Sinusitis

Hina Z Ghory, MD, Chief Resident Physician, Department of Emergency Medicine, New York
Presbyterian Hospital

Rahul Sharma, MD, MBA, FACEP, Assistant Professor, Weill Medical College of Cornell
University; Attending Physician, Department of Emergency Medicine, New York Presbyterian
Hospital-Weill Cornell Medical Center

Updated: Aug 19, 2009

Background
Traditionally, sinusitis is defined as an inflammation of the mucosal lining of one or more of the
paranasal sinuses. The term rhinosinusitis is now used interchangeably with sinusitis to
emphasize the concurrent inflammation of the nasal passages that occurs with sinus mucosal
inflammation. Sinusitis is subdivided into acute (symptoms lasting <4 wk), subacute (symptoms
lasting 4-12 wk), and chronic (symptoms lasting >12 wk).[1 ]

Pathophysiology
The paranasal sinuses are in direct communication with the nasopharynx. The sinuses are
normally sterile, but their proximity to nasopharyngeal flora allows bacterial and viral
inoculation following rhinitis. Diseases that obstruct drainage can result in a reduced ability of
the paranasal sinuses to function normally. The sinus ostia become occluded, leading to
mucosal congestion. The mucociliary transport system becomes impaired, leading to stagnation
of secretions and epithelial damage, followed by decreased oxygen tension and subsequent
bacterial growth.

Acute rhinosinusitis is most commonly associated with viral infections such as the common
cold. In about 0.5-2% of cases, viral sinusitis can progress to acute bacterial sinusitis.[2,3 ]Other
factors that predispose to the development of acute bacterial rhinosinusitis include allergic
rhinitis, impaired mucociliary transport as seen in cystic fibrosis, mechanical obstruction as seen
secondary to foreign bodies, intranasal cocaine use and immunodeficient states.[3 ]

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

Sex : Sinusitis occurs equally in males and females.

Age : Sinusitis is more commonly seen in young or middle-aged adults.[4 ]Sinusitis is rare in
children younger than 1 year because the sinuses are poorly developed prior to that age.

Clinical
History

Sinusitis has 4 main signs.[4 ]

-Mucopurulent rhinorrhea

-Nasal congestion

-Facial pain, pressure, or fullness

-Decreased sense of smell

Some patients report other signs and symptoms. In severe cases, headache, malaise, and fever
may also be present.

-Pain is often exacerbated by head movement, especially leaning forward.

-Patients may report retro-orbital pain if the ethmoid sinus is involved.

-Some patients report dental pain, usually involving the maxillary teeth.

Ear pressure or fullness may also be seen.

Facial pain and headache are rarely reported in children with sinusitis.

Sinusitis needs to be differentiated from a viral upper respiratory infection (URI) or allergic
rhinitis.[5 ]Symptoms of allergic rhinitis are often seasonal and may include clear watery
anterior and posterior nasal discharge, sneezing, and itchy eyes and nose.

Cases of viral rhinosinusitis are often difficult to differentiate from acute bacterial rhinosinusitis.
[5 ]The latter usually presents with a high fever, acute facial pain, swelling or erythema, sinus
tenderness, symptoms of sinusitis lasting greater than 10 days, or symptoms that worsen after
initial improvement.[3 ]

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 maxillary or frontal sinuses may be seen on transillumination.

Partial opacification is a nonspecific finding, and it is not as reliable.

Causes
The most common culprits in acute viral rhinosinusitis are rhinovirus, influenza virus, and
parainfluenza virus.

Community-acquired acute bacterial rhinosinusitis (ABRS) is usually due to a single pathogen,

though 2 pathogens can be isolated in up to 25% of cases.[3 ] Streptococcus pneumoniae and
Haemophilus influenzae are the organisms most commonly found in adult patients diagnosed
with ABRS.

