Sinusitis
last authored: Jan 2010, David LaPierre
last reviewed:
Introduction
Sinusitis is an inflammation of the mucous membranes of the nasal cavity and paranasal sinuses, with fluid within these cavities and/or the underlying bone.
Acute sinusitis has been present for less than 4 weeks. Chronic sinusitis has been present for greater than 12 weeks, while recurrent disease strikes at least 4 times per year, with each bout lasting at least 10 days.
The Case of...
a simple case introducing clincial presentation and calling for a differential diagnosis to get students thinking.
Causes and Risk Factors
Risk factors include:
- medical conditions such as RTIs, allergic rhinitis, cystic fibrosis, immunodeficiency
- anatomic abnormalities, such as a deviated septum, polyps, adenoid hypertrophy, tumours
- irritants: tobacco smoke, air pollution, chlorine
- drugs: decongestant overuse, cocaine
The most common pathogens include:
viruses: rhinovirus, influenza, parainfluenza
adults: S. pneumoniae, H. influenzae, S. aureus, S. pyogenes, Pseudomonas, anaerobes, and gram-negative enteric bacteria.
children:S. pneumoniae, H. influenzae, M catarrhalis
Pathophysiology
Children have only maxillary and ethmoid sinuses by age 6.
Signs and Symptoms
- history
- physical exam
History
A diagnosis of acute bacterial sinusitis can be difficult.
Bacterial sinusitis tends to present with a worsening of symptoms after somewhat of improvement. Other signs suggestive of bacterial infection:
- facial, unilateral pain
- maxillary toothache
- purulent nasal secretions
- poor response to decongestants
- abnormal transillumination
Physical Exam
Investigations
- lab investigations
- diagnostic imaging
Lab Investigations
Diagnostic Imaging
All patients with pronounced frontal headaches should have a radiograph to r/o frontal sinusitis
Perform imaging (ie CT) only if the diagnosis is in doubt.
Chronic sinusitis demonstrates CT or MRI.
Differential Diagnosis
Treatments
Antimicrobial treatment may be beneficial for bacterial sinusitis, but some studies have shown no significant benefit.
First line: amoxicillin , TMP-SMX if allergic to penicillins
Second line: cefuroxime, clarithromycin, ceflacor, cefitime.
If no response is seen after 5-7 days, consider broad-spectrum such as amoxicillin-clavulanic acid, levofloxacin, cephalosporin.
If no response after 3-4 weeks, choose metronidazole or clindamycin for anaerobic coverage.
Other adjuncts that may be helpful include:
- inhaled steam of facial packs
- saline nasal sprays
- oral and nasal decongestants (short time only)
- nasal corticosteriod spray (chronic sinusitis only)
- oral mucolytics (guaifenesin, bromelain
Antihistamines are contraindicated.
Referrals
ENT should be consulted if:
- second-line therapy fails
- > 3 episodes yearly
- development of complications: mucocele, orbital extension, meningitis, intracranial abscess, venus sinus thrombosis
Consequences and Course
Up to 40% of patients will recover spontaneously.
The Case of...
Case #2 - a small story wrapping it all up and asking especially about management.
Additional Resources
any good free online resources for further reading.
Topic Development
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