Otolaryngology Book

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RhinosinusitisAka: Sinusitis, Acute Sinusitis, Sinus Headache

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  1. See Also
    1. Chronic Sinusitis
    2. Allergic Fungal Sinusitis
  2. Pathophysiology
    1. Initial
      1. Mucosal inflammation of paranasal sinuses
      2. Sinus ostia irritation and edema
    2. Next
      1. Sinus obstruction and stasis
      2. Subsequent sinus infection
  3. Epidemiology
    1. Incidence
      1. United States clinic office visits: 1%
      2. Lifetime Incidence: 25%
    2. Sinuses affected
      1. Maxillary sinus
        1. Most commonly infected in adults
      2. Frontal sinus
        1. Next most commonly infected in adults
        2. Absent in 10% population and very young children
        3. Higher risk for intracranial spread
      3. Ethmoid sinus
        1. Most commonly infected in children
      4. Sphenoid sinus
        1. Isolated infection is rare
        2. Higher risk for intracranial spread
  4. Types
    1. Acute Sinusitis
      1. Symptoms as long as 4 weeks
    2. Subacute Sinusitis
      1. Symptoms persist between 4 to 12 weeks
    3. Chronic Sinusitis
      1. Persistent Symptoms beyond 12 weeks
    4. Recurrent Sinusitis
      1. Four or more episodes per year
      2. Each episode lasts 7 days or more
      3. Symptom free intervals last greater than 2 months
  5. Predisposing Factors
    1. Environmental Factors
      1. Allergens (e.g. pollens, molds, animal dander)
      2. Nicotine or smoke exposure
      3. Air pollutants
    2. Anatomic abnormalities
      1. Nasal Polyps
      2. Ciliary disorder
      3. Septal deviation
      4. Concha bullosa
    3. Immune disorder
      1. AIDS
      2. Congenital (IgA or IgG subclas deficiency)
      3. Post-Transplant
      4. Chemotherapy
      5. Diabetes Mellitus
    4. Inflammatory disorder
      1. Wegener's Granulomatosis
      2. Sarcoidosis
    5. Recurrent Upper Respiratory Infection
    6. Mucosal disorder
      1. Cystic Fibrosis
      2. Allergic Rhinitis and other hyperreactivity
      3. Nonallergic (Samter's triad)
        1. Asthma
        2. Nasal Polyps
        3. Aspirin sensitivity
  6. Etiology:
    1. Viral (10-15%)
      1. Rhinovirus (most common viral sinusitis cause)
      2. Influenza
      3. Parainfluenza
      4. Adenovirus
    2. Bacterial
      1. Acute Sinusitis
        1. Streptococcus Pneumoniae
        2. Haemophilus Influenzae
        3. Moraxella
        4. Streptococcus Pyogenes
      2. Chronic Sinusitis
        1. Anaerobes (>50%)
          1. Bacteroides
          2. Anaerobic Gram Positive Cocci
          3. Fusobacterium species
        2. Other less common causes
          1. Staphylococcus aureus
          2. Hemophilus Influenzae
          3. Pseudomonas aeruginosa
          4. Escherichia coli
          5. Beta-hemolytic Streptococcus
          6. Neisseria causes
    3. Fungal (Immunocompromised or Diabetes Mellitus)
      1. Aspergillus
      2. Mucormycosis
      3. Fungus
  7. Symptoms
    1. Classic Sinus Symptoms
      1. Sinus "aching" pain or pressure
        1. Location
          1. Frontal: Frontal Headache
          2. Maxillary: Mid-face, dental (upper teeth) pain
          3. Ethmoid: Retro-orbital pain
          4. Sphenoid: Nonspecific pain radiates top of head
        2. Provocative
          1. Pain increases on bending forward
          2. Pain increases in late morning
          3. Pain on mastication
      2. Foul Nasal discharge or postnasal discharge
        1. Purulent yellow or green Nasal discharge
        2. Discharge color does not indicate bacterial cause
        3. Discharge for >10 days suggests bacterial sinusitis
      3. Associated Nasal Symptoms
        1. Decreased sense of smell (Hyposmia or Anosmia)
