Incidence

1. Sinusitis is very prevalent. However, true incidence is unknown because people with frontal headaches or congestion self-medicate with over-the-counter (OTC) decongestants and then request antibiotics if symptoms persist. Incidence increases in spring and fall (allergy seasons) and in winter (cold season).
2. Can be viral (most common) or bacterial. Bacterial rhinosinusitis is fifth ^{leading reason for prescribing antibiotics.}

Pathogenesis

1. Frequent causes:
   1. Obstruction of mucus flow due to edema of nasal mucosa from allergies and upper respiratory infections (URIs).
   2. Anatomical abnormalities that interfere with normal mucocilliary clearance mechanism.
   3. Exposure to pathogens following URI also causes sinusitis. The most common pathogens include Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis, and Staphylococcus aureus. The incubation period depends on the pathogen.
   4. Dental abscess is responsible for approximately 10% of cases.
   5. Fungi such as Mucor, Rhizopus, and Aspergillus can produce invasive sinusitis in patients with poorly controlled diabetes, patients with leukemia, or immunosuppressed patients.
   6. The common cold is a cause in 0.5% to 5.0% of cases.

Predisposing Factors

1. Recent URI.
2. Allergens (pollens, molds, smoking, occupational exposure such as coal mining, and animal dander).
3. Nicotine/smoke exposure (first- or secondhand smoke).
4. Air pollutants.
5. Deviated septum.
6. Adenoidal hypertrophy.
7. Dental abscess.
8. Diving and swimming.
9. Neoplasms.
10. Cystic fibrosis.
11. Trauma.
12. Medical disorders (diabetes, immune disorders, inflammatory disorders, mucosal disorders, cystic fibrosis, and asthma).
13. Flying or rapid changes in altitude.

Common Complaints

1. Yellow or green nasal discharge.
2. Fever.
3. Sore throat.
4. Facial pain, frontal pain, or pressure that worsens when patient bends forward.
5. Headache.
6. Toothache.

Other Signs and Symptoms

1. Anosmia (loss of sense of smell).
2. Nasal congestion.
3. Cough (worse when lying down); may be chronic.
4. Periorbital edema (especially early morning).
5. Malaise or fatigue.
6. Halitosis.
7. Snoring, mouth breathing.
8. Nasal sounding speech.

Potential Complications to Consider—Immediate Ear, Nose, and Throat Referral

1. Meningitis: Symptoms are increased fever, stiff neck.
2. Subdural and epidural purulent drainage.
3. Brain abscess.
4. Cavernous sinus thrombosis (acute thrombophlebitis due to infection in area where veins drain into cavernous sinus).
5. Tender periorbital edema (orbital cellulitis).

Subjective Data

1. Elicit onset, duration, and course of symptoms.
2. Inquire whether seasons affect symptoms.
3. Ask the patient about recent URI and how it was treated:
   1. Did the patient receive antibiotics?
   2. Did the patient finish the full course of antibiotics?
4. Ask about allergies.
5. Inquire about recent dental problems, especially dental abscesses.
6. Find out what home therapies and OTC medications the patient tried before the office visit.
7. Ask if the patient took a trip recently, especially by airplane.
8. Inquire whether the patient was swimming or diving recently.
9. Review the patient’s medical history for cystic fibrosis, asthma, nasal abnormalities (e.g., deviated septum), and other respiratory problems.

Physical Examination

1. Temperature, blood pressure, pulse, and respirations.
2. Inspect:
   1. Observe eyes for periorbital swelling, “allergic shiners” (dark circles under eyes), tearing, and signs of orbital cellulitis (conjunctival edema, drooping lid, decreased extraocular motion, and vision loss).
   2. Examine ears.
   3. Inspect the nose for erythema, edema, discharge, lack of nostril patency, septal deviation and polyps, and presence of a foreign body.
   4. Transilluminate maxillary and frontal sinuses in a darkened room. Absence of light reflection is not definitive.
   5. Examine the mouth and pharynx for erythema and tonsillar enlargement, check teeth for uneven surfaces (sign of grinding), and check retropharynx for evidence of postnasal drip.
3. Auscultate: Auscultate heart and lungs.
4. Palpate:
   1. Palpate neck for lymphadenopathy.
   2. Palpate sinuses but do not press on eyes:
      1. Frontal sinusitis: Pain and tenderness over lower forehead (worse when bending forward) and purulent drainage from middle meatus of nasal turbinates.
      2. Maxillary sinusitis: Pain and tenderness over cheeks from inner canthus to teeth (referred pain), edematous hard palate (severe cases), and purulent drainage in middle meatus.
      3. Ethmoid sinusitis: Frontal or orbital headache, tenderness and erythema over upper lateral aspect of nose, drainage from anterior ethmoid cells through middle meatus, drainage of posterior cells through superior meatus.
      4. Sphenoid sinusitis (uncommon): Frontal or orbital headache or facial pain (headache referred to top of head and deep into eyes), purulent drainage from superior meatus.
5. Percuss:
   1. Tap maxillary teeth to rule out dental cause.
   2. Percuss maxillary and frontal sinuses.
   3. Percuss over affected area exacerbates pain.
   4. Perform chest percussion, if indicated.
6. Neurologic exam:
   1. Evaluate for signs of meningeal irritation, assessing for Brudzinski’s sign, Kernig’s sign, and nuchal rigidity.

Diagnostic Tests

1. Diagnosis is usually made through history taking and a physical.
2. Consider sinus x-ray films, which show air-fluid level and thickening of sinus mucous membranes with sinusitis for chronic or recurrent sinusitis or complicated cases.
3. CT of sinus indications include chronic sinusitis, recurrent sinusitis, allergic fungal sinusitis, or osteomeatal complex occlusion.

