eMedicine Specialties > Emergency Medicine > Ear, Nose, & Throat

Sinusitis: Differential Diagnoses & Workup

Author: Hina Z Ghory, MD, Chief Resident Physician, Department of Emergency Medicine, New York Presbyterian Hospital
Coauthor(s): Rahul Sharma, MD, MBA, FACEP, Assistant Professor, Weill Medical College of Cornell University; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Contributor Information and Disclosures

Updated: Aug 19, 2009

Differential Diagnoses

Headache, Cluster
Headache, Migraine
Headache, Tension
Otitis Media

Other Problems to Be Considered

Dental infections
Periapical abscess
Upper respiratory tract infection

Workup

Laboratory Studies

  • Acute sinusitis is usually a clinical diagnosis.
  • Rarely, sinusitis may be the presenting disorder in systemic diseases such as Wegener granulomatosis, Churg-Strauss vasculitis, or sarcoidosis. When these diagnoses are considered, the following tests may be informative:
    • Complete blood count with differential
    • Erythrocyte sedimentation rate
    • Antineutrophil cytoplasmic antibodies (ANCA) - Elevated in patients with Churg-Strauss vasculitis and Wegener granulomatosis
    • Serum angiotensin – converting enzyme level - Elevated in patients with sarcoidosis

Imaging Studies

  • Sinus radiography: False-negative results occur in 40% of cases; mucosal thickening or air fluid levels may be seen.
  • A-mode ultrasonography has very little advantage over plain radiography.
  • Computerized tomography (CT): CT scanning is more sensitive than plain radiography for showing evidence of sinusitis. Up to 42% of asymptomatic patients may have signs of mucosal abnormality on CT scan.3 CT scanning is used extensively by otolaryngology (ENT) specialists to confirm the diagnosis of chronic sinusitis or recurrent acute sinusitis. While CT results are nonspecific, a normal CT can be used to rule out sinusitis. CT scanning is also recommended in patients with signs of intracranial or orbital extension.
  • Magnetic resonance imaging (MRI) can be used in conjunction with CT scan to delineate soft tissue extension in complicated sinusitis.
  • Imaging is not mandatory to the diagnosis. Uncomplicated sinusitis is often diagnosed clinically, with studies reserved for complicated cases or patients who are nonresponsive to the usual therapies.

Other Tests

  • Sinus cultures and biopsy: Bacterial or fungal cultures and tissue samples can be obtained directly from the sinus ostia by ENT specialists to diagnose resistant bacteria or unusual organisms. Nasal swabs are not an adequate source of typing the bacteria causing sinusitis.

More on Sinusitis

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

  1. American Academy of Pediatrics. Clinical practice guideline: management of sinusitis. Pediatrics. Sep 2001;108(3):798-808. [Medline].

  2. Ah-See, K. Sinusitis (acute). BMJ Clin Evid. 2008;03:511.

  3. Hwang PH, Getz A. Acute sinusitis and rhinosinusitis in adults. UpToDate. Available at www.uptodate.com. Accessed June 7th, 2009.

  4. Hamilos DL. Clinical manifestations, pathophysiology, and diagnosis of chronic rhinosinusitis. UpToDate. Available at www.uptodate.com. Accessed June 7th, 2009.

  5. Lusk RP, Stankiewicz JA. Pediatric rhinosinusitis. Otolaryngol Head Neck Surg. Sep 1997;117(3 Pt 2):S53-7. [Medline].

  6. Brook I. Microbiology and management of sinusitis. J Otolaryngol. Aug 1996;25(4):249-56. [Medline].

  7. Falagas ME, Giannopoulou KP, Vardakas KZ, Dimopoulos G, Karageorgopoulos DE. Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis of randomised controlled trials. Lancet Infect Dis. Sep 2008;8(9):543-52. [Medline].

  8. [Guideline] National Guidelines Clearinghouse: Adult Sinusitis. Accessed June 28, 2009. [Full Text].

  9. Benninger MS, Sedory Holzer SE, Lau J. Diagnosis and treatment of uncomplicated acute bacterial rhinosinusitis: summary of the Agency for Health Care Policy and Research evidence-based report. Otolaryngol Head Neck Surg. Jan 2000;122(1):1-7. [Medline].

  10. Chow JM. The diagnosis and management of sinusitis. Compr Ther. 1995;21(2):74-9. [Medline].

  11. Duncavage JA. Management of sinusitis. Compr Ther. Apr 1996;22(4):211-6. [Medline].

  12. Joe SA, Thambi R, Huang J. A systematic review of the use of intranasal steroids in the treatment of chronic rhinosinusitis. Otolaryngol Head Neck Surg. Sep 2008;139(3):340-7. [Medline].

  13. Osguthorpe JD, Hadley JA. Rhinosinusitis. Current concepts in evaluation and management. Med Clin North Am. Jan 1999;83(1):27-41, vii-viii. [Medline].

  14. Piccirillo JF. Clinical practice. Acute bacterial sinusitis. N Engl J Med. Aug 26 2004;351(9):902-10. [Medline].

  15. Snow V, Mottur-Pilson C, Gonzales R. Principles of appropriate antibiotic use for treatment of acute bronchitis in adults. Ann Intern Med. Mar 20 2001;134(6):518-20. [Medline].

  16. Williams JW, Simel DL. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA. Sep 8 1993;270(10):1242-6. [Medline].

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Further Reading

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Keywords

sinusitis, sinus inflammation, sinus infection, paranasal sinuses, inflammation of paranasal sinuses, infection of paranasal sinuses, nasopharyngeal flora, sinus disease, upper respiratory infections, URI, acute sinusitis, subacute sinusitis, chronic sinusitis, bacterial sinusitis, allergic rhinitis, severe allergic rhinitis, rhinoviral infection, maxillary sinusitis, Haemophilus influenzae, H influenzae, Streptococcus pneumoniae, S pneumoniae, Bacteroides, Peptostreptococcus, Fusobacterium, Moraxella catarrhalis, M catarrhalis, Staphylococcus aureus, S aureus, Candida, Aspergillus, Phycomycetes

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Contributor Information and Disclosures

Author

Hina Z Ghory, MD, Chief Resident Physician, Department of Emergency Medicine, New York Presbyterian Hospital
Hina Z Ghory, MD is a member of the following medical societies: American Medical Women's Association and Phi Beta Kappa
Disclosure: Nothing to disclose.

Coauthor(s)

Rahul Sharma, MD, MBA, FACEP, Assistant Professor, Weill Medical College of Cornell University; Attending Physician, Department of Emergency Medicine, New York Presbyterian Hospital-Weill Cornell Medical Center
Rahul Sharma, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Daniel J Dire, MD, FACEP, FAAP, FAAEM, Clinical Associate Professor, Department of Emergency Medicine, University of Texas-Houston
Daniel J Dire, MD, FACEP, FAAP, FAAEM is a member of the following medical societies: American Academy of Clinical Toxicology, American Academy of Emergency Medicine, American Academy of Pediatrics, American College of Emergency Physicians, and Association of Military Surgeons of the US
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

Mark W Fourre, MD, Program Director, Department of Emergency Medicine, Maine Medical Center; Associate Clinical Professor, Department of Surgery, University of Vermont School of Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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