Acute Maxillary Sinusitis

Essentials

• Nasal blockage, rhinitis and pressure symptoms over the cheeks are often present during a viral upper respiratory tract infection (URTI). These symptoms are associated with the viral infection and no antimicrobial therapy or further investigations are usually indicated Sinusitis in the Common Cold.
• Diagnosis of acute sinusitis requires clinical examination of the nose and pharynx, in particular. Purulent secretions in the middle nasal meatus, nasopharynx or on the posterior wall of the pharynx suggests bacterial sinusitis.
• Ultrasonography of the maxillary sinus is the first-line imaging study due to its good availability and lack of adverse effects but it cannot be used to differentiate between viral and bacterial sinusitis.
• Imaging of the paranasal sinuses may be useful in the case of acute or chronic sinusitis to confirm the diagnosis.
• Antimicrobial treatment should only be considered for patients with severe symptoms suggesting bacterial infection.
• In recurring sinusitis, any predisposing factors should be identified and an ENT specialist consulted, as necessary.
• For maxillary sinusitis in children, see Sinusitis in Children.

Definitions

• There are maxillary, frontal, sphenoidal and ethmoidal sinuses.
• Sinusitis means inflammation of one or more of these. The most common form of sinusitis is maxillary sinusitis.
• In rhinosinusitis, symptoms and findings often occur simultaneously in the area of both the nasal cavity and sinuses.
• Acute maxillary sinusitis is defined as an inflammation that has lasted no more than 12 weeks. Maxillary sinusitis is defined as chronic if it has lasted more than 12 weeks (see also Chronic or Frequently Recurring Sinusitis).
• If acute purulent sinusitis recurs at least 3-4 times a year, it is called frequently recurring sinusitis.

Aetiology

• Sinusitis is usually preceded by viral URTI.
• Predisposing factors include allergic or other chronic rhinitis, nasal polyps or other tumours in the nasal cavity, structural abnormalities of the middle nasal meatus or septum, dental root infection and, rarely, a foreign body.
• Air impurities, such as tobacco smoke, may also be predisposing factors.
• Obstruction of the natural opening (ostium) to the maxillary sinus and impaired ciliary function play a major role in the development of maxillary sinusitis.
• Rare causes include certain systemic disorders, such as cystic fibrosis, primary ciliary dyskinesia and immunodeficiencies.

Symptoms

• The main symptoms are usually nasal congestion and purulent nasal discharge or postnasal drip.
• In addition, there may be:
  • facial pain, especially around the eyes and over the cheeks
  • toothache in the upper canine teeth or molars
  • prolonged cough (particularly in the mornings), rhinitis or nasal congestion
  • hyposmia.

Diagnosis

• The symptoms of a viral common cold and a sinusitis are quite similar. Bacterial aetiology is suggested by:
  • purulent secretions in the middle nasal meatus, nasopharynx or on the posterior wall of the pharynx
  • impaired general condition or fever (> 38 °C)
  • pain radiating to teeth
  • severe local facial pain that may be worse on one side.
• Clinical examination
  • There is purulent discharge, mucosal swelling or erythema in the nose, particularly the middle nasal meatus.
  • It is easier to examine the nose after applying a decongestant (e.g. wiping the nasal mucosa with a cotton-tipped swab soaked in adrenaline solution).
  • There may be purulent postnasal drip.
• Ultrasonography is a relatively reliable diagnostic method in adults and teenagers but requires training and practice Sinus Ultrasound and Radiography in the Diagnosis of Sinusitis.
  • If ultrasonography of the maxillary sinus repeatedly shows a back-wall -echo at a distance of 4-6 cm, the diagnostic accuracy for acute stasis of secretions may be as good as 80-95%.
  • The state of the mucous membranes (e.g. mucosal oedema) cannot be reliably evaluated with ultrasonography.
  • Ultrasonography cannot be used to differentiate between viral and bacterial sinusitis.
• X-ray examination (occipitomental view of the paranasal sinuses) is not necessary for diagnosing acute sinusitis but it may be useful in confirming the diagnosis of recurrent acute or chronic sinusitis.
• Laboratory investigations are usually not needed for the diagnosis of acute sinusitis. However, in patients with severe symptoms, laboratory investigations (basic blood count with platelet count, CRP) may be necessary to confirm bacterial infection (also other than sinusitis).

Treatment Systemic Corticosteroids for Acute Sinusitis

Follow-up

• If the symptoms of sinusitis resolve completely, no follow-up is indicated.
• If symptoms persist despite treatment:
  • Topical nasal treatment (nasal glucocorticoid, moistening of the nasal mucosa) should be intensified, as necessary.
  • Maxillary sinus puncture should be considered to obtain material for bacterial culture, to confirm the diagnosis and to remove retained secretions.
  • If indicated, antimicrobial therapy in accordance with sensitivity testing should be prescribed.
  • Any predisposing factors should be identified (see above).
    • Allergic or other chronic rhinitis (history, allergy tests)
    • Mucosal oedema, polyps, septal deviation (anterior rhinoscopy)
    • Dental health (odontogenic maxillary sinusitis)

Indications for consulting an ENT specialist

• Symptomatic maxillary sinusitis persisting after 12 weeks despite appropriate treatment
• At least 3-4 recurring episodes of maxillary sinusitis a year
• Suspicion of a complication of maxillary sinusitis, in which case the patient should be referred to emergency services.

Surgical treatment

• In specialized care, surgical treatment may be considered for the management of chronic or frequently recurring maxillary sinusitis Chronic or Frequently Recurring Sinusitis.
• The most common type of surgery is endoscopic paranasal surgery carried out through the nostrils (FESS, functional endoscopic sinus surgery), seeChronic or Frequently Recurring Sinusitis.

Management after maxillary surgery

• See Chronic or Frequently Recurring Sinusitis.