A 55-year-old woman reports sinus pressure for the past 2 weeks along with headache, rhinorrhea, postnasal drip, and cough that followed a cold 3 weeks ago. She has chronic allergic rhinitis, but now the pressure on the right side of her face has become intense and her right upper molars are painful. The nasal discharge has become discolored and she feels feverish. She is diagnosed clinically with right maxillary sinusitis and elects antibiotic treatment with amoxicillin. Two weeks later when her symptoms have persisted, a CT is ordered and she is found to have air-fluid levels in both maxillary sinuses and loculated fluid on the right side (Figures 33-1 and 33-2). The antibiotic is changed to amoxicillin/clavulanate and she is given information about nasal saline irrigation for symptom relief. If the symptoms don't improve, the clinician plans to send her to ear, nose, and throat (ENT) for further evaluation.
Bilateral maxillary sinusitis on axial CT. Note that fluid levels are greater on the right. (Reproduced with permission from Chris McMains, MD.)
Maxillary sinusitis on coronal CT of same patient. (Reproduced with permission from Chris McMains, MD.)
Rhinosinusitis is symptomatic inflammation of the paranasal sinuses, nasal cavity, and their epithelial lining.1 Mucosal edema blocks mucous drainage, creating a culture medium for viruses and bacteria. Rhinosinusitis is classified by duration as acute (<4 weeks), subacute (4 to 12 weeks), or chronic (>12 weeks).
Rhinosinusitis is common in the United States, with an age-adjusted prevalence of 11.7% of the adult population in 2015.2 The prevalence is increased in women and in individuals living in the southern United States.
Only 10% of adults with symptoms of sinusitis actually have bacterial infection; in contrast 60% of children with sinusitis have a bacterial cause.3 Of adult patients with acute viral sinusitis accompanying an upper respiratory tract infection (URI), only 0.5% to 2.5% develop superimposed acute bacterial sinusitis.4
The prevalence of chronic rhinosinusitis in patients referred for evaluation of potential chronic rhinosinusitis, based on symptoms, ranges from 65% to 80%.1
Children average 6 to 8 colds per year. In one study of 112 children with URIs, 8% developed sinusitis.5
ETIOLOGY AND PATHOPHYSIOLOGY
Sinus cavities are lined with mucus-secreting respiratory epithelium. The mucus is transported by ciliary action through the sinus ostia (openings) to the nasal cavity. Under normal conditions, the paranasal sinuses are sterile cavities and there is no mucus retention.
Bacterial sinusitis occurs when ostia become obstructed or ciliary action is impaired, causing mucus accumulation and secondary bacterial overgrowth.
The causes of sinusitis include6:
Infection—Most commonly viral (e.g., rhinovirus, parainfluenza, and influenza) followed by bacterial infection (e.g., Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, and Staphylococcus aureus).4 In immunocompromised patients, fulminant fungal sinusitis may occur (e.g., rhinocerebral mucormycosis—Figure 33-3). Biofilms may play a role in recalcitrant disease.7
Noninfectious obstruction—Allergic, polyposis, barotrauma (e.g., deep-sea diving, airplane travel), chemical irritants, tumors (e.g., squamous cell carcinoma, granulomatous disease, inverting papilloma), and conditions that alter mucus composition (e.g., cystic fibrosis).
Mucormycosis sinusitis in a patient with diabetes showing the classic black nasal discharge. (Reproduced with permission from Randal A. Otto, MD.)
The diagnosis is based on the clinical picture with typical symptoms listed below. Symptoms arising from viral infection generally peak by day 5 or before.
