II. Pathophysiology

  1. Initial
    1. Mucosal inflammation of Paranasal Sinuses
    2. Sinus ostia irritation and edema
    3. Ciliary transport impaired by infection results in stasis of mucous
  2. Next
    1. Sinus obstruction and stasis
    2. Subsequent sinus infection

III. Epidemiology

  1. Incidence: 31 Million cases per year in U.S.
    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

IV. 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

V. Risk 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

VI. 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. HaemophilusInfluenzae
      3. Moraxella catarrhalis
      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

VII. 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

VIII. Symptoms: Red Flags (consider imaging and 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

IX. 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

X. 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-S14
  3. Symptoms worsen after 5-7 days ("double sickening")
    1. Typical course: Onset, then improvement, then worse again
  4. Purulent Nasal discharge
  5. Maxillary tooth or facial pain (especially if unilateral)
  6. Unilateral Maxillary Sinus tenderness
  7. References
    1. Hickner (2001) Ann Intern Med 134:498-505
    2. Lanza (1997) Otolaryngol Head Neck Surg 117:S1-7

XI. 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

XII. Imaging

  1. Indications for Imaging
    1. Complicated Sinusitis
    2. Chronic or recurrent Sinusitis
    3. Sinusitis refractory to maximal medical therapy
      1. Example: Amoxicillin course for 10 days followed by Levaquin course for 10-14 days
    4. Imaging is not needed in routine cases
      1. Empiric therapy for 1-2 courses is appropriate
  2. Sinus XRay (not recommended)
    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 except for complicated cases (e.g. neoplasm)
      1. More false positive results
    2. Indications
      1. Suspected neoplasm
      2. Fungal Sinusitis

XIII. Complications

  1. Orbital Cellulitis
  2. Meningitis
  3. Extradural abscess
  4. Subdural abscess
  5. Brain abscess
  6. Osteomyelitis
  7. Cavernous Sinus Thrombosis

XIV. Management

  1. See Acute Sinusitis Management
  2. Referral Indications
    1. See Red Flag Symptoms above

Images: Related links to external sites (from Google)

Ontology: Sinusitis (C0037199)

Definition (MSH) Inflammation of the NASAL MUCOSA in one or more of the PARANASAL SINUSES.
Definition (NCI) An acute or chronic infectious process affecting the mucous membranes of the paranasal sinuses.
Definition (NCI) A disorder characterized by an infectious process involving the mucous membranes of the paranasal sinuses.
Definition (MEDLINEPLUS)

Sinusitis means your sinuses are infected or inflamed. Your sinuses are hollow air spaces within the bones surrounding the nose. They produce mucus, which drains into the nose. If your nose is swollen, this can block the sinuses and cause pain and infection.

Sinusitis can be acute, lasting for less than four weeks, or chronic, lasting much longer. Acute sinusitis often starts as a cold, which then turns into a bacterial infection. Allergies, pollutants, nasal problems and certain diseases can also cause sinusitis.

Symptoms of sinusitis can include fever, weakness, fatigue, cough and congestion. There may also be mucus drainage in the back of the throat, called postnasal drip. Treatments include antibiotics, decongestants and pain relievers. Using heat pads on the inflamed area, saline nasal sprays and vaporizers can also help.

