- Rhinosinusitis is an inflammatory condition most commonly involving the maxillary sinus; next, in order of frequency, are the ethmoid, frontal, and sphenoid sinuses.
- Sinusitis accounts for millions of visits to primary care physicians each year and is the fifth most common diagnosis for which antibiotics are prescribed.
- Definition: sinusitis of <4 weeks' duration
- Etiology: Infectious and noninfectious causes lead to sinus ostial obstruction and retention of mucus.
- Infectious causes include viruses (e.g., rhinovirus, parainfluenza virus, influenza virus) and bacteria (e.g., S. pneumoniae, nontypable Haemophilus influenzae, and-in children-Moraxella catarrhalis).
- In immunocompromised pts, fungi (e.g., Rhizopus, Mucor, and occasionally Aspergillus) can be involved.
- Nosocomial cases are often polymicrobial and involve Staphylococcus aureus and gram-negative bacilli.
- Noninfectious causes include allergic rhinitis, barotrauma, and exposure to chemical irritants.
- Infectious causes include viruses (e.g., rhinovirus, parainfluenza virus, influenza virus) and bacteria (e.g., S. pneumoniae, nontypable Haemophilus influenzae, and-in children-Moraxella catarrhalis).
- Clinical manifestations: Common manifestations include nasal drainage and congestion, facial pain or pressure, and headache.
- Tooth pain and halitosis can be associated with bacterial sinusitis.
- Pain localizes to the involved sinus and is often worse when the pt bends over or is supine.
- Advanced frontal sinusitis can present as Pott's puffy tumor: swelling and pitting edema over the frontal bone from a communicating subperiosteal abscess.
- Life-threatening complications include meningitis, epidural abscess, and brain abscess.
- Diagnosis: It is difficult to distinguish viral from bacterial sinusitis clinically, although viral cases greatly outnumber bacterial cases.
- Only 40-50% of pts with symptoms of >10 days' duration, purulent nasal drainage, nasal obstruction, and facial pain have bacterial sinusitis.
- If fungal sinusitis is a consideration, involved areas should be biopsied.
- Except in nosocomial cases, sinus CT or radiography is not recommended for acute sinusitis. Nosocomial sinusitis should be confirmed by sinus CT, with sinus aspirates sent for culture and susceptibility testing (ideally before antimicrobial treatment is initiated).
| TREATMENT | ||
Acute Sinusitis
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- Definition: sinusitis of >12 weeks' duration
- Etiology: commonly associated with bacterial or fungal infection
- Chronic bacterial sinusitis: Impaired mucociliary clearance leads to repeated infections as opposed to one persistent infection.
- Pts have constant nasal congestion and sinus pressure, with periods of increased severity.
- Sinus CT can define the extent of disease, detect an underlying anatomic defect or obstructing process, and assess response to treatment.
- Endoscopy-derived tissue samples for histology and culture should be obtained to guide treatment.
- Repeated antibiotic courses are required, often for 3-4 weeks at a time. Adjunctive measures include intranasal administration of glucocorticoids, sinus irrigation, and surgical evaluation.
- Chronic fungal sinusitis: a noninvasive disease in immunocompetent hosts, typically due to Aspergillus and dematiaceous molds. Recurrence is common.
- Mild, indolent disease is usually cured with endoscopic surgery and without antifungal agents.
- Unilateral disease with a mycetoma (fungus ball) in the sinus is treated with surgery and-if bony erosion has occurred-antifungal agents.
- Allergic fungal sinusitis, seen in pts with nasal polyps and asthma, presents as pansinusitis and thick, eosinophil-laden mucus with the consistency of peanut butter.