Acute bacterial rhinosinusitis is diagnosed when symptoms are present for 10 days or longer or when symptoms worsen after initial stability or improvement ("double worsening" or "double sickening"); it can also be presumed in patients with unusually severe presentations or extrasinus manifestations of infection.1
Similar diagnostic criteria are used for children—persistent illness with any quality of nasal discharge or daytime cough or both lasting more than 10 days without improvement OR worsening course OR severe onset (i.e., concurrent fever [≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days).8
Chronic rhinosinusitis is diagnosed after 12 or more weeks based on two or more of: mucopurulent drainage (anterior, posterior, or both), nasal obstruction (congestion), facial pain-pressure-fullness, or decreased sense of smell AND inflammation documented by purulent mucus or edema in the middle meatus or anterior ethmoid region, polyps in nasal cavity or the middle meatus, and/or radiographic imaging showing inflammation of the paranasal sinuses.1
Most cases are seen in conjunction with viral upper respiratory infections and represent sinus inflammation rather than infection.4
The American Academy of Otolaryngology guideline recommends a diagnosis of acute rhinosinusitis with up to 4 weeks of purulent nasal drainage accompanied by nasal obstruction; facial pain, pressure, or fullness; or both.1 Other guidelines do not require presence of purulent nasal drainage for diagnosis.4 The Infectious Disease Society of America recommends a diagnosis of acute sinusitis with up to 4 weeks of at least 2 major symptoms (the above or hyposmia or anosmia) or one major symptom and at least two minor symptoms (i.e., headache; ear pain, pressure, or fullness; halitosis; dental pain; cough; and fatigue).9
Localizing symptoms include facial pain or pressure over the involved sinus when bending over or supine (i.e., forehead in frontal sinusitis, cheek with maxillary sinusitis, between the eyes with ethmoid sinusitis, and neck and top of the head with sphenoid sinusitis) and maxillary tooth pain, most commonly the upper molars; the latter is seen more often with bacterial sinusitis.
In a study of patients with chronic rhinosinusitis, diagnosis based on symptoms was problematic, and only dysosmia (impairment in the sense of smell) and the presence of polyps could distinguish between normal and abnormal radiographs.10
Most sinus infections involve the maxillary sinus followed in frequency by the ethmoid (anterior), frontal, and sphenoid sinuses; however, most cases involve more than one sinus.5
Children are more likely to have inflammation in the posterior ethmoid and sphenoid sinuses.11
Routine culture of nasal or nasopharyngeal secretions is not recommended, as these have not been shown to differentiate between bacterial and viral rhinosinusitis. Culture may be considered for patients with immune compromise who have persistent symptoms despite initial antibiotic treatment.4
If culture is needed because of suspected bacterial resistance or persistence of infection, one meta-analysis found endoscopically directed middle meatal cultures to be reasonably sensitive (80.9%), specific (90.5%), and accurate (87.0%; 95% confidence interval, 81.3% to 92.8%) compared with maxillary sinus taps.12
Radiography should not be obtained for patients meeting diagnostic criteria for acute rhinosinusitis, unless a complication or alternate diagnosis is suspected.1 If performed in cases of clinical uncertainty or for complications (e.g., orbital, intracranial, or soft-tissue involvement), the American College of Radiology (ACR) recommends computed tomography (CT) without contrast or magnetic resonance imaging (MRI) without and with contrast.13 (Figures 33-4 and 33-5) There are considerable limitations to the sensitivity of plain films, especially in diagnosing ethmoid and sphenoid disease.
For children, ACR recommends CT of the paranasal sinuses without contrast or magnetic resonance imaging if there are orbital or intracranial complications.14
Nasal endoscopy, identifying purulent material within the drainage area of the sinuses, may be useful in diagnosing acute sinusitis.12 In one case series of patients with suspected chronic rhinosinusitis, the addition of endoscopy to symptom criteria had similar sensitivity (88.7% vs. 84.1%) but significantly improved specificity (66% vs. 12.3%) using CT as the gold standard.15
For chronic rhinosinusitis, inflammation is documented objectively using anterior rhinoscopy, nasal endoscopy, or CT.
Mucopyocele in the sphenoid sinus (arrow) as a complication of bacterial sinusitis. (Reproduced with permission from Randal A. Otto, MD.)
Frontal sinusitis eroded through the frontal bone inward toward the brain threatening such complications as a brain abscess and cavernous sinus thrombosis. Seen on CT scan. (Reproduced with permission from Randal A. Otto, MD.)
Potentially life-threatening complications include subperiosteal orbital abscess, meningitis, epidural or cerebral abscess, and cavernous sinus thrombosis (Figures 33-6 and 33-7).
The risk of frontal sinusitis includes eroding through the frontal bone forward and causing a Pott's puffy tumor, spreading into the brain and cavernous sinuses (Figure 33-5).
Orbital abscess is highly dangerous and can be the result of spread from the frontal or ethmoid sinuses (Figure 33-6).
In immunocompromised patients, fulminant fungal sinusitis may cause orbital swelling, cellulitis, proptosis, ptosis, impairment of extraocular motion, nasopharyngeal ulceration, epistaxis, and bony erosion. Nasal mucosa may appear black (Figure 33-3), blanched white, or erythematous.
Hospitalized patients may be critically ill with "fever of unknown origin" and without localizing symptoms. Infections in these patients are often polymicrobial including Pseudomonas aeruginosa, Klebsiella pneumoniae, and Enterobacter.16
Right orbital abscess with proptosis as a complication of frontal sinusitis eroding through the superior orbital bones. (Reproduced with permission from Randal A. Otto, MD.)
