Sinusitis

Background

1. Acute (<4 weeks)
   1. Acute viral
   2. Acute bacterial (0.5-2% of cases)
2. Subacute (4-12 weeks)
3. Chronic (>12 weeks)
4. Other causes
   1. Fungal infections
   2. Allergies

Clinical Features

1. Defined as 2 or more of the following:
   1. Blockage or congestion of nose
   2. Facial pain or pressure
   3. Hyposmia (diminished ability to smell)
   4. Anterior or posterior nasal discharge lasting <12wk
2. Additional symptoms:
   1. Tooth pain
   2. Fever
   3. Sinus pressure while bending forward to changing head position

Diagnosis

1. Consider CT only for toxic pts (to r/o complication)

DDX

1. Migraine
2. Craniofacial neoplasm
3. Foreign body retention
4. Dental caries

Treatment

1. <10 days of symptoms
   1. Symptomatic treatment b/c most likely viral
      1. Analgesia
      2. Mechanical irrigation with buffered, hypertonic saline
      3. Topical glucocorticoids
      4. Topical decongestants (e.g. oxymetazoline for no more than 3d)
      5. Antihistamines
      6. Mucolytics
2. >10 days of symptoms OR if pt gets better and then worse again (“double sickening”)
   1. Mild bacterial sinusitis (pain is mild and temperature <38.3˚C)
      1. Another seven days of observation
   2. Severe bacterial sinusitis (pain is moderate-severe or temperature ≥38.3˚C)
      1. Consider amoxicillin
      2. Consider fluoroquinolone or amoxicillin-clavulanate if pt has had abx in past 4-6wks
3. Antibiotic Failure
   1. Obtain culture
   2. Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal inbutation)
   3. Consider foreign body
   4. Consider fungal treatment

Complications

1. Meningitis
2. Cavernous sinus thrombosis
3. Intracranial abscess
4. Orbital cellulitis
5. Frontal bone osteomyelitis (Pott's puffy tumor)
6. Extradural or subdural empyema

Source

• UpToDate
• Tintinalli