Introduction
Background
Sinusitis is the inflammation/infection of 1 or more paranasal sinuses and occurs with obstruction of the normal drainage mechanism. It is traditionally subdivided into acute (symptoms lasting <3 wk), subacute (symptoms lasting 3 wk to 3 mo), and chronic (symptoms lasting > 3 mo).
Pathophysiology
The paranasal sinuses, a part of the upper respiratory tract, are in direct communication with the nasopharynx. The sinuses are normally sterile. Because of the proximity to nasopharyngeal flora, obstruction can cause bacterial infection.
Diseases that obstruct drainage can result in a reduced ability of the paranasal sinuses to function normally. The sinus ostia may become occluded, leading to mucosal congestion. The mucociliary transport system becomes impaired, leading to more stagnation of secretion and epithelial damage, followed by decreased oxygen tension and subsequent bacterial growth.
Frequency
United States
An estimated more than 30 million patients in the United States have sinus disease. Upper respiratory infections (URIs) are one of the most common presentations in the ED. A viral infection associated with the common cold is the most frequent etiology of acute sinusitis. Only a small percentage (as low as 2%) of viral sinusitis cases are complicated by bacterial sinusitis. The challenge is to differentiate a simple URI and allergic rhinitis from sinusitis. Medical treatment is expensive, with an estimated $5 billion spent annually; another $60 billion is spent on surgical treatment each year.
Mortality/Morbidity
Sinusitis is rarely life threatening, but the close proximity of the paranasal sinuses to the central nervous system, the multiple fascial plains of the neck, and the associated venous and lymphatic channels can lead to serious complications.
Age
An estimated 5-10% of URIs in children are related to sinusitis, while up to 10% of URIs in adults are related to sinusitis. Sinusitis is rare in children younger than 1 year because the sinuses are poorly developed before that age.
Clinical
History
- Presentation of sinusitis is often nonspecific.
- Patients may present with a persistent cold.
- Most complaints are related to the involved sinus.
- Common complaints are nasal congestion, purulent drainage, and facial pain with headache.
- Pain is often exacerbated by leaning forward or any head movement.
- Patients may complain of retro-orbital pain if the ethmoid sinus is involved.
- Some patients complain of dental pain or alteration in smell.
- In pediatric patients, most URIs last 5-7 days.
- By 10 days, the URI almost always improves.
- Most rhinoviral infections improve within 7-10 days so the complaint of persistent or worsening symptoms may indicate a developing bacterial sinusitis.
- Pediatric patients may complain of a daytime cough and persistent nasal discharge.
- Complaints of facial pain and headache are rare in children.
Physical
- Purulent secretions in the middle meatus (highly predictive of maxillary sinusitis) may be seen using a nasal speculum and a directed light.
- Fever is seen in fewer than 2% of individuals with sinusitis.
- Facial tenderness to palpation is present.
- Complete opacification of sinus on transillumination is present.
- Partial opacification is a nonspecific finding, and it is not as reliable.
Causes
Acute sinusitis is usually bacterial in origin. A URI or severe allergic rhinitis leading to obstruction of the ostia and stasis of drainage often precedes it.
- Haemophilus influenzae and Streptococcus pneumoniae are the organisms most commonly found in adults. In chronic sinusitis, the infecting organisms are variable, and a higher incidence of anaerobic organisms is seen (eg, Bacteroides, Peptostreptococcus, and Fusobacterium species).
- In children, similar organisms are seen, with the addition of Moraxella catarrhalis. In older children and young adults, Staphylococcus aureus is an occasional finding.
- In systemically impaired hosts, Candida, Aspergillus, and Phycomycetes may be the cause. Risk factors include the following: diabetes mellitus, cancer, hepatic disease, renal failure, burns, extreme malnutrition, and immunosuppressive diseases.
More on Sinusitis |
 Overview: Sinusitis |
| Differential Diagnoses & Workup: Sinusitis |
| Treatment & Medication: Sinusitis |
| Follow-up: Sinusitis |
| References |
| Next Page » |
References
American Academy of Pediatrics. Clinical practice guideline: management of sinusitis. Pediatrics. Sep 2001;108(3):798-808. [Medline].
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].
Brook I. Microbiology and management of sinusitis. J Otolaryngol. Aug 1996;25(4):249-56. [Medline].
Chow JM. The diagnosis and management of sinusitis. Compr Ther. 1995;21(2):74-9. [Medline].
Duncavage JA. Management of sinusitis. Compr Ther. Apr 1996;22(4):211-6. [Medline].
Osguthorpe JD, Hadley JA. Rhinosinusitis. Current concepts in evaluation and management. Med Clin North Am. Jan 1999;83(1):27-41, vii-viii. [Medline].
Piccirillo JF. Clinical practice. Acute bacterial sinusitis. N Engl J Med. Aug 26 2004;351(9):902-10. [Medline].
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].
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].
Further Reading
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
