Sinusitis

Esther K. Chung, MD, MPHKaren P. Zimmer, MD, MPH

Sinusitis - BASICS

Sinusitis - description

• Sinusitis is inflammation of the mucous membranes lining the paranasal sinuses, but most commonly is used to describe bacterial rhinosinusitis, which is a clinical diagnosis made by the presence of upper respiratory tract symptoms that have not improved in 10 days or have worsened after 5–7 days. Diagnosis of sinusitis should be considered based on persistence and/or severity of symptoms.
• Classification based on duration of symptoms:
  • Acute: Persistent nasal and sinus symptoms for 10–30 days
  • Subacute: Clinical symptoms for 4–12 weeks
  • Chronic: Symptoms lasting at least 12 weeks
  • Recurrent: Acute sinusitis with complete resolution of 10 days between episodes; 3 episodes in 6 months or 4 episodes in 1 year
• Classification by severity of illness:
  • Persistent symptoms: With >10–14 days but <30 days; nasal discharge and/or daytime cough
  • Severe: Temperature of >39°C (102.2°F) with concurrent purulent nasal discharge for 3 days and/or, facial pain, headache, and/or periorbital edema

Sinusitis - general prevention

• Avoid allergen exposure and treat allergies if present.
• Practice daily nasal hygiene through the use of normal saline drops/spray.
• Improve mucociliary clearance by increasing ambient humidity with a humidifier.

Sinusitis - pathophysiology

• Normal sinus function depends on patency of paranasal sinus ostia, function of the ciliary apparatus, and secretion quality.
• A buildup of secretions is due to ostial obstruction, reduction in ciliary function, and overproduction of secretions.

Sinusitis - etiology

• Viral pathogens (e.g., rhinovirus, parainfluenza virus) have been recovered in respiratory isolates, but their significance is unknown.
• Most illnesses of short duration (<7 days) are thought to be from viral infections and should not be treated with antibiotics.
• Bacterial pathogens: Increasing prevalence of penicillin resistance:
  • Streptococcus pneumoniae (30–40%)
  • Haemophilus influenzae, nontypeable (~20–28%)
  • Moraxella catarrhalis (~20–28% in children)
  • Group A Streptococci
  • Group C Streptococci
  • Peptostreptococci
  • Other Moraxella species
  • Streptococcus viridans
  • Eikenella corrodens
  • Staphylococcus aureus
  • Pseudomonas aeruginosa (in patients with cystic fibrosis)
  • Anaerobic organisms
  • Fungal pathogen: Aspergillus

Sinusitis - DIAGNOSIS

Sinusitis - signs & symptoms

Sinusitis - history

• Some or all of the following may be present:
  • Nasal discharge: Consistency, color. In older patients, nasal discharge may not be the primary complaint, but concurrent rhinitis is a common feature.
  • Postnasal drainage, nasal congestion
  • Fever
  • Recent history of a upper respiratory infection
  • Sore throat from mouth breathing due to nasal obstruction
  • Cough present during the day; may be worse at night
  • Malodorous breath
  • Hyposmia/anosmia
  • Maxillary dental pain
  • Ear pressure or fullness
  • Headache and facial pain are uncommon in young children with sinusitis, but may be seen in older children and adolescents
  • Fatigue
  • Irritability
  • Snoring
  • Hyponasal speech

Sinusitis - physical exam

• Fever may be present.
• Nasal-sounding voice may be present.
• Malodorous breath may be noted.
• Purulent drainage in the nose and/or oropharynx may be appreciated.
• Nasal mucosa may be erythematous, pale, and/or boggy.
• Frontal, maxillary, and ethmoid areas may be tender to palpation/percussion.
• Headache and/or facial pain may change with position, increasing in intensity as the patient leans forward.
• Transillumination is not a reliable aid in diagnosis.
• Proptosis, eye swelling, and impaired extraocular movements suggest orbital infection.

Sinusitis - tests

Sinusitis - lab

• Keep in mind that the overall clinical impression is thought to be more accurate than any single test.
• For chronic or recurrent sinusitis, consider:
  • Sweat chloride test to rule out cystic fibrosis
  • Immunoglobulin levels, IgG subclass levels, complement levels, and testing for HIV
  • Mucosal biopsy to assess ciliary function

