Question

Sinusitis: Management and Prevention

Dr.Sunil Kumar · Accepted Answer

Sinusitis: Management and Prevention

Sinusitis is infl ammation of the mucous membranes lining one or more of the paranasal sinuses. The various presentations are as folllows:
acute sinusitis: infection lasting less than 30 days, with complete resolution of symptoms
subacute infection: lasts from 30 to 90 days, with complete resolution of symptoms
recurrent acute infection: episodes of acute infection lasting less than 30 days, with resolution of symptoms, which

Recur at intervals of at least 10 days apart
chronic sinusitis: infl ammation lasting more than 90 days, with persistent upper respiratory symptoms
acute bacterial sinusitis superimposed on chronic sinusitis:

New symptoms that occur in patients with residual symptoms from prior infection (s). With treatment, the new symptoms resolve but the residual ones do not.
Physical findings and clinical presentation
patients often give a history of a recent upper respiratory illness with some improvement, then a relapse.
mucopurulent secretions in the nasal passage
purulent nasal and postnasal discharge lasting more than 7 to 10 days
facial tightness, pressure, or pain
nasal obstruction
headache
decreased sense of smell
purulent pharyngeal secretions, brought up with cough, often worse at night
erythema, swelling, and tenderness over the infected sinus in a small proportion of patients
diagnosis cannot be excluded by the absence of such findings.
these fi ndings are not common, and do not correlate with number of positive sinus aspirates.
intermittent low-grade fever in about one half of adults with acute bacterial sinusitis
toothache is a common complaint when the maxillary sinus is involved.
periorbital cellulitis and excessive tearing with ethmoid sinusitis
orbital extension of infection: chemosis, proptosis, impaired extraocular movements.

Characteristics of acute sinusitis in children with upper respiratory tract infections:
persistence of symptoms
cough
bad breath
symptoms of chronic sinusitis (may or may not be present)
nasal or postnasal discharge
fever
facial pain or pressure
headache
nosocomial sinusitis is typically seen in patients with nasogastric tubes or nasotracheal intubation.

Cause
each of the four paranasal sinuses is connected to the nasal cavity by narrow tubes (ostia), 1 to 3 mm in diameter; these drain directly into the nose through the turbinates. The sinuses are lined with a ciliated mucous membrane (mucoperiosteum).
acute viral infection
infection with the common cold or infl uenza
mucosal edema and sinus infl ammation
decreased drainage of thick secretions, obstruction of the sinus ostia
subsequent entrapment of bacteria

A. Multiplication of bacteria
B. Secondary bacterial infection

Other predisposing factors
tumors
polyps
foreign bodies
congenital choanal atresia
other entities that cause obstruction of sinus drainage
allergies
asthma
dental infections lead to maxillary sinusitis.
viruses recovered alone or in combination with bacteria (in 16% of cases):
rhinovirus
coronavirus
adenovirus
parainfluenza virus
respiratory syncytial virus
the principal bacterial pathogens in sinusitis are streptococcus pneumoniae, nontypeable haemophilus influenzae, and moraxella catarrhalis.
in the remainder of cases, fi ndings include streptococcus pyogenes, staphylococcus aureus, alpha-hemolytic streptococci, and mixed anaerobic infections (peptostreptococcus, fusobacterium, bacteroides, prevotella).

Infection is polymicrobial in about one third of cases.
anaerobic infections seen more often in cases of chronic sinusitis and in cases associated with dental infection; anaerobes are unlikely pathogens in sinusitis in children.
fungal pathogens are isolated with increasing frequency in immunocompromised patients but remain uncommon
Pathogens in the paranasal sinuses. Fungal pathogens include aspergillus, pseudallescheria, sporothrix, phaeohyphomycoses, zygomycetes.
nosocomial infections occur in patients with nasogastric tubes, nasotracheal intubation, cystic fi brosis, or those who are immunocompromised.
s. Aureus
pseudomonas aeruginosa
klebsiella pneumoniae
enterobacter spp.
proteus mirabilis

Organisms typically isolated in chronic sinusitis:
s. Aureus
s. Pneumoniae
h. Infl uenzae
p. Aeruginosa
anaerobes

Differential diagnosis
migraine headache
cluster headache
dental infection
trigeminal neuralgia

Workup
water s projection: sinus radiograph
ct scan
much more sensitive than plain radiographs in detecting acute changes and disease in the sinuses
recommended for patients requiring surgical intervention, including sinus aspiration; it is a useful adjunct to

Guide therapy:
transillumination
used for diagnosis of frontal and maxillary sinusitis
place transilluminator in the mouth or against cheek to assess maxillary sinuses, and under the medial aspect of the supraorbital ridge to assess frontal sinuses.
absence of light transmission indicates that sinus is filled with fluid.
dullness (decreased light transmission) is less helpful in diagnosing infection.
endoscopy
used to visualize secretions coming from the ostia of infected sinuses
culture collection via endoscopy often contaminated by nasal flora; not nearly as good as sinus puncture
sinus puncture
gold standard for collecting sinus cultures
generally reserved for treatment failures, suspected intracranial extension, nosocomial sinusitis.

Treatment Nonpharmacologic therapy
sinus drainage
nasal vasoconstrictors, such as phenylephrine nose drops, 0.25% or 0.5%

topical decongestants should not be used for more than a few days because of the risk of rebound congestion.
systemic decongestants
nasal or systemic corticosteroids, such as nasal beclomethasone, short-course oral prednisone
nasal irrigation, with hypertonic or normal saline (saline may act as a mild vasoconstrictor of nasal blood fl ow)
use of antihistamines has no proved benefi t, and the drying effect on the mucous membranes may cause crusting,

Which blocks the ostia, thus interfering with sinus drainage.
analgesics, antipyretics.

Antimicrobial therapy
most cases of acute sinusitis have a viral cause and will resolve within 2 weeks without antibiotics.
current treatment recommendations favor symptomatic treatment for those with mild symptoms.
antibiotics should be reserved for those with moderate to severe symptoms who meet the criteria for diagnosis of

Bacterial sinusitis.

antibiotic therapy is usually empirical, targeting the common pathogens.
first-line antibiotics include amoxicillin, tmp-smz.
second-line antibiotics include clarithromycin, azithromycin, amoxicillin-clavulanate, cefuroxime axetil, loracarbef, ciprofloxacin, levofloxacin.
for patients with uncomplicated acute sinusitis, the less expensive first-line agents appear to be as effective as the

Costlier second-line agents.

Surgery
surgical drainage indicated
if intracranial or orbital complications suspected
for many cases of frontal and sphenoid sinusitis
for chronic sinusitis recalcitrant to medical therapy
surgical d bridement imperative for treatment of fungal sinusitis

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Sinusitis: Management and Prevention

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