Sinusitis

Pulmonology

Clinicals - History

Fact Explanation
Nasal congestion Sinusitis is an infectious or non-infectious inflammation of one or more para nasal sinuses. The infection may be bacterial, viral or fungal. Non-infectious sinusitis is allergic in origin. Acute sinusitis is defined as the infection lasts less than 4 weeks and symptoms resolves completely with treatment. In sub acute cases, the infection lasts 4 - 12 weeks whereas in chronic sinusitis it lasts more than 12 weeks with or without treatment.
The majority of cases follow a viral upper respiratiory tract infection which involves the whole upper respiratory epithelium including the para nasal sinuses. Such infections cause hyperaemia and edema of the mucosa which block the ostia. There will be a cellular infiltration and an increase in mucous production which blocks the nasal passage.
Nasal congestion
Sinusitis is an infectious or non-infectious inflammation of one or more para nasal sinuses. The infection may be bacterial, viral or fungal. Non-infectious sinusitis is allergic in origin. Acute sinusitis is defined as the infection lasts less than 4 weeks and symptoms resolves completely with treatment. In sub acute cases, the infection lasts 4 - 12 weeks whereas in chronic sinusitis it lasts more than 12 weeks with or without treatment.
The majority of cases follow a viral upper respiratiory tract infection which involves the whole upper respiratory epithelium including the para nasal sinuses. Such infections cause hyperaemia and edema of the mucosa which block the ostia. There will be a cellular infiltration and an increase in mucous production which blocks the nasal passage.
Nasal discharge Excessive mucous production causes initial watery nasal discharge. Stasis of secretion occurs due to paralyzed cilia. This leads to secondary bacterial infection which makes the nasal discharge purulent. Nasal discharge
Excessive mucous production causes initial watery nasal discharge. Stasis of secretion occurs due to paralyzed cilia. This leads to secondary bacterial infection which makes the nasal discharge purulent.
Fever Due to the infection. Fever
Due to the infection.
Cough As an attempt to evacuate the excessive upper respiratory secretions. Cough
As an attempt to evacuate the excessive upper respiratory secretions.
Bad breath Bad breath from the nose or rhinohalitosis is associated with chronic sinus infections. Bacterial growth in the mucous produces this odor. Bad breath
Bad breath from the nose or rhinohalitosis is associated with chronic sinus infections. Bacterial growth in the mucous produces this odor.
Decreased sense of smell Excessive mucous blocks the nasal olfactory apparatus. Additionally the ciliary system is paralyzed transiently. Both these causes suppress the olfactory function of the nose. Decreased sense of smell
Excessive mucous blocks the nasal olfactory apparatus. Additionally the ciliary system is paralyzed transiently. Both these causes suppress the olfactory function of the nose.
Headache Dull throbbing pain in the forehead due to the increased pressure inside the sinus cavities. Headache
Dull throbbing pain in the forehead due to the increased pressure inside the sinus cavities.
Facial pain When the sinuses become congested, this leads to a feeling of pressure in the forehead and in the cheekbones. There also may be a 'swishing' sensation in the head when the head is bent forwards. If the frontal sinuses are affected the patient complains of a pain in the mid of the forehead. The pain is in around the nasal bridge if the infection affects the sphenoid sinus. Pain in the maxillary prominence and upper teeth is complained in maxillary sinusitis. An infection of the ethmoid sinuses can also affect the frontal and maxillary sinuses, which are located in the forehead and cheekbone. This is because they are interconnected. Facial pain
When the sinuses become congested, this leads to a feeling of pressure in the forehead and in the cheekbones. There also may be a 'swishing' sensation in the head when the head is bent forwards. If the frontal sinuses are affected the patient complains of a pain in the mid of the forehead. The pain is in around the nasal bridge if the infection affects the sphenoid sinus. Pain in the maxillary prominence and upper teeth is complained in maxillary sinusitis. An infection of the ethmoid sinuses can also affect the frontal and maxillary sinuses, which are located in the forehead and cheekbone. This is because they are interconnected.
Predisposing factors There are several local and general factors which predispose to bacterial sinusitis.
Local : Pre-existing viral or allergic rhinitis, Nasal foreign body, upper respiratoty tract infections such as tonsillitis, nasal anatomical variations such as septal deviation, gastro esophageal reflux and exposure to air pollutants.
General : immunocompromized host, mucociliary disorders such as Kartagener syndrome.

