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. [1,2,3] 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. [1,2,4]
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. [1,2,5]
Fever Due to the infection. [1,2]
Cough As an attempt to evacuate the excessive upper respiratory secretions. [1,2,4]
Bad breath Bad breath from the nose or rhinohalitosis is associated with chronic sinus infections. Bacterial growth in the mucous produces this odor. [1,2,3]
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. [1,2,5]
Headache Dull throbbing pain in the forehead due to the increased pressure inside the sinus cavities. [1,2,6]
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. [2,6,7]
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. [1,2,3,5,7] Immunosuppressive states secondary to chemotherapy, hematologic disorders, transplantation, and AIDS are the risk factors for developing fungal sinusitis as an opportunistic infection. [8] Acute viral sinusitis is typically preceded by a viral upper respiratory infection such as the common cold. [1]
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. [1,9]
References
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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

Examination

Fact Explanation
Mild edema in the nasal mucosa Due to the associated mild inflammation of the nasal mucosa. [1]
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. [1,2,3]
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. [1,2,4]
Anatomical anomalies Nasal anomalies such as nasal septal deviations and abnormal turbinates. [1,2]
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. [1,5]
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. [6,7,8]
References
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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

Differential Diagnoses

Fact Explanation
Allergic rhinitis Allergic rhinitis is an allergic inflammation of the nasal airways characterized by rhinorrhea, nasal congestion and obstruction. [1]
Asthma Asthma is a recurrent chronic inflammatory disease of the airways characterized by shortness of breath, wheezing and cough. The symptoms usually occurs at night and the cough is usually non productive despite of mucus obstruction of the airway. [2]
Migraine Migraine is a chronic neurological disorder characterized by recurrent moderate to severe headache. This is usually associated with several other symptoms such as nausea, vomiting and sensitivity to light, sound, or smell. There are several other symptoms which are common to both migraine and sinusitis namely facial pain, sinus pressure, nasal congestion, rhinorrhoea and teary eyes. [3]
Tension headache is the most common type of primary headache. The headache is often described as a constant pressure, as if the head were being squeezed in a vice. The pain is frequently bilateral and can be mild to moderate, but may be severe at times. [4]
Cystic Fibrosis Cystic fibrosis is an autosomal recessive genetic disorder that affects most critically the lungs, and also the pancreas, liver, and intestine. An abnormality in transportation of chloride and sodium across an epithelium leads to thick, viscous secretions. Patients present with cough, which is chronic or recurrent and can be dry, mucoid and purulent. Prolonged symptoms of bronchiolitis occur in infants. [5]
References
  1. WANG DE Y. Management of allergic rhinitis in general practitioners. Asia Pac Allergy [online] 2012 Oct, 2(4):233-6 [viewed 26 May 2014] Available from: doi:10.5415/apallergy.2012.2.4.233
  2. BRITISH THORACIC SOCIETY, SCOTTISH INTERCOLLEGIATE GUIDELINES NETWORK. British guideline on the management of asthma. Thorax [online] 2003 Feb:i1-94 [viewed 13 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/12653493
  3. AL-HASHEL JY, AHMED SF, ALROUGHANI R, GOADSBY PJ. Migraine misdiagnosis as a sinusitis, a delay that can last for many years. J Headache Pain [online] 2013 Dec 12:97 [viewed 26 May 2014] Available from: doi:10.1186/1129-2377-14-97
  4. FERNáNDEZ-DE-LAS-PEñAS C. What do we know about chronic tension-type headache? Discov Med [online] 2009 Dec, 8(43):232-6 [viewed 26 May 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/20040276
  5. PIER GB. The challenges and promises of new therapies for cystic fibrosis. J Exp Med [online] 2012 Jul 2, 209(7):1235-9 [viewed 20 May 2014] Available from: doi:10.1084/jem.20121248

Investigations - for Diagnosis

Fact Explanation
Full blood count Neutrophilic leucocytosis is found in some patients due to infection. [1,2,3]
Erythrocyte sedimentation rate (ESR) Above normal due to infection and ongoing inflammation. [1,4]
CRP Above normal due to infection and ongoing inflammation.[1,4]
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. [2,3,5]
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. [3,4]
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. [6]
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. [7]
Sweat Chloride Test This test is used to exclude cystic fibrosis. [8]
References
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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

Management - General Measures

Fact Explanation
Adequate hydration To prevent dehydration. [1]
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. [1,2]
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. [1,3]
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. [1]
Oral analgesics/antipyretics Acetaminophen and ibuprofen can help mild-to-moderate pain symptoms. And they help to reduce fever. [1]
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. [1,4]
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. [5]
References
  1. 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
  2. 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
  3. 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
  4. 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
  5. 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

Management - Specific Treatments

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. [1,2,3]
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. [1,5,6]
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. [7,8]
References
  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. 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
  3. 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
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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