Sinusitis

 

• Definition and time course

  Inflammation of the paranasal sinuses, either infectious, allergic, or autoimmune.

  Acute sinusitis:

  • <12 weeks.
  • Usually from a viral URTI, or a bacterial infection (2%) by Strep. pneumo or H. influenzae.

  Chronic rhinosinusitis:

  • >12 weeks.
  • May be triggered by an acute infection, or due to recurrent infection, allergy, or anatomical abnormality.
  • Sub-classified by presence or absence of nasal polyps, which are chronic inflammatory lesions of the nasal and paranasal sinuses.
  • May be difficult to distinguish from chronic rhinitis, but management is similar anyway.

• Risk factors

  • Allergic rhinitis.
  • Anatomical: nasal polyps, facial injury, congenital abnormality.
  • Respiratory disease: asthma, CF, primary ciliary dyskinesia (Kartagener's).
  • Immunodeficiency
  • Pregnancy
  • Smoking

• Signs and symptoms

  Pain:

  • Pain and tenderness over the sinus (i.e. upper cheek). May also present as a more subtle facial fullness, especially in chronic rhinosinusitis.
  • May radiate to cause a frontal headache, or to the teeth. Occasionally, referred to temple or occiput.
  • Worse on straining or bending forward.

  Other signs and symptoms:

  • Red nose, cheeks, or eyelids.
  • Blocked nose, postnasal drip, hyposmia.
  • Persistent cough.

  Features suggesting bacterial infection:

  • Purulent discharge.
  • Severe or persistent (>10 days) symptoms.
  • Fever
  • Mild illness which then becomes worse ('double-sickening').

  Nasal polyps:

  • Non-tender, grey lumps, in contrast to the tender, red nasal turbinates.
  • Usually bilateral, single or in clusters. If unilateral (and especially if bleeding), consider urgent ENT referral for possible malignancy.
  • May cause nasal obstruction, hyposmia, and snoring.

• Management

  Acute sinusitis usually self-resolves within 2 weeks, even bacterial infection. However, treatment options include:

  • Symptomatic relief with intranasal decongestants (max. 1 week), simple analgesia, saline nasal irrigation, and warm face packs.
  • Nasal corticosteroids for 2 weeks if symptoms persist >10 days.
  • Antibiotics only needed for severe symptoms, or in individuals with CF or immunodeficiency. Phenoxymethylpenicillin (pen V) or, if systemically unwell, co-amoxiclav.

  Chronic rhinosinusitis:

  • Intranasal steroids.
  • Saline nasal irrigation.
  • Most polyps are steroid-responsive (consider short-course oral if intranasal ineffective), but a minority will require removal via endoscopic sinus surgery.
  • Consider short-course antibiotics if purulent. Long antibiotic courses are sometimes used, though evidence is limited.

• Complications

  • Orbital cellulitis.
  • Meningitis