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Sinusitis, Acute: Differential Diagnoses & Workup

Author: Brian E Benson, MD,, Attending Physician, Department of Otolaryngology, St Luke's-Roosevelt Hospital Center; Clinical Assistant Professor, Department of Otolaryngology, Hackensack University Medical Center; Director, The Voice Center, Hackensack University Medical Center
Coauthor(s): Linas Riauba, MD, Assistant Professor of Clinical Medicine, Department of Medicine, Section of Infectious Disease, University Hospital, University of Medicine and Dentistry of New Jersey; Tracey Quail Davidoff, MD, Senior Clinical Instructor, Department of Emergency Medicine, Rochester General Hospital
Contributor Information and Disclosures

Updated: Feb 10, 2009

Differential Diagnoses

Adenoviruses
Mucormycosis
Allergic and Environmental Asthma
Parainfluenza Virus
Asthma
Rhinitis, Allergic
Bronchitis
Rhinocerebral Mucormycosis
Haemophilus Influenzae Infections
Rhinoviruses
Human T-Cell Lymphotrophic Viruses
Sarcoidosis
Immunosuppression
Sinusitis, Chronic
Influenza
Staphylococcal Infections
Kartagener Syndrome
Streptococcus Group A Infections
Lymphoma, B-Cell
Streptococcus Group B Infections
Moraxella Catarrhalis Infections

Other Problems to Be Considered

Gastroesophageal reflux
Cystic fibrosis
Immotile cilia syndrome
Migraine headache
Sinonasal polyposis
Chemical rhinitis
Nasal foreign body
Chronic invasive fungal sinusitis
Sinonasal neoplasm

Workup

Laboratory Studies

  • The erythrocyte sedimentation rate and C-reactive protein level may be elevated in rhinosinusitis, but these findings are nonspecific.
  • The findings of CBC count with differential may be within reference ranges.
  • Nasal cytology examinations may be useful to elucidate the following entities:
    • Allergic rhinitis
    • Eosinophilia
    • Nasal polyposis
    • Aspirin sensitivity
  • Sweat chloride test screening should be performed if cystic fibrosis is suggested.
  • Ciliary function studies help screen for Kartagener syndrome.
  • Tests for immunodeficiency are indicated if history findings indicate recurrent infection, to include the following:
    • Immunoglobulin studies
    • HIV serology
  • Cultures of nasal secretions are of limited value because they are usually contaminated by normal flora.

Imaging Studies

  • Findings on standard radiography are insensitive, especially for ethmoidal disease. Waters view is best.
  • CT scanning is the preferred imaging method for rhinosinusitis.
    • A screening sinus CT scan is adequate for diagnosis and less expensive than other methods but is necessary only in cases of treatment failure or chronic rhinosinusitis.
    • A complete sinus CT scan with frontal and coronal planes is used if an alternate diagnosis (eg, tumors) must be excluded.
    • CT scan findings are used to differentiate orbital cellulitis from periorbital cellulitis as a complication or to evaluate extension into intracranial space.
  • MRI is useful only if fungal infection or a tumor is suggested.
  • Ultrasonography is of limited use.

Procedures

  • Paranasal biopsy is used to help exclude neoplasia, fungal disease, and granulomatous disease.
  • Fiberoptic sinus endoscopy is used to visualize posterior sinonasal structures. This test is useful in chronic or recurrent rhinosinusitis and to help exclude structural lesions, fungal disease, and granulomatous diseases.

More on Sinusitis, Acute

Overview: Sinusitis, Acute
Differential Diagnoses & Workup: Sinusitis, Acute
Treatment & Medication: Sinusitis, Acute
Follow-up: Sinusitis, Acute
References
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References

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  2. Gwaltney JM Jr. Acute community-acquired sinusitis. Clin Infect Dis. Dec 1996;23(6):1209-23; quiz 1224-5. [Medline].

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  4. Ray NF, Baraniuk JN, Thamer M. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol. Mar 1999;103(3 Pt 1):408-14. [Medline].

  5. Hansen JG, Schmidt H, Rosborg J, Lund E. Predicting acute maxillary sinusitis in a general practice population. BMJ. Jul 22 1995;311(6999):233-6. [Medline].

  6. Gwaltney JM, Hendley JO, Simon G. Rhinovirus infections in an industrial population. II. Characteristics of illness and antibody response. JAMA. Nov 6 1967;202(6):494-500. [Medline].

  7. Hickner JM, Bartlett JG, Besser RE. Principles of appropriate antibiotic use for acute rhinosinusitis in adults: background. Ann Intern Med. Mar 20 2001;134(6):498-505. [Medline].

  8. Jacobs MR, Bajaksouzian S, Windau A, Good CE, Lin G, Pankuch GA. Susceptibility of Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis to 17 oral antimicrobial agents based on pharmacodynamic parameters: 1998-2001 U S Surveillance Study. Clin Lab Med. Jun 2004;24(2):503-30. [Medline].

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  10. Brook I, Foote PA, Hausfeld JN. Increase in the frequency of recovery of meticillin-resistant Staphylococcus aureus in acute and chronic maxillary sinusitis. J Med Microbiol. Aug 2008;57:1015-7. [Medline].

