Sinusitis

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

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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)

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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

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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

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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

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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
  • Antihistamines avoided
    • 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)