Contents
Inflammation of sinuses resulting in thick nasal mucus, a plugged nose, and pain in the face.
- A sinus infection should be considered in any child whose cold symptoms have not resolved by 7-10 days
Aetiology
Causative organisms:
- Acute sinusitis: (Commonly) S. pneumoniae, H. influenzae and M. catarrhalis
- Chronic sinusitis:
- Common bacterial causes of acute sinusitis
- S. aureus, anaerobes and occasionally fungi
- Allergic fungal sinusitis: Atopy in immunocompetent patients
Risk factors:
- Recurrent upper respiratory infections
- Dental caries (infection spreads to maxillary sinus)
- Allergic rhinitis
- Cystic fibrosis
- Immunodeficiency
- Ciliary dyskinesia
- Daycare attendance
- Exposure to tobacco smoke
Sinus involvement:
- Adults: Maxillary > Ethmoid > Frontal > Sphenoid
- Children: Ethmoid (M/C)
Clinical features
Acute rhinosinusitis:
Presents as an episode of upper respiratory infection (URTI) with worsening of nasal discharge and cough 7-10 days after onset of symptoms
Diagnostic criteria: Severe URI + fever (>38.5°C ) + purulent rhinorrhea
- Headache
- Fever
- Purulent nasal discharge
Chronic rhinosinusitis:
Symptoms of sinusitis lasting longer than 30 days
- Nasal obstruction
- Malaise
- Headache
Complications
Local complications:
- Mucocele, mucopyocele: Seen in frontal > ethmoid > maxillary > sphenoid
- Mucous retention cyst
- Osteomyelitis
Orbital complications (60-75%):
Most commonly seen in ethmoidal sinusitis as a result from direct extension from the ethmoids
- Early orbital complications: Periorbital (preseptal) cellulitis
- More severe complications:
- Orbital abscess
- Cavernous sinus thrombosis
- Life-threatening infection of the cavernous sinus:
- Ophthalmoplegia
- Vision loss
- Toxaemia
Intracranial complications (15-20%):
Commonly associated with frontal and sphenoid sinus infections.
- Meningitis
- Abscesses
Diagnosis
Rhinoscopy:
Plain radiography:
- Water’s view (occipitomental view or nose-chin position): Maxillary sinus
- Caldwell view (occipitofrontal view or nose-forehead position): Frontal sinus
- Submentovertical (basal) view: Sphenoid sinus
- Right & left oblique views: Posterior ethmoid sinus & optic foramen of corresponding side
- Lateral view: Anterior & posterior extent of sphenoid, frontal & maxillary sinuses
Diagnostic nasal endoscopy:
Definitive diagnostic test
Management
Acute sinusitis:
- Amoxicillin (10-14 days) (First-line)
- Refractory infections: Longer courses and second-line antibiotics
- Sinusitis + orbital/intracranial complications: Parenteral antibiotics
- Adjuvants:
- Oral decongestants
- Mucolytic agents
- Topical nasal saline
Antihistaminesavoided- Due to their drying effect
Chronic sinusitis:
- Coamoxiclav, high-dose amoxicillin or cefuroxime (3 to 6 weeks)
- Penicillin allergy: Macrolide antibiotic
- Adjuvants: Topical nasal steroids
Surgical intervention:
Indicated in orbital/intracranial complications or in refractory chronic sinusitis
- Adenoidectomy: To remove a potential bacterial reservoir for the sinuses (in younger children)
- Functional endoscopic sinus surgery (FESS)