Sinusitis - imaging

• Imaging is not recommended in uncomplicated cases of sinusitis in children ≤6 years of age; and it is controversial in children >6 years of age.
• Sinus radiographs:
  • Caldwell view (anteroposterior) for identifying frontal sinusitis
  • Waters view (occipitomental) for identifying maxillary sinusitis
  • Plain radiographs do not adequately identify ethmoid sinusitis.
  • Findings suggestive of sinusitis include complete sinus opacification, mucosal thickening ≥4 mm, and air–fluid levels.
• CT scans of the paranasal sinuses: Useful in complicated, recurrent and chronic sinusitis; poor response to medical therapy; and/or history of polyposis
• CT scan of the head with contrast: Indicated when sinusitis is accompanied by signs of increased intracranial pressure, meningeal irritation, proptosis, toxic appearance, limited extraocular movements, or focal neurologic deficits, or in patients being considered for sinus-related surgery
• MRI of the sinuses: Reserve for complicated cases; will show mucosal thickening and fluid; imaging modality of choice for fungal sinusitis
• Pitfalls:
  • Sinus radiographs may be abnormal in asymptomatic children or those with mild upper respiratory infections.
  • Studies have shown a relatively high incidence of sinus abnormalities on CT scan in asymptomatic children, especially in infants <12 months of age. The significance of opacified sinuses in asymptomatic children is not well understood.
  • Up to 1/3 of patients with symptoms of chronic sinusitis may have normal CT scans.

Sinusitis - differencial diagnosis

• Infection: Viral upper respiratory infection with or without mucopurulent rhinitis
• Environmental: Allergic rhinitis
• Drug-induced: Rhinitis medicamentosa
• Tumors:
  • Nasal polyps
  • Hypertrophied adenoids
  • Neoplasms
• Trauma: Foreign body (e.g., bead, cotton, tissue)
• Congenital:
  • Septal deviation
  • Unilateral choanal atresia
  • Immotile cilia
• Other: Vasomotor rhinitis

Sinusitis - TREATMENT

Sinusitis - general measures

• If orbital or CNS infection is suspected by history and examination, antibiotics should be started immediately, and emergency CT studies should be performed.
• Pitfalls:
  • Diagnosis of sinusitis is being made with increasing frequency and may result in overtreatment, given that up to 45% will have spontaneous resolution.
  • With widespread antibiotic use, there are increasing numbers of resistant organisms.

Sinusitis - medication

• Antibiotics:
  • Appropriate drug choice is dependent on local resistance patterns.
  • High-risk children include: Age <2 years, antibiotic use within 3 months, and day care attendance
  • First-line treatment (no major risk factors): Amoxicillin 45 mg/kg/d divided b.i.d. 10–21 days or 7 days symptomfree
  • 1st-line treatment (high-risk children): Amoxicillin/Clavulanic acid (80–90 mg/kg/d of amoxicillin component with 6.4 mg/kg/d of clauvulanate divided b.i.d. x 10–21 days or 7 days symptom-free
  • Second-line treatment: Second–generation or higher cephalosporins (i.e., cefuroxime axetil 30 mg/kg/d divided in 2 doses), macrolides (i.e., clarithromycin 15 mg/kg/d divided b.i.d., azithromycin 10 mg/kg/d on day 1 then 5 mg/kg/d for 4 days)
  • Course of therapy is controversial, but treatment to 7 days beyond symptom resolution is generally accepted.
  • Complicated sinusitis (CNS or orbital involvement): IV antibiotics and hospitalization; ceftriaxone (100 mg/kg/d in 2 doses) or ampicillin–sulbactam (200 mg/kg/d in 4 divided doses); vancomycin (60 mg/kg/d divided into 4 doses) is added to cefotaxime if source of infection is known or highly likely to be caused by penicillin-resistant S. pneumoniae
  • Chronic sinusitis: Use a broad-spectrum antibiotic for 4 weeks; amoxicillin/clavulanate (80–90 mg/kg/d of amoxicillin component with 6.4 mg/kg/d of clavulanate divided in 2 doses); macrolides (clarithromycin, azithromycin); or cefuroxime axetil (250–500 mg in 2 divided doses)
• Other pharmaceuticals:
  • Decongestants: These decrease nasal airway resistance and increase ostia patency in some studies, but the overall effect on acute sinusitis is unknown.
    • Topical decongestants should be used only for short-term therapy (5–7 days), because rebound mucosal congestion may occur.
    • Systemic decongestants (e.g., pseudoephedrine) have side effects that include tachycardia, hypertension, jitteriness, and insomnia.
  • Mucolytics, such as guaifenesin, may improve mucous clearance.
  • Topical nasal steroids: May reduce and prevent mucosal swelling, which can lead to ostial occlusion; particularly useful for patients with allergic rhinitis.
• Other:
  • Humidifier: Improves mucociliary clearance
  • Normal saline: Squirt into each nostril daily or b.i.d.; removes sensitizing agents, increases humidity, and enhances mucociliary transport; vasoconstricts, and improves drainage and ventilation.