Immunosuppressive states secondary to chemotherapy, hematologic disorders, transplantation, and AIDS are the risk factors for developing fungal sinusitis as an opportunistic infection.

Acute viral sinusitis is typically preceded by a viral upper respiratory infection such as the common cold.
Predisposing factors
There are several local and general factors which predispose to bacterial sinusitis.
Local : Pre-existing viral or allergic rhinitis, Nasal foreign body, upper respiratoty tract infections such as tonsillitis, nasal anatomical variations such as septal deviation, gastro esophageal reflux and exposure to air pollutants.
General : immunocompromized host, mucociliary disorders such as Kartagener syndrome.

Immunosuppressive states secondary to chemotherapy, hematologic disorders, transplantation, and AIDS are the risk factors for developing fungal sinusitis as an opportunistic infection.

Acute viral sinusitis is typically preceded by a viral upper respiratory infection such as the common cold.
Complications of sinusitis Periorbital sinusitis or orbital sinusitis, meningitis, intracranial abscess, intracranial venous thrombosis and sepsis are possible complications of acute sinusitis. Most of these complications are common to acute sphenoidal sinusitis. So, if left untreated sphenoidal sinusitis can be life threatening condition specially due to the development of intracranial venous thrombosis. Complications of sinusitis
Periorbital sinusitis or orbital sinusitis, meningitis, intracranial abscess, intracranial venous thrombosis and sepsis are possible complications of acute sinusitis. Most of these complications are common to acute sphenoidal sinusitis. So, if left untreated sphenoidal sinusitis can be life threatening condition specially due to the development of intracranial venous thrombosis.

Clinicals - Examination

Fact Explanation
Mild edema in the nasal mucosa Due to the associated mild inflammation of the nasal mucosa. Mild edema in the nasal mucosa
Due to the associated mild inflammation of the nasal mucosa.
Nasal discharge Inflammation of both sinuses and nasal mucosa cause excessive production of mucous that causes nasal discharge which will be watery initially in case of associated or proceeding viral infection and then become purulent due to bacterial sinusitis. Nasal discharge
Inflammation of both sinuses and nasal mucosa cause excessive production of mucous that causes nasal discharge which will be watery initially in case of associated or proceeding viral infection and then become purulent due to bacterial sinusitis.
Sinus tenderness Inflammation in the mucosal layer of sinuses causes tenderness.If the frontal sinuses are affected the the tenderness can be elicited in the mid of the forehead. The tenderness can be demonstrated around the nasal bridge if the infection affects the sphenoid sinus. Maxillary tenderness can be elicited in maxillary sinusitis. Sinus tenderness
Inflammation in the mucosal layer of sinuses causes tenderness.If the frontal sinuses are affected the the tenderness can be elicited in the mid of the forehead. The tenderness can be demonstrated around the nasal bridge if the infection affects the sphenoid sinus. Maxillary tenderness can be elicited in maxillary sinusitis.
Anatomical anomalies Nasal anomalies such as nasal septal deviations and abnormal turbinates. Anatomical anomalies
Nasal anomalies such as nasal septal deviations and abnormal turbinates.
Redness of nose, cheek and eye lid Due to the co existing inflammation of the surrounding facial tissues. And the erythema is well demarcated in the presence of periorbital cellulitis as a complication of acute sinusitis. Redness of nose, cheek and eye lid
Due to the co existing inflammation of the surrounding facial tissues. And the erythema is well demarcated in the presence of periorbital cellulitis as a complication of acute sinusitis.
Signs of acute local complications Acute local complications can cause several intracranial manifestations including meningitis. Diplopia and blurring of vision, cellulitis, proptosis, chemosis, ophthalmoplegia, orbital cellulitis are common acute orbital complications.
An unusual complication of acute sinusitis includes Toxic shock syndrome.
Other complications are cavernous or sagittal sinus thrombosis, encephalitis, or subdural, extradural, or intracerebral abscesses. Cases have been reported regarding sixth nerve palsy associated with sphenoidal sinusitis.
Signs of acute local complications
Acute local complications can cause several intracranial manifestations including meningitis. Diplopia and blurring of vision, cellulitis, proptosis, chemosis, ophthalmoplegia, orbital cellulitis are common acute orbital complications.
An unusual complication of acute sinusitis includes Toxic shock syndrome.
Other complications are cavernous or sagittal sinus thrombosis, encephalitis, or subdural, extradural, or intracerebral abscesses. Cases have been reported regarding sixth nerve palsy associated with sphenoidal sinusitis.