Mucopyocele (red arrow) in the right frontal sinus seen on MRI scan as a complication of frontal sinusitis. (Reproduced with permission from Randal A. Otto, MD.)
Upper respiratory tract infections—These are common infections, primarily viral (most commonly rhinovirus), that cause 2 to 4 infections per year in adults and 6 to 8 infections per year in children. Infections are self-limited (lasting approximately 7 to 10 days) and typical symptoms include rhinorrhea, nasal congestion, sore throat, and cough. URI often precedes acute sinusitis.
Allergic rhinitis—Sneezing, itching, watery rhinorrhea.
Tumor (usually squamous cell carcinoma)—Rare; unilateral epistaxis or discharge and obstruction, recurrent sinusitis, sinus pain.
Other causes of facial pain include:
Migraine headache or cluster headache—Moderate to severe head pain that is usually deep seated, persistent, and pulsatile. There is a history of multiple occurrences, and head pain may be associated with nausea, vomiting, photophobia, and scotomata. Attacks last 4 to 72 hours.
Trigeminal neuralgia—Painful condition characterized by excruciating, paroxysmal, shocklike pain lasting seconds to minutes along the distribution of the trigeminal nerve (ophthalmic, maxillary, and/or mandibular branches). Pain may be triggered by face washing, air draft, or chewing.
Dental pain—Tooth pain may be secondary to caries or gingivitis. When caries extend into the tooth pulp, the tooth becomes sensitive to percussion and hot and cold food and beverages. If pulp necrosis occurs, pain becomes severe, sharp, throbbing, and often worse when supine. Abscess formation results in pain, swelling, and erythema of the gum and surrounding tissue, and possibly purulent drainage.
Temporal arteritis—Unilateral pounding headache that may be associated with visual changes and systemic symptoms (e.g., fever, weight loss, muscle aches). Onset is usually older adults (older than age 50 years), and laboratory testing reveals an elevated erythrocyte sedimentation rate (>50).
Duration of illness assists in decision making, as most patients improve without specific treatment. A period of watchful waiting for up to 7 days is consistent with guidelines1; up to 3 days is recommended for children.8 Treatment of symptoms, including pain, is important.
Nasal saline irrigation for acute upper respiratory tract infection in adults is generally not helpful, although data are limited17; one large trial in children found benefit in reducing nasal secretions and nasal breathing. SORⒷ In adults with chronic sinusitis, nasal saline irrigation alone may provide symptom relief.18 SORⒷ High-volume saline irrigation in addition to topical steroids is considered first-line therapy for symptoms in chronic rhinosinusitis.19
Analgesics (acetaminophen or nonsteroidal antiinflammatory drugs alone or in combination with an opioid) should be used for pain.1
Oral and topical (nasal) decongestants are NOT recommended for adults or children based on lack of randomized controlled trials (RCTs) demonstrating effectiveness.1,20 Topical agents can cause rebound nasal congestion after discontinuation. Antihistamines may be helpful in patients with sinusitis and allergic rhinitis.4
Topical corticosteroids appear to be of benefit in improvement and resolution of symptoms for acute sinusitis.21 SORⒷ Oral steroids do not appear to be of benefit for acute disease.22 For patients with chronic rhinosinusitis and nasal polyps, consider a short course of systemic corticosteroids (1–3 weeks), a short course of doxycycline (3 weeks), or a leukotriene antagonist.19
Patients with uncomplicated acute bacterial rhinosinusitis may be offered watchful waiting with symptomatic treatment (if there is assurance of follow-up) or antibiotics.1 Patients who fail to improve after 7 days or who have severe symptoms may be offered oral antibiotics. SORⒶ
Adults—Amoxicillin (500 to 1000 mg orally three times daily or 875 mg orally twice daily) for 5–10 days or amoxicillin/clavulanate (500 mg of amoxicillin and 125 mg of clavulanate orally three times daily or 875 mg of amoxicillin and 125 mg of clavulanate orally twice daily) for 5–10 days; the higher doses are recommended for patients at high risk of having an amoxicillin-resistant organism, from regions with high endemic rates (>10%) of invasive S. pneumoniae, those with severe infection, age >65 years, recent hospitalization, antibiotic use within the past month, or those who are immunocompromised.1 For patients allergic to penicillin, use doxycycline.4
