Sinusitis is infl ammation of the mucous membranes lining one or more of the paranasal sinuses. The various presentations are as folllows:
● Acute sinusitis: infection lasting less than 30 days, with complete resolution of symptoms
● Subacute infection: lasts from 30 to 90 days, with complete resolution of symptoms
● Recurrent acute infection: episodes of acute infection lasting less than 30 days, with resolution of symptoms, which
recur at intervals of at least 10 days apart
● Chronic sinusitis: infl ammation lasting more than 90 days, with persistent upper respiratory symptoms
● Acute bacterial sinusitis superimposed on chronic sinusitis:
new symptoms that occur in patients with residual symptoms from prior infection(s). With treatment, the new
symptoms resolve but the residual ones do not.
PHYSICAL FINDINGS AND CLINICAL PRESENTATION
● Patients often give a history of a recent upper respiratory illness with some improvement, then a relapse.
● Mucopurulent secretions in the nasal passage
● Purulent nasal and postnasal discharge lasting more than 7 to 10 days
● Facial tightness, pressure, or pain
● Nasal obstruction
● Decreased sense of smell
● Purulent pharyngeal secretions, brought up with cough, often worse at night
● Erythema, swelling, and tenderness over the infected sinus in a small proportion of patients
● Diagnosis cannot be excluded by the absence of such findings.
● These fi ndings are not common, and do not correlate with number of positive sinus aspirates.
● Intermittent low-grade fever in about one half of adults with acute bacterial sinusitis
● Toothache is a common complaint when the maxillary sinus is involved.
● Periorbital cellulitis and excessive tearing with ethmoid sinusitis
● Orbital extension of infection: chemosis, proptosis, impaired extraocular movements.
Characteristics of acute sinusitis in children with upper respiratory tract infections:
● Persistence of symptoms
● Bad breath
● Symptoms of chronic sinusitis (may or may not be present)
● Nasal or postnasal discharge
● Facial pain or pressure
● Nosocomial sinusitis is typically seen in patients with nasogastric tubes or nasotracheal intubation.
● Each of the four paranasal sinuses is connected to the nasal cavity by narrow tubes (ostia), 1 to 3 mm in diameter; these drain directly into the nose through the turbinates. The sinuses are lined with a ciliated mucous membrane (mucoperiosteum).
● Acute viral infection
● Infection with the common cold or infl uenza
● Mucosal edema and sinus infl ammation
● Decreased drainage of thick secretions, obstruction of the sinus ostia
● Subsequent entrapment of bacteria
a. Multiplication of bacteria
b. Secondary bacterial infection
Other predisposing factors
● Foreign bodies
● Congenital choanal atresia
● Other entities that cause obstruction of sinus drainage
● Dental infections lead to maxillary sinusitis.
● Viruses recovered alone or in combination with bacteria (in 16% of cases):
● Parainfluenza virus
● Respiratory syncytial virus
● The principal bacterial pathogens in sinusitis are Streptococcus pneumoniae, nontypeable Haemophilus influenzae, and Moraxella catarrhalis.
● In the remainder of cases, fi ndings include Streptococcus pyogenes, Staphylococcus aureus, alpha-hemolytic streptococci, and mixed anaerobic infections (Peptostreptococcus, Fusobacterium, Bacteroides, Prevotella).
Infection is polymicrobial in about one third of cases.
● Anaerobic infections seen more often in cases of chronic sinusitis and in cases associated with dental infection; anaerobes are unlikely pathogens in sinusitis in children.
● Fungal pathogens are isolated with increasing frequency in immunocompromised patients but remain uncommon
pathogens in the paranasal sinuses. Fungal pathogens include Aspergillus, Pseudallescheria, Sporothrix, phaeohyphomycoses, Zygomycetes.
● Nosocomial infections occur in patients with nasogastric tubes, nasotracheal intubation, cystic fi brosis, or those who are immunocompromised.
● S. aureus
● Pseudomonas aeruginosa
● Klebsiella pneumoniae
● Enterobacter spp.
● Proteus mirabilis
Organisms typically isolated in chronic sinusitis:
● S. aureus
● S. pneumoniae
● H. infl uenzae
● P. aeruginosa
● Migraine headache
● Cluster headache
● Dental infection
● Trigeminal neuralgia
● Water’s projection: sinus radiograph
● CT scan
● Much more sensitive than plain radiographs in detecting acute changes and disease in the sinuses
● Recommended for patients requiring surgical intervention, including sinus aspiration; it is a useful adjunct to
● Used for diagnosis of frontal and maxillary sinusitis
● Place transilluminator in the mouth or against cheek to assess maxillary sinuses, and under the medial aspect of the supraorbital ridge to assess frontal sinuses.
● Absence of light transmission indicates that sinus is filled with fluid.
● Dullness (decreased light transmission) is less helpful in diagnosing infection.
● Used to visualize secretions coming from the ostia of infected sinuses
● Culture collection via endoscopy often contaminated by nasal flora; not nearly as good as sinus puncture
● Sinus puncture
● Gold standard for collecting sinus cultures
● Generally reserved for treatment failures, suspected intracranial extension, nosocomial sinusitis.
● Sinus drainage
● Nasal vasoconstrictors, such as phenylephrine nose drops, 0.25% or 0.5%
● Topical decongestants should not be used for more than a few days because of the risk of rebound congestion.
● Systemic decongestants
● Nasal or systemic corticosteroids, such as nasal beclomethasone, short-course oral prednisone
● Nasal irrigation, with hypertonic or normal saline (saline may act as a mild vasoconstrictor of nasal blood fl ow)
● Use of antihistamines has no proved benefi t, and the drying effect on the mucous membranes may cause crusting,
which blocks the ostia, thus interfering with sinus drainage.
● Analgesics, antipyretics.
● Most cases of acute sinusitis have a viral cause and will resolve within 2 weeks without antibiotics.
● Current treatment recommendations favor symptomatic treatment for those with mild symptoms.
● Antibiotics should be reserved for those with moderate to severe symptoms who meet the criteria for diagnosis of
● Antibiotic therapy is usually empirical, targeting the common pathogens.
● First-line antibiotics include amoxicillin, TMP-SMZ.
● Second-line antibiotics include clarithromycin, azithromycin, amoxicillin-clavulanate, cefuroxime axetil, loracarbef, ciprofloxacin, levofloxacin.
● For patients with uncomplicated acute sinusitis, the less expensive first-line agents appear to be as effective as the
costlier second-line agents.
● Surgical drainage indicated
● If intracranial or orbital complications suspected
● For many cases of frontal and sphenoid sinusitis
● For chronic sinusitis recalcitrant to medical therapy
● Surgical débridement imperative for treatment of fungal sinusitis