Investigations - Diagnosis

Fact Explanation
Full blood count Neutrophilic leucocytosis is found in some patients due to infection. Full blood count
Neutrophilic leucocytosis is found in some patients due to infection.
Erythrocyte sedimentation rate (ESR) Above normal due to infection and ongoing inflammation. Erythrocyte sedimentation rate (ESR)
Above normal due to infection and ongoing inflammation.
CRP Above normal due to infection and ongoing inflammation. CRP
Above normal due to infection and ongoing inflammation.
Culture of nasal secretions This is of limited value in diagnosing sinusitis as the nasal cavity resides namy organisms including pathogens and normal flora. The most common organisms isolated from patients with acute sinusitis include Streptococcus pneumoniae, Haemophilus influenzae,
Moraxella catarrhalis and Staphylococcal
species.
Culture of nasal secretions
This is of limited value in diagnosing sinusitis as the nasal cavity resides namy organisms including pathogens and normal flora. The most common organisms isolated from patients with acute sinusitis include Streptococcus pneumoniae, Haemophilus influenzae,
Moraxella catarrhalis and Staphylococcal
species.
Sinus content aspiration This test is not routinely done because it is invasive. Direct antral puncture aspiration is the only accurate way to obtain a culture of sinus content. Sinus content aspiration
This test is not routinely done because it is invasive. Direct antral puncture aspiration is the only accurate way to obtain a culture of sinus content.
Plain sinus x-ray Waters view (occipitofrontal), Caldwell view (angled posteroanterior) and lateral view are the commonly used projections.
Mucosal thickening, air fluid levels, and complete opacification of the
involved sinus are the common findings indicative of acute sinusitis.But they have limited role in the management.
Plain sinus x-ray
Waters view (occipitofrontal), Caldwell view (angled posteroanterior) and lateral view are the commonly used projections.
Mucosal thickening, air fluid levels, and complete opacification of the
involved sinus are the common findings indicative of acute sinusitis.But they have limited role in the management.
Computed Tomography CT scan is more specific and gives more detailed information regarding sinusitis. The importance of CT scans is to aid in the diagnosis and management of recurrent and chronic sinusitis. It is also used to define the anatomy of the sinuses prior to surgery. Computed Tomography
CT scan is more specific and gives more detailed information regarding sinusitis. The importance of CT scans is to aid in the diagnosis and management of recurrent and chronic sinusitis. It is also used to define the anatomy of the sinuses prior to surgery.
Sweat Chloride Test This test is used to exclude cystic fibrosis. Sweat Chloride Test
This test is used to exclude cystic fibrosis.

