controlled trial. JAMA. Dec 3 2003;290(21):2824-30. [Medline].
22. Wald ER. Sinusitis. Pediatr Ann. Dec 1998;27(12):811-8. [Medline].
23. Wald ER. Microbiology of acute and chronic sinusitis in children and adults. Am J Med Sci. Jul 1998;316(1):13-20. [Medline].
24. Wald ER. Expanded role of group A streptococci in children with upper respiratory infections. Pediatr Infect Dis J. Aug 1999;18(8):663-5. [Medline].
25. Westergren V. Artificial ventilation-acquired sinopathy in the critically ill - the maxillary sinuses revisited. Clin Exp Allergy. Mar 1999;29(3):298-305. [Medline].
26. Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. Sep 2007;137(3 Suppl):S1-31. [Medline].

Article Last Updated: Dec 12, 2007