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A review of this frequently seen condition on A4Medicine. Sinus infection accounts for close to 16 million office visits per year ( USA ). Sinusitis is more common from early fall to early spring. It is much more common in adults than children. approximately 0.5 % of upper respiratory tract infections are complicated by sinusitis. Acute sinusitis is the second most common infectious disease seen by GPs ( Acute sinusitis Can Fam Physician 2011). This review covers acute sinusitis presentation.

Sinusitis is an inflammation of the mucosal lining of the paranasal sinuses .

 Inflammation of the sinus cavities is almost always accompanied
 by inflammation of the nasal cavities – 
RHINOSINUSITIS is a more suitable and preferred term

Obstruction of sinus drainage pathways Ciliary impairment Altered mucus quantity and quality

Causes risk factors – Viral infection- most common cause and include
○ Respiratory syncytial virus
♦ Rhinovirus
♦ Parainfluenza
♦ Influenza with rhinovirus
 Acute bacterial infection
Following an episode of viral sinusitis 0.5 % to 2 % cases will progress to acute bacterial sinusitis

Sinusitis is one of the commonest reasons a healthcare professional will prescribe an antibiotic

Most commonly implicated bacteria are
♣ Streptococcus pneumoniae
♦ Haemophilus influenzae 
 Allergic and non-allergic rhinitis
 Anatomical variations
♦ abnormality of osteomeatal complex
♦ septal deviation 
♦ cleft palate
♦ concha bullosa – pneumatized ( air filled ) cavity withih a turbinate in the nose ( Google )
♦ hypertrophic middle turbinates
 Cigarette smoking –> can damage cilia Asthma – chronic sinusitis and nasal polyps Diabetes – risk chronic sinusitis Swimming , diving , high altitude climbing Dental infections and procedures Diagnosed more frequently in women than men Aspirin sensitivity.Cystic fibrosis Neoplasia Mechanical ventilation Use of nasal tubes such as NG feeding tubes Sarcoidosis Immunodeficiency Wegeners granulomatosis Sinus surgery Immotile cilia syndrome

Presentation- Most common cause of acute sinusitis is a viral infection – usually follows a common cold Clinical findings may include Pain over cheek – radiating to frontal region or teeth ↑↑ with straining or bending down Facial pain or pressure Headache Persistent cough ( ↑↑ at night ) Tenderness pressure over the floor of the frontal sinuses immediately above inner canthus Nasal blockage ( obstruction / congestion ) Disoloured nasal discharge ( ant / post nasal drip ) Hyposmia – reduced sense smell Toothache

Acute Bacterial Sinusitis -ABRS- Discoloured discharge 
○ unilateral predominance
♦ purulent secretions in the nasal cavity
 Severe local pain ( unilateral predominance )
 Fever > 38°
 Elevated ESR / CRP
 Double sickening – a deterioration after an initial milder phase of illness. Caused by a virus in
 > 98 % cases takes an 
average 2.5 weeks to resolve
 and antibiotics only likely to 
help if features suggestive 
of bacterial infection

Examination- Inspect and palpate the maxillofacial area Check nasal cavity- rhinoscopy for
♠ nasal inflammation
♦ mucosal oedema
♦ mucupurulent nasal discharge
♦ nasal polyps
♦ anatomical abnormalities eg deviated nasal septum
♦ nasal foreign body
♦ sinonasal tumour

Caution- Periorbital oedema / erythema Displaced globe Double vision Ophthalmoplegia Reduced visual acuity

 Severe frontal headache Swelling over frontal bone Symptoms and signs of
meningitis Focal neurological signs

Management- Paracetamol or NSAID
 Intranasal decongestant
Topical agents preferred over systemic
Up to 3-5 days – prevent rebound congestion
eg Oxymetazoline nasal spray
 Intranasal corticosteroid
patients with congestion
low systemic SEs
advised min 1 month use
 Irrigating nose with nasal saline solution Warm face packs Adequate hydration Ipratropium – if congested ( topical anticholinergic )

Immunocompromised or severe illness-High dose amoxicillin/ clavulanic acid -
ist line ( IDSA ) 
Amoxicillin or Phenoxymethypenicillin
( CKS )
 Clindamycin + a 3rd gen cephalosporin
(if allergic to penicillin )
 Doxycyline suitable alternative
 Quinolones – may be tried if treatment with above not possible

Imaging – Testing- Clinical diagnosis based on history and examination No investigation indicated in uncomplicated acute sinusitis CT – examination of choice
Not required in acute sinusitis MRI – if complication is suspected XR – obsolete but can show
air fluid levels – indicate bacterial cause 
size and integrity of para-nasal sinuses Ultrasound – conflicting evidence can be combined with radiography Sinus culture – endoscopic or sinus puncture

Pre-existing co-motbidity as
♦ significant heart , lung , renal , liver or neuromuscular disease
♦ Immunosuppression
♦ Cystic fibrosis
 Acute cough and older than 65 with two risk factors
Acute cough and older than 80 with one risk factor
♦ hospitilization in previous year
♦ type 1 or 2 diabetes
♦ congestive heart failure
♦ on oral steroid therapy

Referral ENT-Frequent recurrent episodes Unremitting or progressive facial pain Nasal polyps – causing sig obstruction Trial of intranasal steroids for 3 months with no benefit Immunodeficiency Complication suspected Suspected allergic or immunological aetiology and associated co-morbidities as asthma Structural anomalies as deviated nasal septum Sinus surgery indicated


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