Management - Supportive

Fact Explanation
Adequate hydration To prevent dehydration. Adequate hydration
To prevent dehydration.
Instillation of nasal cavities with normal saline It is a simple, inexpensive treatment that relieves the symptoms of nasal congestion, reduces use of medical resources, and could help minimize
antibiotic resistance. The procedure involves flushing the nasal cavity with saline solution, which promotes
improved mucociliary clearance by moisturizing the nasal cavity and removing encrusted material. Evidence shows that pulsating saline lavage can
remove bacteria also.
Instillation of nasal cavities with normal saline
It is a simple, inexpensive treatment that relieves the symptoms of nasal congestion, reduces use of medical resources, and could help minimize
antibiotic resistance. The procedure involves flushing the nasal cavity with saline solution, which promotes
improved mucociliary clearance by moisturizing the nasal cavity and removing encrusted material. Evidence shows that pulsating saline lavage can
remove bacteria also.
Steam inhalation It is a common home therapy for upper respiratory tract infections though there is a lack of evidence to show that it helps. There's also a risk of burns and scalds. Steam inhalation
It is a common home therapy for upper respiratory tract infections though there is a lack of evidence to show that it helps. There's also a risk of burns and scalds.
Nasal decongestants Decongestant medication such as nasal sprays, nose drops, tablets, and liquids may help to relieve symptoms. They're available over-the-counter and can help unblock the nose, allowing to breathe more easily. It gives only a symptomatic relief. There is a risk of rebound congestion with the long term use of topical decongestions. so it is not recommended to use more than 72 hours. Oxymetazoline and phenylephrine are among the commonly used decongestants. Nasal decongestants
Decongestant medication such as nasal sprays, nose drops, tablets, and liquids may help to relieve symptoms. They're available over-the-counter and can help unblock the nose, allowing to breathe more easily. It gives only a symptomatic relief. There is a risk of rebound congestion with the long term use of topical decongestions. so it is not recommended to use more than 72 hours. Oxymetazoline and phenylephrine are among the commonly used decongestants.
Oral analgesics/antipyretics Acetaminophen and ibuprofen can help mild-to-moderate pain symptoms. And they help to reduce fever. Oral analgesics/antipyretics
Acetaminophen and ibuprofen can help mild-to-moderate pain symptoms. And they help to reduce fever.
Antihistamines Antihistamines inhibit the action of histamine by either blocking its attachment to histamine receptors, or inhibiting the enzymatic activity of histidine decarboxylase and thus relieves classic symptoms of an allergic reaction such as runny nose and watery eyes. Antihistamines have a definite role where a clear allergic component is demonstrated.
They also relieve the nasal congestion by reducing the mucous production.
Antihistamines
Antihistamines inhibit the action of histamine by either blocking its attachment to histamine receptors, or inhibiting the enzymatic activity of histidine decarboxylase and thus relieves classic symptoms of an allergic reaction such as runny nose and watery eyes. Antihistamines have a definite role where a clear allergic component is demonstrated.
They also relieve the nasal congestion by reducing the mucous production.
Mucolytic agents A mucolytic agent is an agent which dissolves thick mucus and is usually used to help relieve respiratory difficulties. Supersaturated potassium iodide solution and guaifenesin are commonly used. Mucolytic agents
A mucolytic agent is an agent which dissolves thick mucus and is usually used to help relieve respiratory difficulties. Supersaturated potassium iodide solution and guaifenesin are commonly used.

Management - Specific

Fact Explanation
Antibiotic therapy Standard 1st line antibiotic is amoxicilln as it retains the best coverage of oral B- lactam agents against Streptococcus pneumoniae. A 10 - 14 day regimen of 500mg amoxicillin 3 times a day is recommended as first-line therapy.
Clarithromycin can be used in an amoxicillin allergy. Azithromycin is another alternate. The second line antibiotics are Amoxicillin/clavulanic acid or co-amoxiclav and cephalosporins such as cefuroximes.
Antibiotic therapy
Standard 1st line antibiotic is amoxicilln as it retains the best coverage of oral B- lactam agents against Streptococcus pneumoniae. A 10 - 14 day regimen of 500mg amoxicillin 3 times a day is recommended as first-line therapy.
Clarithromycin can be used in an amoxicillin allergy. Azithromycin is another alternate. The second line antibiotics are Amoxicillin/clavulanic acid or co-amoxiclav and cephalosporins such as cefuroximes.
Functional endoscopic sinus surgery Surgery is a treatment of choice for chronic sinusitis. The absolute indications are extrasinus spread of sinus infection, mucocele or pyocele, fungal sinusitis or massive nasal polyps that obstruct the sinuses. Functional endoscopic sinus surgery is the surgery of choice. It is minimally invasive technique used to restore sinus ventilation and normal function.

An endocsopic approach is used to relieve any nasal blockage such as nasal polyps and scar tissue. Sometimes straightening the septum and reducing the size of the turbinates are performed if required.
Functional endoscopic sinus surgery
Surgery is a treatment of choice for chronic sinusitis. The absolute indications are extrasinus spread of sinus infection, mucocele or pyocele, fungal sinusitis or massive nasal polyps that obstruct the sinuses. Functional endoscopic sinus surgery is the surgery of choice. It is minimally invasive technique used to restore sinus ventilation and normal function.

