Rhinosinusitis

Acute Rhinosinusitis

Acute sinusitis is inflammation of the sinus cavities of the skull. Inflammation results in blockage, build-up of fluid, and pressure. It is most commonly viral. If symptoms last for more than 7-10 days it suggests a bacterial etiology, and antibiotics are indicated. The diagnosis of acute sinusitis is clinical.

Etiology	Features
Acute viral rhinosinusitis	Self-limiting and resolves within 7 days. Nasal discharge and cough may last a further 3-4 days.
Acute bacterial rhinosinusitis	Discoloured mucus, severe local pain, Fever 38 C, Raised CRP/ESR, and ‘Double sickening’’

• Criteria for the diagnosis of acute sinusitis in adults Sudden onset of 2 or more symptoms for < 12 weeks
  • Nasal blockage/obstruction/congestion OR nasal discharge (anterior or posterior drip)
  • +/- Facial pain or pressure
  • +/- Reduction or loss of smell
• Criteria for the diagnosis of acute sinusitis in children Sudden onset of 2 or more symptoms for < 12 weeks
  • Nasal blockage/ obstruction/ congestion
  • +/- Discoulored nasal discharge
  • +/- Cough (daytime or night-time)
• Risk factors for Acute Bacterial Rhinosinusitis (DIIIMMES)
  • Dental infection/procedure
  • Iatrogenic (Sinus surgery, NG tube placement, Nasal packing)
  • Impaired cilia motility: Cystic fibrosis, Kartegener syndrome
  • Immunodeficiecy
  • Mucosal oedema: Allergic rhinitis, URTI
  • Mechanical obstruction: polyp, foreign body, tumor
  • Environmental Factors e.g. Occupation
  • Smoking
• Signs and symptoms
  • Facial pain
    • Dental and nasal pain (maxillary)
    • Eye pain (ethmoidal)
    • Frontal pain (frontal and sphenoidal)
  • Fullness
  • Purulent nasal discharge
  • Headache
  • Tooth pain
• Physical exam
  • Tenderness on palpation
  • Tenderness on motion of the head
  • Decreased transillumination
• Investigations
  • Sinus CT: best initial test
  • Sinus aspiration: most accurate test
• Indications for antibiotics in Acute Rhinosinusitis Antibiotics are reserved for Acute Bacterial Rhinosinusitis
  • URTI symptoms worsen within 10 days after initial improvement (“Double sickening sign”)
  • Signs and symptoms fail to resolve in 10 days
• Treatment
  • Decongestants and nasal steroids e.g. Oxymetazoline and Mometasone for mild symptoms
  • Antihistamines
  • Analgesics e.g. Paracetamol and NSAIDS
  • Nasal irrigation with saline
  • Steam/heated humidified air +/- Eucalyptus, menthol
  • Amoxicillin/clavulanate for Acute bacterial rhinosinusitis
• Complications
  • Facial osteomyelitis (Pott’s puffy tumor)
  • Orbital cellulitis (ethmoidal sinusitis) → Blindness
  • Cavernous sinus thrombosis (sphenoidal sinusitis): bilateral chemosis (edema of conjunctiva), proptosis, fixed orbit, and visual loss. Treatment ivolves broad spectrum IV antibiotics for 3-4 weeks
  • Meningitis
  • Brain/meningeal abscess

Chronic Bacterial Rhinosinusitis

Chronic Bacterial Rhinosinusitis results from untreated or inadequately treated acute (<4 weeks) or subacute (4 – 12 weeks) rhinosinusitis. It is considered if inflammation lasts for more than 12 weeks (3 months).

• Associated conditions
  • Allergic Rhinitis
  • Asthma
  • Immunodeficiency
  • Dental infections
  • Poor mucociliary clearance: Kartegener syndrome, cystic fibrosis
  • Granulomatous disease: Sarcoidosis
  • GERD
  • Obstructive sleep apnoea
• Signs and symptoms
  • Chronic purulent discharge
  • Less pain
• Physical examination
  • Mucopurulent discharge
  • Hypertrophied turbinates
  • +/- polyps
• Investigations
  • Nasal endoscopy
  • CT paranasal sinuses: to determine the site of infection, for anatomic abnormalities or polyps
  • Culture
• Treatment
  • Intranasal steroids: 1st line treatmentAntibiotics for 2-6 weeksOral corticosteroids for 2-3 weeks for nasal polyposisFunctional endoscopic sinus surgery