Children—Amoxicillin (45 to 90 mg/kg divided twice daily).8 For children with moderate to severe illness or those younger than 2 years, attending childcare, or who have recently been treated with an antimicrobial, consider high-dose amoxicillin-clavulanate (80–90 mg/kg per day of the amoxicillin component with 6.4 mg/kg per day of clavulanate in 2 divided doses with a maximum of 2 g per dose).8
In a Cochrane review of 10 high-quality trials evaluating antibiotic treatment for acute rhinosinusitis, antibiotics shortened time to cure in only five per 100 at any time point between 7 and 14 days and caused adverse effects in 27% (vs. 15% with placebo).23 Comparisons between classes of antibiotics showed no significant differences.1
The modest benefit of antibiotics for improving rates of clinical cure or improvement at 7 to 12 days (number needed to treat = 7–18) must be weighed against the risks of harm (primarily gastrointestinal, but also skin rash, vaginal discharge, headache, dizziness, and fatigue [number needed to harm = 8–12]).4
COMPLEMENTARY AND ALTERNATIVE MEDICINE
Surgery and intravenous antibiotics are primarily used for complications, including abscess and cases with orbital involvement.6
Patients with fungal sinusitis are treated with aggressive debridement and adjunctive antifungals (e.g., amphotericin).6
Based on three RCTs, endoscopic sinus surgery is not superior to medical treatment; in one study there was a lower relapse rate (2.4% vs. 5.6% without surgery).25 SORⒷ Patients should be selected based on the severity of disease (frequency of antibiotics/oral steroid use), comorbidities (asthma, cystic fibrosis, aspirin sensitivity, etc.), and overall clinical picture (presence of polyps or fungal disease).
Cochrane authors found lack of supporting evidence for use of endoscopic balloon sinus ostial dilation vs. conventional surgical modalities in the management of patients with chronic rhinosinusitis who failed medical treatment.26
Cure or improvement rate for acute sinusitis within 2 weeks is high in both the placebo group (73%–85%) and the antibiotic group (77%–88%).4
For patients with chronic sinusitis, a retrospective study of medical treatment reported treatment success in about half of patients (N = 74); 26 patients had partial resolution, and 45 patients underwent surgery. Facial pressure/pain, mucosal inflammation, and higher endoscopic severity grade predicted treatment failure.27
Nasal congestion, purulent rhinitis, and facial pain following a cold may indicate a sinus infection. Symptoms due to a cold usually abate within 1 week.
Patients can consider nasal saline irrigation and topical nasal steroids.
Patients should be encouraged to see their primary care provider if symptoms persist or worsen after 10 days, suggesting bacterial infection that may benefit from antibiotic treatment.
Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262-280.
Rosenfeld RM, Piccirillo JF, Chandrasehar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl):S1-S39.
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et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics.
et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis.
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et al. Prevalence of sinusitis signs on MRI in a non-ENT pediatric population. Rhinology.
et al. Endoscopically directed middle meatal cultures versus maxillary sinus taps in acute bacterial maxillary rhinosinusitis: a meta-analysis. Otolaryngol Head Neck Surg.
LN. Evaluating the diagnosis of chronic rhinosinusitis based on clinical guidelines and endoscopy. Otolaryngol Head Neck Surg.
et al. Hospital-acquired sinusitis is a common cause of fever of unknown origin in orotracheally intubated critically ill patients. Crit Care.
GKP. Saline nasal irrigation for acute upper respiratory tract infections. Cochrane Database Syst Rev. 2015;(3):CD006821.
et al. Saline irrigation for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016;(2):CD0011995.
ER. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database Syst Rev. 2014;(4):CD007909.
J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev. 2013;(4):CD005149.
et al. Systemic corticosteroid monotherapy for clinically diagnosed acute rhinosinusitis: a randomized controlled trial. CMAJ.
MB, van Driel
et al. Antibiotics for clinically diagnosed acute rhinosinusitis in adults. Cochrane Database Syst Rev. 2012;(4):CD006089.
E. Herbal medicines for the treatment of rhinosinusitis: a systematic review. Otolaryngol Head Neck Surg.
DA. Functional endoscopic sinus surgery for chronic rhinosinusitis. Cochrane Database Syst Rev. 2006;3:CD004458.
S. Functional endoscopic balloon dilation of sinus ostia for chronic rhinosinusitis. Cochrane Database Syst Rev. 2011;(2):CD008515.
JA. Efficacy of targeted medical therapy in chronic rhinosinusitis, and predictors of failure. Am J Rhinol Allergy.