Sinusitis - surgery

• Maxillary sinus aspiration: If unresponsive to multiple antibiotics, severe facial pain, and orbital or intracranial complications; should be performed by a trained ear, nose, and throat (ENT) specialist.
• Surgery: Performed as a last resort after medical therapy attempted and in patients with orbital or CNS complications

Sinusitis - FOLLOW UP

Sinusitis - prognosis

• Spontaneous resolution in up to 50% of patients
• Usually improves within 72 hours of initiation of antibiotics
• Excellent for those who are otherwise healthy

Sinusitis - complications

• Periorbital cellulitis
• Orbital cellulitis
• Orbital abscess
• Meningitis
• Intracranial abscess
• Optic neuritis
• Cavernous or sagittal sinus thrombosis
• Epidural, subdural, and brain abscesses
• Osteomyelitis of the maxilla
• Osteomyelitis of the frontal bone (Pott puffy tumor)

Sinusitis - patient monitoring

• Immediate referral is indicated if there are CNS symptoms, periorbital edema, visual changes, facial swelling, extraocular muscle involvement, or proptosis
• Radiographic soft tissue changes may last for up to 8 weeks; therefore, reimaging is of limited value.
• Referral to an otolaryngologist when the sinusitis is chronic and not responsive to medical therapy; recurrent; complicated; or when there is polyposis

Sinusitis - bibliography

1. American Academy of Pediatrics Subcommittee on Management of Sinusitis and Committee on Quality Improvement. 2001; Clinical practice guideline: Management of sinusitis. Pediatrics. 2001;108:798–808.
2. Dyskewicz M. Rhinitis and sinusitis. J Allergy Clin Immunol. 2003;111:S520–S529.
3. Ioannidis JPA, Lau JL. American Academy of Pediatrics: Technical report: Evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children: A systematic overview. Pediatrics. 2001;108(3):e57.
4. Leung AKC, Kellner JD. Acute sinusitis in children: Diagnosis and management. J Pediatr Health Care. 2004;18:72–76.
5. Zacharisen M, Casper R. Pediatric sinusitis. Immunol Allergy Clin North Am. 2005;25:313–332.

Sinusitis - CODES

Sinusitis - icd9

• 461.0 Maxillary
• 461.1 Frontal
• 461.2 Ethmoid
• 473.9 Chronic

Sinusitis - FAQ

• Q: Are all of the sinuses present at birth?
• A: No, the maxillary and ethmoid sinuses form during the 3rd and 4th gestational month, and are present at birth. They continue to enlarge until the preteen years. The sphenoid sinuses are pneumatized by 5 years; isolated sphenoid sinusitis is rare. The frontal sinuses are present at age 7–8 years and are not completely developed until late adolescence.
• Q: Does the nasal discharge seen with sinusitis have to be purulent and thick?
• A: No. Although the nasal discharge is often described as purulent and thick, it may also be clear or mucoid, or thick or thin. Multiple studies have shown that a change in color or consistency is not a specific sign of a bacterial infection.
• Q: Are radiographic studies useful in the diagnosis of sinusitis?
• A: There is evidence to suggest that plain radiographs (x-rays) have limited value in the diagnosis of sinusitis, and are not recommended in cases of uncomplicated sinusitis. Mucosal thickening may be seen with viral upper respiratory tract infections and allergic rhinitis. Studies have shown that x-rays do not correlate well with CT scans in the diagnosis of chronic sinusitis.
• Q: Can one make the diagnosis of sinusitis based on CT scan results alone?
• A: No. Up to 50% of patients who had CT scans performed for other reasons had soft tissue changes in their sinuses. Mucosal thickening and opacification on CT imaging have been seen in large numbers of asymptomatic patients. These findings seem to occur more frequently in infants younger than 12 months of age. Given the poor specificity of CT imaging of the paranasal sinuses, results must be used in the context of the patient’s clinical presentation.

Book Source Details

• Book Title: The 5-Minute Pediatric Consult
• Author(s): M. William Schwartz MD; et al.
• Year of Publication: 2008
• Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.

Other Book Chapters Related to Sinusitis

Read excerpts from these other book chapters related to Sinusitis:

Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Williams & Wilkins.

More About Causes of Sinusitis

• Back to symptom: Sinusitis: Introduction (review 317 causes)
• Next Book Extract About Sinusitis: Medications causing Sinusitis
• All Book Extracts: All Online Book Extracts for Sinusitis

More About This Book: Title: The 5-Minute Pediatric Consult Authors: M. William Schwartz MD; et al. Publisher: Lippincott Williams & Wilkins Copyright: 2008 ISBN: 0-7817-7577-9

 » Next page: Medications causing Sinusitis

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