Sinusitis

Sinusitis

MM Carr DDS MD MEd

Reviewed by DA Kirkpatrick MD FRCSC, Lecturer, Department of Otolaryngology, Dalhousie University

Definition

Sinusitis is defined as a condition manifested by inflammation of the mucous membranes of the nasal cavity and paranasal sinuses, fluids within these cavities, and/or the underlying bone.

Clinical Criteria for Diagnosis

Major Factors

Facial pain/pressure

Facial congestion/fullness

Nasal obstruction

Nasal discharge: purulent, or discoloured postnasal drainage

Hyposmia/anosmia

Purulent discharge in nose

Fever (acute sinusitis)

Minor Factors

Headache

Halitosis

Fatigue

Dental pain

Cough

Ear pressure/fullness

In General Terms:

To diagnose sinusitis the patient must have more than 2 major factors or 1 major and 2 minor factors

Diagnosis

Duration

Acute Sinusitis:

4 or fewer weeks in duration

Chronic Sinusitis:

More than 4 weeks in duration

Recurrent Acute Sinusitis:

Four or more episodes per year, each episode lasting at least 10 days, without signs of chronic sinusitis between

Physical Signs of Sinusitis

1. Swelling and erythema: maxillary, orbital, or frontal region
2. Anterior rhinoscopy (nasal speculum exam):
   • Hyperemia
   • Edema
   • Crusts
   • Purulence
   • Polyps
3. Nasal endoscopy:
   • Bluish colour of turbinates
   • Pus in middle meatus/sinus ostia
   • Polyps
   • Concha bullosa (large pneumatized middle turbinate)
   • Anatomic anomalies (deviated nasal septum)

Inciting Factors in Sinusitis

All of these lead to sinus outflow obstruction (either anatomical or functional).

1. Host Factors
   • Allergic/immune conditions
   • Anatomic abnormalities
   • Genetic conditions
     • Cystic fibrosis
     • Immotile cilia syndrome
   • Systemic diseases
   • Neoplasm
2. Environmental Factors
   • Infectious/viral agents
   • Trauma
   • Noxious chemicals
   • Iatrogenic
     • Medications
     • Surgery

Investigations

Best imaging modality is CT (coronal and axial) to demonstrate mucosal thickening, polyps, fluid levels in sinuses, as well as underlying anatomical abnormalities predisposing to sinusitis. Plain sinus films may show opacification or air-fluid levels, but can appear normal in true sinusitis.

Other investigations depend on the clinical situation:

• Patients with underlying allergic rhinitis:
  • Skin tests for allergies
  • Total IgE
  • Nasal secretions cytology (abundant eosinophils)
• Patients with serious complications:
  • Cultures: antral aspiration
• Patients with suspected immunodeficiency:
  • CBC with differential and smear
  • Serum immunoglobulins: IgG, IgA, IgM, IgG subclasses
  • Antibody titers
  • Delayed hypersensitivity skin tests
  • CH50
  • Other immunological tests
• Patients with suspected autoimmune disorders:
  • Sarcoidosis: ACE levels
  • Wegener's granulomatosis: Antineutrophil cytoplasmic antibody (cANCA)
• Patients with suspected cystic fibrosis:
  • Sweat test
  • EM of respiratory epithelium

Treatment of Acute Sinusitis

1. Saline nasal spray
   • Clears nasal crusts and thick mucus
2. Humidification
   • Only in dry environments
   • Guard against fungal growth in the humidifier
3. Mucolytics
   • Guaifenesin thins mucus allowing better clearance
4. Topical decongestants
   • Stimulates alpha-adrenergic receptors in nasal mucosa which vasoconstricts and shrinks swollen mucosa.
   • Oxymetazoline relieves nasal obstruction quickly
   • Short term use only
   • Some experimental evidence that topical decongestants result in increased mucosal inflammation, presumably by decreasing mucosal blood flow
5. Systemic decongestants
   • Helps relieve symptoms quickly
   • Minimal drying effects, so mucus can still be cleared
   • Careful with patients with other medical conditions
6. Antibiotics
   • 70% of acute sinusitis is caused by S. pneumoniae or H. influenzae
   • Treat for 10-14 days
   • Some recommended antibiotics are:
     • Amoxicillin or Amoxicillin-clavulanate
     • Clarithromycin or Azithromycin
     • Cefprozil
     • Cefuroxime axetil
     • Loracarbef
     • Levofloxacin
   • NOT Penicillin, Erythromycin, Cephalexin, Tetracycline

Treatment of Chronic Sinusitis

1. Antibiotics vs. Strep and Staph (Antibiotics as above plus:)
   • Clindamycin
   • Metronidazole
   • Because anaerobic bacteria are associated with chronic sinusitis
2. If there is an allergic component:
   • Avoidance of allergens
   • Topical nasal steroids
   • Topical cromolyn sodium
   • Antihistamines
   • Systemic steroids
   • Immunotherapy
3. Surgery

References

Report of the rhinosinusitis task force committee meeting. Otolaryngology-Head Neck Surgery 1997;117(3 Pt 2):S1-S49