eMedicine Specialties > Infectious Diseases > HEENT Infections

Sinusitis, Chronic: Differential Diagnoses & Workup

Author: Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Coauthor(s): Himal Bajracharya, MBBS, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, Kansas University Medical Center; Daniel Hinthorn, MD, Director, Division of Infectious Diseases, Professor, Departments of Internal Medicine, Pediatrics and Family Medicine, University of Kansas
Contributor Information and Disclosures

Updated: Jun 17, 2009

Differential Diagnoses

Fever of Unknown Origin
Gastroesophageal Reflux Disease
Rhinitis, Allergic
Rhinocerebral Mucormycosis
Sinusitis, Acute

Other Problems to Be Considered

Temporomandibular joint syndrome
Asthma
Other chronic rhinitis
Nasal and sinus cavity tumors
Facial pain attributable to other causes
Nasal polyp
Dental infection
Periodontal abscess

Workup

Laboratory Studies

  • Studies of chronic sinusitis have demonstrated no correlation between nasal flora and culture from the sinuses.
  • Nasal swab cultures have no diagnostic value.
  • Occasionally, an abundance of eosinophils in the nasal smear suggests an allergic etiology.
  • Specimens obtained from sinus openings via endoscopy correlate well with those obtained with endoscopic surgery or sinus puncture. These should be processed for cultivation of aerobic and anaerobic bacteria, as well as fungi. Specimens evaluated for anaerobic bacteria should be sent in proper transport media. Liquid specimens are preferred to swab specimens.
  • Routine blood cell counts and sedimentation rates are generally unhelpful; however, these may be elevated in patients with fever.
  • In severe cases, blood cultures, including fungal blood cultures, may be helpful.
  • Perform allergy testing if allergy is thought to be the underlying cause.
  • Associated immune deficiency is evaluated with serum immunoglobulin and IgG subclass determination, antibody response to specific antigens, and HIV antibody testing (when indicated).

Imaging Studies

The cornerstone in the diagnostic workup of chronic sinusitis is the radiologic examination.

  • Plain radiography
    • Routine sinus radiography has limited value in the evaluation of chronic sinusitis.
    • Plain radiography may show mucosal thickenings or sinus opacities.
    • Air fluid levels are uncommon in chronic sinusitis.
    • Ethmoid sinuses and the ostiomeatal complex are not visualized well on plain sinus radiography.
  • CT scan
    • Contrast-enhanced CT scan is the current radiologic criterion standard for the evaluation of sinus diseases, although performing CT scanning in all patients with chronic sinus disease may be prohibitively expensive or medically unnecessary.
    • CT scans are usually indicated after failure of maximal medical therapy, before surgical planning for evaluation of suspected complications, and when a neoplasm is a possibility.
    • Coronal CT scan of the sinus correlates best with the surgical approach, permitting visualization of the anatomy of the nasal cavity, ostiomeatal complex, sinus cavities, and surrounding structures such as the orbit, cribriform plate, and optic canal. Anatomic obstructions at the ostiomeatal complex and dental pathologies are visualized well. Specific entities in the sinus cavity, such as aspergilloma, are also visualized well.
    • CT scan combined with endoscopic examination helps the surgeon to make operative decisions.
    • Most centers now offer limited sinus CT scans that consist of 5-12 coronal cuts. These limited or screening CT scans cost about the same as a plain radiography but provide more information.
  • MRI
    • MRI is generally reserved only for complex cases.
    • Soft-tissue contrast is better with MRI.
    • Neoplasms, orbital and intracranial complications, and fungal sinusitis can be better evaluated with MRI.

Procedures

  • Cultures are most accurate if obtained with endoscopy.

More on Sinusitis, Chronic

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

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  2. Biel MA, Brown CA, Levinson RM, et al. Evaluation of the microbiology of chronic maxillary sinusitis. Ann Otol Rhinol Laryngol. Nov 1998;107(11 Pt 1):942-5. [Medline].

  3. Brook I. Acute and chronic bacterial sinusitis. Infect Dis Clin North Am. Jun 2007;21(2):427-48, vii. [Medline].

  4. United States Food and Drug Administration. Zicam cold remedy nasal products (Cold Remedy Nasal Gel, Cold Remedy Nasal Swabs, and Cold Remedy Saws, Kids Size). MedWatch Public Health Advisory. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm166996.htm. Accessed June 16, 2009.

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Further Reading

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Keywords

chronic sinusitis, acute sinusitis, sinus infection, paranasal sinus, postnasal drip, facial pain, hyposmia, rhinitis, fungal sinusitis, cystic fibrosis, CF, asthma, nasal polyps, allergy, allergies, gastroesophageal reflux disease, GERD, brain abscess, meningitis, Streptococcus pneumoniae, S pneumoniae, Haemophilus influenzae, H influenzae, Moraxella catarrhalis, M catarrhalis, functional endoscopic sinus surgery, FESS

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Contributor Information and Disclosures

Author

Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society
Disclosure: Nothing to disclose.

Coauthor(s)

Himal Bajracharya, MBBS, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, Kansas University Medical Center
Himal Bajracharya, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Daniel Hinthorn, MD, Director, Division of Infectious Diseases, Professor, Departments of Internal Medicine, Pediatrics and Family Medicine, University of Kansas
Daniel Hinthorn, MD is a member of the following medical societies: American Academy of Family Physicians and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Kenneth C Earhart, MD, Deputy Head, Disease Surveillance Program, United States Naval Medical Research Unit #3
Kenneth C Earhart, MD is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

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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