NIH: National Institute of Allergy and Infectious Diseases

Definition (CSP) inflammatory process of the mucous membranes of the paranasal sinuses that occurs in three stages: acute, subacute, and chronic; results from any condition causing ostial obstruction or from pathophysiologic changes in the mucociliary transport mechanism.
Concepts Disease or Syndrome (T047)
MSH D012852
SnomedCT 275483004, 36971009, 195649005
English Sinusitides, SINUSITIS, Sinusitis, NOS, sinusitis (diagnosis), sinusitis, Sinusitis NOS, Sinusitis [Disease/Finding], sinus infection, Sinus Infection, Sinusitis, Sinusitis (disorder), inflammation; nasal sinus, inflammation; sinus, nasal sinus; inflammation, sinus; inflammation, Unspecified sinusitis
French SINUSITE, Sinusite SAI, Sinusite
Portuguese SINUSITE, Sinusite NE, Sinusite
Spanish SINUSITIS, Sinusitis NEOM, Sinusitis, sinusitis (trastorno), sinusitis
German SINUSITIS, Sinusitis NNB, Sinusitis, Nasennebenhöhlenentzündung, Nebenhöhlenentzündung
Dutch sinusitis NAO, neusbijholte; ontsteking, ontsteking; neusbijholte, ontsteking; sinus, sinus; ontsteking, sinusitis, Sinusitis
Italian Sinusite NAS, Sinusite
Japanese 副鼻腔炎, 副鼻腔炎NOS, フクビクウエン, フクビクウエンNOS
Swedish Bihåleinflammation
Czech sinusitida, vedlejší nosní dutiny - zánět, zánět paranazálních dutin, zánět vedlejších nosních dutin, Sinusitida NOS, Sinusitida
Finnish Sinuiitti
Russian SINUSIT, СИНУСИТ
Croatian SINUSITIS
Polish Zapalenie zatok przynosowych
Hungarian Sinusitis k.m.n., sinusitis

Ontology: Acute sinusitis (C0149512)

Concepts Disease or Syndrome (T047)
ICD9 461.9, 461
ICD10 J01 , J01.9, J01.90
SnomedCT 195649005, 155498004, 195653007, 15805002, 155501004, 266378004
English ACUTE SINUSITIS, Acute Sinusitis, Acute infection of nasal sinus, NOS, Acute inflammation of nasal sinus, NOS, Acute sinusitis, NOS, Acute sinusitis NOS, Acute sinusitis, unspecified, SINUSITIS ACUTE, acute sinusitis (diagnosis), acute sinusitis, Sinusitis (& acute) (disorder), Sinusitis acute NOS, Acute sinusitis NOS (disorder), acute infection of sinus, acute inflammation of sinus, Sinusitis;acute, sinusitis acute, acute sinus infection, Acute sinusitis, Acute infection of sinus, Acute inflammation of sinus, Acute inflammation of nasal sinus, Acute sinusitis (disorder), acute; sinusitis, sinusitis; acute, Sinusitis (& acute)
Italian Sinusite acuta, Sinusite acuta NAS, Sinusite acuta, non specificata
Dutch sinusitis acuut NAO, acute sinusitis, niet-gespecificeerd, acuut; sinusitis, sinusitis; acuut, Acute sinusitis, niet gespecificeerd, acute sinusitis, Acute sinusitis
French Sinusite aiguë, non précisée, Sinusite aiguë SAI, Sinusite aiguë
German akute Sinusitis, unspezifisch, Sinusitis akut NNB, Akute Sinusitis, nicht naeher bezeichnet, Akute Sinusitis, akute Sinusitis
Portuguese Sinusite aguda NE, Sinusite aguda
Spanish Sinusitis aguda no especificada, Sinusitis aguda NEOM, Sinusitis (& acute), Acute sinusitis, Acute sinusitis NOS, Sinusitis, inflamación aguda de seno paranasal, sinusitis aguda (trastorno), sinusitis aguda, SAI (trastorno), sinusitis aguda, SAI, sinusitis aguda, Sinusitis aguda
Japanese 急性副鼻腔炎、詳細不明, 急性副鼻腔炎, 急性副鼻腔炎NOS, キュウセイフクビクウエンショウサイフメイ, キュウセイフクビクウエンNOS, キュウセイフクビクウエン
Czech Akutní sinusitida, blíže neurčená, Akutní sinusitida, Akutní sinusitida NOS
Korean 급성 굴염, 상세불명의 급성 굴염
Hungarian Sinusitis acuta k.m.n., heveny sinusitis, k.m.n., acut sinusitis