        2. Halitosis
        3. Snoring
        4. Mouth breathing
        5. Nasal or hyponasal speech
      4. Generalized symptoms
        1. Fatigue
        2. Fever
    2. Symptoms not correlating with sinusitis
      1. Sore Throat (except with postnasal discharge)
      2. Sneezing
  8. Symptoms: Red Flag (consider immediate ENT referral)
    1. High Fever over 102.2 F (39 C) or peristent fever
    2. Visual complaints (e.g. Diplopia)
    3. Periorbital edema or erythema
    4. Mental status changes
    5. Severe facial or dental pain
    6. Infraorbital hypesthesia
  9. Signs
    1. Nasal Mucosa edema and erythema
      1. Contrast with Allergic Rhinitis (pale, boggy mucosa)
    2. Nasal exam to view pus discharge from lateral wall
      1. Instruments
        1. Nasal speculum (minimal visualization)
        2. Flexible Nasolaryngoscopy
        3. Rigid optical scope (Otolaryngology use)
      2. Middle Meatus (hiatus semilunaris)
        1. Drains Maxillary, Frontal, and Anterior Ethmoid
        2. Consider local Topical Decongestant application
      3. Superior Meatus (Rarely discharge is seen)
        1. Drains posterior ethmoid sinus
    3. Turbinates enlarged
    4. Sinus tenderness to percussion
    5. Sinus Transillumination in darkened room
      1. Frontal and maxillary sinus
  10. Diagnosis: Findings most suggestive of bacterial cause
    1. See Sinusitis Prediction Rules
    2. Symptoms persist beyond 10 to 14 days
      1. Under 10 days, viral sinusitis predominates
      2. By day 10, 40% of sinusitis resolves spontaneously
      3. 0.5% of viral URIs develop into bacterial sinusitis
        1. Low (1997) CMAJ 156:S1
    3. Symptoms worsen after 5-7 days ("double sickening")
    4. Purulent Nasal discharge
    5. Maxillary tooth or facial pain (esp. if unilateral)
    6. Unilateral maxillary sinus tenderness
    7. References
      1. Hickner (2001) Ann Intern Med 134:498
      2. Lanza (1997) Otolaryngol Head Neck Surg 117:S1
  11. Labs
    1. Culture of nasal mucosa
      1. Not cost effective or helpful in management
      2. Does not correlate with sinus mucosa cultures
    2. Endoscope directed micro-swab culture
      1. Swab of hiatus semilunaris
      2. Protected from nasal contamination
      3. Accuracy: 80-85% compared with antral puncture
  12. Radiology
    1. Indications for Imaging
      1. Complicated sinusitis
      2. Chronic or recurrent sinusitis
      3. Sinusitis refractory to maximal medical therapy
      4. Imaging is not needed in routine cases
        1. Empiric therapy for 1-2 courses is appropriate
    2. Sinus XRay (Sinus CT preferred)
      1. Single Waters' View XRay is sufficient
      2. Indication (rarely indicated unless CT not available)
        1. Complicated Acute Sinusitis
        2. Suspected Chronic Sinusitis
    3. Sinus CT (gold standard) Indications
      1. Osteomeatal complex occlusion
      2. Chronic Sinusitis
      3. Recurrent Sinusitis
      4. Allergic Fungal Sinusitis
    4. Sinus MRI
      1. No advantage over Sinus CT (and more false positives)
      2. Indications
        1. Suspected neoplasm
        2. Fungal Sinusitis
  13. Complications
    1. Orbital Cellulitis
    2. Meningitis
    3. Extradural abscess
    4. Subdural abscess
    5. Brain abscess
    6. Osteomyelitis
    7. Cavernous Sinus Thrombosis
  14. Management
    1. See Acute Sinusitis Management
  15. Referral Indications
    1. See Red Flag Symptoms above
  16. Reference
    1. Giebink (1994) Pediatr Infect Dis J 13(suppl 1):S55
    2. Hadley (1997) Otolaryngol Head Neck Surg 117:S8
    3. Lanza (1997) Otolaryngol Head Neck Surg 117:S1
    4. Osguthorpe (2001) Am Fam Physician 63:69
    5. Slavin (1991) J Allergy Clin Immunol 88:141
    6. Williams (1993) JAMA 270:1242

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