An endocsopic approach is used to relieve any nasal blockage such as nasal polyps and scar tissue. Sometimes straightening the septum and reducing the size of the turbinates are performed if required.
Balloon sinuplasty The indications of balloon sinuplasty are as same as in Functional endoscopic sinus surgery. It is a novel technique where the surgeons use balloons to dilate the sinus openings instead of an endoscopic access. Balloon sinuplasty causes less trauma to the surrounding tissue and the natural sinus openings are preserved. Recovery may also be faster than conventional sinus surgery. This method is contraindicated in the presence of a nasal polyps or in patients with extensive scarring of their sinus openings. Balloon sinuplasty
The indications of balloon sinuplasty are as same as in Functional endoscopic sinus surgery. It is a novel technique where the surgeons use balloons to dilate the sinus openings instead of an endoscopic access. Balloon sinuplasty causes less trauma to the surrounding tissue and the natural sinus openings are preserved. Recovery may also be faster than conventional sinus surgery. This method is contraindicated in the presence of a nasal polyps or in patients with extensive scarring of their sinus openings.

Concise, fact-based medical articles to refresh your knowledge

Access a wealth of content and skim through a smartly presented catalog of diseases and conditions.

  1. AH-SEE K. Sinusitis (acute) Clin Evid (Online) [online] :0511 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3275132
  2. AHMAD Z. Balloon sinuplasty. Indian J Otolaryngol Head Neck Surg [online] 2010 Sep, 62(3):225-8 [viewed 27 May 2014] Available from: doi:10.1007/s12070-010-0084-7
  3. AL-SWIAHB JN, AL DOUSARY SH. Computer-aided endoscopic sinus surgery: a retrospective comparative study Ann Saudi Med [online] 2010, 30(2):149-152 [viewed 27 May 2014] Available from: doi:10.4103/0256-4947.60522
  4. BAARTMANS M, KERKHOF E, VLOEMANS J, DOKTER J, NIJMAN S, TIBBOEL D, NIEUWENHUIS M. Steam inhalation therapy: severe scalds as an adverse side effect Br J Gen Pract [online] 2012 Jul, 62(600):e473-e477 [viewed 27 May 2014] Available from: doi:10.3399/bjgp12X652337
  5. DESROSIERS M, EVANS GA, KEITH PK, WRIGHT ED, KAPLAN A, BOUCHARD J, CIAVARELLA A, DOYLE PW, JAVER AR, LEITH ES, MUKHERJI A, SCHELLENBERG RR, SMALL P, WITTERICK IJ. Canadian clinical practice guidelines for acute and chronic rhinosinusitis Allergy Asthma Clin Immunol [online] , 7(1):2 [viewed 27 May 2014] Available from: doi:10.1186/1710-1492-7-2
  6. FARRELL PM, ROSENSTEIN BJ, WHITE TB, ACCURSO FJ, CASTELLANI C, CUTTING GR, DURIE PR, LEGRYS VA, MASSIE J, PARAD RB, ROCK MJ, CAMPBELL PW III. Guidelines for Diagnosis of Cystic Fibrosis in Newborns through Older Adults: Cystic Fibrosis Foundation Consensus Report J Pediatr [online] 2008 Aug, 153(2):S4-S14 [viewed 27 May 2014] Available from: doi:10.1016/j.jpeds.2008.05.005
  7. FERNANDEZ IJ, STANZANI M, TOLOMELLI G, PASQUINI E, VIANELLI N, BACCARANI M, SCIARRETTA V. Sinonasal risk factors for the development of invasive fungal sinusitis in hematological patients: Are they important? Allergy Rhinol (Providence) [online] 2011, 2(1):6-11 [viewed 27 May 2014] Available from: doi:10.2500/ar.2011.2.0009
  8. JACOB SM, CHANDY TT, CHERIAN VT. Oral bisoprolol improves surgical field during functional endoscopic sinus surgery. J Anaesthesiol Clin Pharmacol [online] 2014 Jan, 30(1):59-64 [viewed 27 May 2014] Available from: doi:10.4103/0970-9185.125705