In chronic sinusitis, the infecting organisms vary, and a higher incidence of anaerobic organisms
is seen (eg, Bacteroides, Peptostreptococcus, and Fusobacterium species).[6 ]

In children, similar organisms are seen, with the addition of Moraxella catarrhalis. In older
children and young adults, Staphylococcus aureus is an occasional culprit.

Nosocomial sinusitis presenting as fever of unknown origin can be seen in patients with
prolonged intensive care unit stays or intubation.[3 ]These patients are at risk of infection with
gram-negative organisms including Pseudomonas aeruginosa, Klebsiella pneumoniae,
Enterobacter species, Proteus mirabilis, and Serratia marcescens. Gram-positive cocci such as S
aureus can also be seen.

Acute invasive fungal rhinosinusitis can be caused by Candida, Aspergillus, and Phycomycetes
species. Risk factors include diabetes mellitus, cancer, hepatic disease, renal failure, burns,
extreme malnutrition, and other immunosuppressive diseases.

Differential Diagnoses : Headache, Cluster, Headache, Migraine, Headache, Tension, Otitis

Media

Other Problems to Be Considered : Dental infections, Periapical abscess, Upper respiratory tract
infection

Workup
Laboratory Studies

Acute sinusitis is usually a clinical diagnosis.

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): CT scanning is more sensitive than plain radiography for
showing evidence of sinusitis. Up to 42% of asymptomatic patients may have signs of mucosal
abnormality on CT scan.[3 ]CT scanning is used extensively by otolaryngology (ENT) specialists
to confirm the diagnosis of chronic sinusitis or recurrent acute sinusitis. While CT results are
nonspecific, a normal CT can be used to rule out sinusitis. CT scanning is also recommended in
patients with signs of intracranial or orbital extension.

Magnetic resonance imaging (MRI) can be used in conjunction with CT scan to delineate soft
tissue extension in complicated sinusitis.

Imaging is not mandatory to the diagnosis. Uncomplicated sinusitis is often diagnosed clinically,
with studies reserved for complicated cases or patients who are nonresponsive to the usual
therapies.

Other Tests

Sinus cultures and biopsy: Bacterial or fungal cultures and tissue samples can be obtained
directly from the sinus ostia by ENT specialists to diagnose resistant bacteria or unusual
organisms. Nasal swabs are not an adequate source of typing the bacteria causing sinusitis.

Treatment
Emergency Department Care

The treatment of sinusitis is mostly symptomatic and does not shorten the duration of
the infection. Acute viral sinusitis usually resolves without treatment in 7-10 days.[3 ]Up to 75
percent of cases of acute bacterial rhinosinusitis resolve without any treatment in 1 month.[3 ]
While in the emergency department and upon discharge, patients may obtain significant
immediate relief with the administration of first-generation antihistamines, decongestants, and
nonsteroidal anti-inflammatory drugs (NSAIDs).

Topical decongestants such as oxymetazoline can be used to decrease mucosal edema.

To prevent rebound congestion, they should not be used for more than 3 days.

Warm compresses to the face give symptomatic relief.

 Corticosteroids: A 15-day course of intranasal corticosteroids may reduce symptom
duration when compared to placebo.[2 ]Mometasone 200, 400, and 800 mcg twice daily for 15
days is the usual regimen given, with minimal adverse effects. Systemic steroids have no proven
benefit in sinusitis.

Topical ipratropium bromide 0.06% can be used to decrease rhinorrhea.

Antihistamines have not been shown to be of benefit in decreasing nasal congestion; in

fact, they may cause overdrying of the nasal mucosa.

Mucolytics such as guaifenesin can be used to thin secretions, though they have not
been definitively shown to be of benefit.

Antibiotics: In clinically diagnosed acute sinusitis, little evidence from randomized

controlled trials supports the use of antibiotics for the treatment of acute sinusitis.[2 ]
Antibiotics have been shown to have a role in the treatment of acute maxillary sinusitis that is
diagnosed radiologically or bacteriologically. Antibiotics are indicated for sinusitis that is
thought to be bacterial (see History), including sinusitis that is severe or involves the frontal,
ethmoid, or sphenoid sinuses, since this type of sinusitis is more prone to complications.