  11. [Best Evidence] Zalmanovici A, Yaphe J. Steroids for acute sinusitis. Cochrane Database Syst Rev. Apr 18 2007;CD005149. [Medline].

  12. [Best Evidence] Williamson IG, Rumsby K, Benge S, Moore M, Smith PW, Cross M, et al. Antibiotics and topical nasal steroid for treatment of acute maxillary sinusitis: a randomized controlled trial. JAMA. Dec 5 2007;298(21):2487-96. [Medline].

  13. [Best Evidence] Ahovuo-Saloranta A, Borisenko OV, Kovanen N, Varonen H, Rautakorpi UM, Williams JW Jr, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev. Apr 16 2008;CD000243. [Medline].

  14. Young J, De Sutter A, Merenstein D, van Essen GA, Kaiser L, Varonen H, et al. Antibiotics for adults with clinically diagnosed acute rhinosinusitis: a meta-analysis of individual patient data. Lancet. Mar 15 2008;371(9616):908-14. [Medline].

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  17. Bailey BJ, Calhoun KH, et al. Head & Neck Surgery - Otolaryngology, 3rd edition. 2001;vol 1.

  18. Benninger MS, Payne SC, Ferguson BJ, Hadley JA, Ahmad N. Endoscopically directed middle meatal cultures versus maxillary sinus taps in acute bacterial maxillary rhinosinusitis: a meta-analysis. Otolaryngol Head Neck Surg. Jan 2006;134(1):3-9. [Medline].

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  21. [Best Evidence] Karageorgopoulos DE, Giannopoulou KP, Grammatikos AP, Dimopoulos G, Falagas ME. Fluoroquinolones compared with beta-lactam antibiotics for the treatment of acute bacterial sinusitis: a meta-analysis of randomized controlled trials. CMAJ. Mar 25 2008;178(7):845-54. [Medline].

  22. Meltzer EO, Bachert C, Staudinger H. Treating acute rhinosinusitis: comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo. J Allergy Clin Immunol. Dec 2005;116(6):1289-95. [Medline].

  23. Meltzer EO, Hamilos DL, Hadley JA, Lanza DC, Marple BF, Nicklas RA, et al. Rhinosinusitis: developing guidance for clinical trials. J Allergy Clin Immunol. Nov 2006;118(5 Suppl):S17-61. [Medline].

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  27. Varonen H, Rautakorpi UM, Nyberg S, Honkanen PO, Klaukka T, Palva E, et al. Implementing guidelines on acute maxillary sinusitis in general practice--a randomized controlled trial. Fam Pract. Apr 2007;24(2):201-6. [Medline].

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Further Reading

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Keywords

acute sinusitis, rhinosinusitis, acute rhinosinusitis, common cold, seasonal allergy, bacterial infection, flu, Streptococcus pneumoniae, S pneumoniae, Haemophilus influenzae, H influenzae, acute ethmomaxillary sinusitis, rhinitis, subacute sinusitis, subacute rhinosinusitis, maxillary sinusitis, ethmoidal sinusitis, frontal sinusitis, sphenoidal viral sinusitis, bacterial sinusitis, fungal orbital sinusitis, intracranial sinusitis, maxillary rhinosinusitis, ethmoidal rhinosinusitis, frontal rhinosinusitis, sphenoidal viral rhinosinusitis, bacterial rhinosinusitis, fungal orbital rhinosinusitis, intracranial rhinosinusitis, acute viral rhinosinusitis, acute bacterial rhinosinusitis, acute viral sinusitis, acute bacterial sinusitis

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Contributor Information and Disclosures

Author

Brian E Benson, MD,, Attending Physician, Department of Otolaryngology, St Luke's-Roosevelt Hospital Center; Clinical Assistant Professor, Department of Otolaryngology, Hackensack University Medical Center; Director, The Voice Center, Hackensack University Medical Center
Brian E Benson, MD, is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, and Sigma Xi
Disclosure: Nothing to disclose.

Coauthor(s)

Linas Riauba, MD, Assistant Professor of Clinical Medicine, Department of Medicine, Section of Infectious Disease, University Hospital, University of Medicine and Dentistry of New Jersey
Linas Riauba, MD is a member of the following medical societies: American Medical Association and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Tracey Quail Davidoff, MD, Senior Clinical Instructor, Department of Emergency Medicine, Rochester General Hospital
Tracey Quail Davidoff, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Forensic Examiners, American College of Physicians, and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Thomas Herchline, MD, Professor of Medicine, Wright State University Boonshoft School of Medicine; Medical Director, Public Health, Dayton and Montgomery County, Ohio
Thomas Herchline, MD is a member of the following medical societies: American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Gordon L Woods, MD, Consulting Staff, Department of Internal Medicine, University Medical Center
Gordon L Woods, MD is a member of the following medical societies: Society of General Internal Medicine
Disclosure: Nothing to disclose.

CME Editor

Eleftherios Mylonakis, MD, Clinical and Research Fellow, Department of Internal Medicine, Division of Infectious Diseases, Massachusetts General Hospital
Eleftherios Mylonakis, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians, American Society for Microbiology, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Chief Editor

Burke A Cunha, MD, Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital
Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

 
 
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