  9. KOMATSU H, MATSUMOTO F, KASAI M, KURANO K, SASAKI D, IKEDA K. Cavernous sinus thrombosis caused by contralateral sphenoid sinusitis: a case report. Head Face Med [online] 2013 Mar 13:9 [viewed 27 May 2014] Available from: doi:10.1186/1746-160X-9-9
  10. LEE KYUNG CHUL, LEE SUNG JIN. Clinical Features and Treatments of Odontogenic Sinusitis. Yonsei Med J [online] 2010 December [viewed 27 May 2014] Available from: doi:10.3349/ymj.2010.51.6.932
  11. MELTZER EO, HAMILOS DL. Rhinosinusitis Diagnosis and Management for the Clinician: A Synopsis of Recent Consensus Guidelines Mayo Clin Proc [online] 2011 May, 86(5):427-443 [viewed 27 May 2014] Available from: doi:10.4065/mcp.2010.0392
  12. NEMZEK W, POSTMA G, POIRIER V, HECHT S. MR features of pachymeningitis presenting with sixth-nerve palsy secondary to sphenoid sinusitis. AJNR Am J Neuroradiol [online] 1995 Apr, 16(4 Suppl):960-3 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/7611085
  13. NICOLI TK, MäKITIE A. Images in clinical medicine. Frontal sinusitis causing epidural abscess and puffy tumor. N Engl J Med [online] 2014 Mar 13, 370(11):e18 [viewed 27 May 2014] Available from: doi:10.1056/NEJMicm1307740
  14. OKUYEMI KS, TSUE TT. Radiologic Imaging in the Management of Sinusitis, Am Fam Physician[online]. 2002 Nov 15,66(10),1882-1887. [viewed 27 May 2014] Available from: http://www.aafp.org/afp/2002/1115/p1882.html
  15. OSGUTHORPE, J.D. Adult Rhinosinusitis: Diagnosis and Management, Am Fam Physician[online], 2001,63,69-76. [viewed 27 May 2014] Available from: http://www.aafp.org/afp/2001/0101/p69.html
  16. PAPSIN B, MCTAVISH A. Saline nasal irrigation: Its role as an adjunct treatment. Can Fam Physician [online] 2003 Feb:168-73 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12619739
  17. RAGHUNANDHAN S, PRASHANTH S, NATARAJAN K, ANAND KUMAR RS, KAMESWARAN M. Balloon sinuplasty - the first Indian experience. Indian J Otolaryngol Head Neck Surg [online] 2009 Jun, 61(2):99-104 [viewed 27 May 2014] Available from: doi:10.1007/s12070-009-0045-1
  18. SHIN HS. Clinical significance of unilateral sinusitis. J Korean Med Sci [online] 1986 Sep, 1(1):69-74 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3053611
  19. TAN HK, ONG YK. Acute isolated sphenoid sinusitis. Ann Acad Med Singapore [online] 2004 Sep, 33(5):656-9 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/15531965
  20. WALD E. R.. Acute Otitis Media and Acute Bacterial Sinusitis. Clinical Infectious Diseases [online] December, 52(Supplement 4):S277-S283 [viewed 27 May 2014] Available from: doi:10.1093/cid/cir042
  21. WANG M, YUAN F, QI WW, CHENG JY, YUAN XP, HAN L, XING ZM. Anatomy, classification of intersinus septal cell and its clinical significance in frontal sinus endoscopic surgery in Chinese subjects. Chin Med J (Engl) [online] 2012 Dec, 125(24):4470-3 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23253722
  22. WORRALL G. Acute sinusitis Can Fam Physician [online] 2008 Jan, 54(1): 82 - 83 [viewed 27 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2293324
  23. ŞENBIL N, GüRER YK, ÜNER Ç, BARUT Y. Sinusitis in children and adolescents with chronic or recurrent headache: a case-control study J Headache Pain [online] 2008 Feb, 9(1):33-36 [viewed 27 May 2014] Available from: doi:10.1007/s10194-008-0007-0