Differential Diagnoses

1. Sinusitis.
2. Headache (cluster, migraine).
3. Rhinitis (allergic or vasomotor).
4. Nasal polyps.
5. Tumor.
6. URI.
7. Trigeminal neuralgia.

Plan

1. General interventions:
   1. Teach patient to avoid smoking and secondhand smoke.
   2. Drinking extra fluids helps to loosen secretions and hydrate the body.
   3. Encourage patient to use medications as prescribed. OTC medications such as antihistamines and decongestants should be used with caution.
   4. Application of warm, moist compresses to the face several times a day will help with discomfort.
   5. Humidifiers should be used daily. Advise patient to clean humidifiers on a regular basis.
   6. Nasal saline to the nares three times a day will help to keep nasal passages moist.
2. See Section III: Patient Teaching Guide “Sinusitis.”
3. Pharmaceutical therapy:
   1. Antibiotics for infection:
      1. Drugs of choice for acute sinusitis:
         1. Adults:
            • First-line treatment: Amoxicillin-clavulanate (Augmentin) 500 mg orally three times a day or 875 mg orally twice daily for 5 to 7 days.
            • High-risk patients where nonsusceptible Streptococcus pneumoniae is greater than 10% for the following patients: Older than 65 years of age, recent hospitalization, recent use of antibiotics in the past month, or immunocompromised patients; Augmentin 2,000 mg (two extended-release tablets) orally every 12 hours for 5 to 7 days.
            • Penicillin/beta-lactam allergy: Doxycycline 100 mg orally twice daily or 200 mg orally daily for 5 to 7 days, levofloxacin 500 mg orally daily for 5 to 7 days, moxifloxacin 400 mg orally daily, or cefpodoxime 200 mg orally twice daily for 5 to 7 days.
      2. The same antibiotics can be used for chronic sinusitis, but treatment should last 3 to 4 weeks.
4. Oral and topical decongestants to correct the underlying edematous mucosa (use cautiously with hypertension):
   1. Adults: Pseudoephedrine sulfate (Afrin) 0.05% spray or drops, two to three drops or sprays per nostril twice daily. Maximum for 3 to 5 days.
   2. Adults: Phenylephrine (Neo-Synephrine) spray or drops, two to three drops or one to two sprays of 0.25% solution per nostril, or small amount of jelly to nasal mucosa, every 4 hours as needed. Do not use for more than 3 to 5 days.
   3. Pseudoephedrine HCl 30 to 60 mg every 4 to 6 hours as needed for congestion for adults.
   4. Nasal saline to nares three times daily as needed for hydrating nasal mucosa 0.25% solution spray or drops, two to three drops or one to two sprays per nostril every 4 hours as needed. Do not use for more than 3 to 5 days.
5. Intranasal corticosteroid sprays may be used to decrease nasal inflammation:
   1. Beclomethasone dipropionate (Beconase AQ, Vancenase AQ); fluticasone (Flonase). Adults: Two sprays daily.
   2. Mometasone furoate monohydrate (Nasonex): Two sprays daily.
6. Antihistamines are recommended to block histamine production in response to the allergy triggers and prevent allergy symptoms:
   1. Loratadine (Claritin): 10 mg daily.
   2. Fexofenadine (Allegra): 180 mg daily.
   3. Levocetirizine HCl (Xyzal): 5 mg daily.
   4. Leukotriene inhibitors (Singulair, Accolate) for severe allergies and/or asthma: 10 mg daily.

Follow-Up

1. Recheck the patient in 3 to 4 days if signs and symptoms are not improving with use of treatment prescribed.
2. New recommendations include treating patients with antibiotic therapy for 5 to 7 days. Patients not improving may be resistant to antibiotics and may be switched to a different antibiotic.

Consultation/Referral

1. Admission to hospital is needed if the patient has fever with facial cellulitis and mental changes.
2. Refer chronic sinusitis patients to an otolaryngologist if they do not improve in 4 weeks.
3. Refer patients to a physician or ear, nose, and throat (ENT) specialist for suspected neoplasm, abscess, osteomyelitis, meningitis, or sinus thrombosis.

Individual Considerations

1. Pregnancy:
   1. Amoxicillin/Augmentin are the desired antibiotics for use during pregnancy.
   2. Patients who are allergic to penicillin should be treated with azithromycin.
   3. Doxycycline and fluoroquinolones are not recommended during pregnancy.
2. Geriatrics:
   1. Precautionary measures should be used for patients with long-term nasogastric tubes. These patients are at higher risk for development of occult sinusitis.
   2. Nose-blowing precautions should be used for patients currently prescribed warfarin (Coumadin) and/or aspirin and other anticoagulants.
   3. Avoid use of trimethoprim/sulfamethoxazole (TMP-SMX) with warfarin because the medication can cause a significant increase in prothrombin time (PT)/international normalized ratio (PT/INR).
   4. Inappropriate antibiotic therapy with geriatrics can cause significant risks and adverse effects that include drug interactions and contraindications, side effects related to polypharmacy, age-related metabolisms, risks of multidrug-resistant organisms, and Clostridium difficile:
   5. Home treatment suggestions for geriatrics:
      1. Safe (reliable brand) home humidifier with automatic shut off and adequate weight balance to prevent hot steam spillage and avoid burns.
      2. Drinking plenty of water or hot/cold herbal teas—staying well hydrated.
      3. Placing a warm, moist washcloth over nose and sinuses.
      4. Using gentle saline rinses; or while showering, breathing in steam an extra couple of minutes when showering.
      5. Minimizing exposure to allergens (dust and dander).