Sinusitis

Background

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

Clinical Features

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

Differential Diagnosis

• Migraine
• Craniofacial neoplasm
• Foreign body retention
• Dental caries

Diagnosis

• Consider CT only for toxic patients (to rule-out complication)

Treatment

<10 days of symptoms

• Symptomatic treatment b/c most likely viral
  • Analgesia
  • Mechanical irrigation with buffered, hypertonic saline
  • Topical glucocorticoids
  • Topical decongestants (e.g. oxymetazoline for no more than 3d)
  • Antihistamines
  • Mucolytics

>10 days of symptoms OR if pt gets better and then worse again (“double sickening”)

• Mild bacterial sinusitis (pain is mild and temperature <38.3˚C)
  • Another seven days of observation
• Severe bacterial sinusitis (pain is moderate-severe or temperature ≥38.3˚C)
  • Consider amoxicillin
  • Consider fluoroquinolone or amoxicillin-clavulanate if pt has had antibiotics in past 4-6wks

Antibiotic Failure

• Obtain culture
• Consider nosocomial bacterial sinusitis (e.g. after prolonged nasotracheal inbutation)
• Consider foreign body
• Consider fungal treatment

Complications

• Meningitis
• Cavernous sinus thrombosis (ethmoid/sphenoid)
• Intracranial abscess
• Orbital cellulitis (ethmoid)
• Frontal bone osteomyelitis (Pott's puffy tumor)
• Extradural or subdural empyema