Penicillins, cephalosporins, and macrolides seem to be equally efficacious.[2 ]A 10-14 day

regimen of amoxicillin 500 mg 3 times a day is considered first-line therapy.[8 ]The risk of
adverse effects should be weighed against the severity of disease and patient comorbidities
prior to initiating antibiotic treatment.

Instruct patients to drink a lot of fluids. Use of a humidifier or vaporizer helps keep secretions
moist and loose.

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.

These agents are used to loosen secretions for clearance.

Oxymetazoline (Afrin)

Applied directly to mucous membranes, where it stimulates alpha-adrenergic receptors and

causes vasoconstriction. Decongestion occurs without drastic changes in blood pressure,
vascular redistribution, or cardiac stimulation.

Dosing
Adult 2-3 sprays or 2-3 gtt of 0.05% solution in each nostril bid

Use for maximum of 3 d only; patients can become dependent

Phenylephrine (Neo-Synephrine)

A strong postsynaptic alpha-receptor stimulant with little effect on the beta-receptors of the
heart.

Dosing

Adult 1-2 sprays per nostril q3-4h

Pseudoephedrine (Sudafed)

Stimulates vasoconstriction by directly activating the alpha-adrenergic receptors of the

respiratory mucosa. Induces bronchial relaxation and increases heart rate and contractility by
stimulating beta-adrenergic receptors. Available in 30- and 60-mg tablets, 30-mg/5 mL elixir,
and in a sustained-release form 120 mg.

Dosing

Adult 60 mg PO q4-6h; 120 mg SR q12h; not to exceed 240 mg/d

Trimethoprim and sulfamethoxazole (Bactrim, Septra)

Inhibits bacterial synthesis of dihydrofolic acid by competing with para-aminobenzoic acid. By

inhibiting the enzyme dihydrofolate reductase, the production of tetrahydrofolic acid
decreases. These effects inhibit bacterial growth. Bacterial resistance appears to develop more
slowly with this drug combination than with either drug alone. DOC along with AMP/CL.
Available in elixir 40/200 per 5 mL, single strength (80/400) and double strength (160/800).

Dosing

Adult 5 mg/kg (based on trimethoprim) IV q6h; 1 tab (double strength) PO bid

Amoxicillin and clavulanate (Augmentin)

Drug combination that extends the antibiotic spectrum of penicillin to include bacteria normally
resistant to beta-lactam antibiotics. Administer treatment for a minimum of 10 d. Available in
125-, 250-, and 500-mg tablets and in 125 and 250/5 mL elixir.

Dosing

Adult 500 mg PO q12h; 250 mg PO q8h

Amoxicillin (Amoxil, Polymox)

Treats infections caused by susceptible organisms and can be used as prophylaxis in minor
procedures. An alternative therapy, but some resistant organisms are beginning to be seen in
the US.

Dosing

Adult 250-500 mg PO q8h; not to exceed 3 g/d

Clarithromycin (Biaxin)

Reversibly binds to the P site of the 50S ribosomal subunit of susceptible organisms and may
inhibit RNA-dependent protein synthesis by stimulating the dissociation of peptidyl tRNA from
ribosomes.

Dosing

Adult 250-500 mg PO q12h for 7-14 d

Levofloxacin (Levaquin)

The S-enantiomer of ofloxacin, a fluoroquinolone antibiotic with improved activity against

gram-positive organisms. Best used only in severe or refractory sinusitis.

Dosing

Adult 500 mg PO qd for 7-21 d

Follow-up

Complications

Chronic sinusitis

Osteomyelitis

Orbital cellulitis

Intracranial extension resulting in septic cavernous thrombosis

Prognosis
The prognosis is generally good with appropriate treatment.

References

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