Categories
ORGAN SYSTEMS Otolaryngeal system (ENT)

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

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
    • 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)

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