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

Sinusitis

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

Introduction

Background

Traditionally, sinusitis is defined as an inflammation of the mucosal lining of one or more of the paranasal sinuses. The term rhinosinusitis is now used interchangeably with sinusitis to emphasize the concurrent inflammation of the nasal passages that occurs with sinus mucosal inflammation. Sinusitis is subdivided into acute (symptoms lasting <4 wk), subacute (symptoms lasting 4-12 wk), and chronic (symptoms lasting >12 wk).¹

Pathophysiology

The paranasal sinuses are in direct communication with the nasopharynx. The sinuses are normally sterile, but their proximity to nasopharyngeal flora allows bacterial and viral inoculation following rhinitis. Diseases that obstruct drainage can result in a reduced ability of the paranasal sinuses to function normally. The sinus ostia become occluded, leading to mucosal congestion. The mucociliary transport system becomes impaired, leading to stagnation of secretions and epithelial damage, followed by decreased oxygen tension and subsequent bacterial growth.

Acute rhinosinusitis is most commonly associated with viral infections such as the common cold. In about 0.5-2% of cases, viral sinusitis can progress to acute bacterial sinusitis.^2,3 Other factors that predispose to the development of acute bacterial rhinosinusitis include allergic rhinitis, impaired mucociliary transport as seen in cystic fibrosis, mechanical obstruction as seen secondary to foreign bodies, intranasal cocaine use and immunodeficient states.³

Acute bacterial sinusitis that does not completely resolve can progress to chronic sinusitis. Other factors associated with chronic sinusitis include allergic rhinitis, fungal colonization of the sinuses, and nasal polyposis. Nasal polyposis, more commonly seen in patients with aspirin sensitivity and asthma, results from a localized allergic hyperresponsivity to bacterial endotoxins. Diseases such as cystic fibrosis, primary ciliary dyskinesia, Wegener granulomatosis, Churg-Strauss vasculitis, and sarcoidosis have also been known to be affiliated with chronic rhinosinusitis.⁴

Frequency

United States

In the United States, approximately 1 billion cases of acute rhinosinusitis and 20 million cases of acute bacterial rhinosinusitis are diagnosed every year.³ About 50% of people with clinically diagnosed acute sinusitis have a bacterial sinus infection.² Medical treatment of rhinosinusitis is expensive, with an estimated $3 billion spent annually.³

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.

Sex

Sinusitis occurs equally in males and females. 

Age

Sinusitis is more commonly seen in young or middle-aged adults.⁴ Sinusitis is rare in children younger than 1 year because the sinuses are poorly developed prior to that age.

Clinical

History

• Sinusitis has 4 main signs.⁴
  • Mucopurulent rhinorrhea
  • Nasal congestion
  • Facial pain, pressure, or fullness
  • Decreased sense of smell
• Some patients report other signs and symptoms.
  • In severe cases, headache, malaise, and fever may also be present.
  • Pain is often exacerbated by head movement, especially leaning forward.
  • Patients may report retro-orbital pain if the ethmoid sinus is involved.
  • Some patients report dental pain, usually involving the maxillary teeth.
  • Ear pressure or fullness may also be seen.
  • Facial pain and headache are rarely reported in children with sinusitis.
• Sinusitis needs to be differentiated from a viral upper respiratory infection (URI) or allergic rhinitis.⁵ Symptoms of allergic rhinitis are often seasonal and may include clear watery anterior and posterior nasal discharge, sneezing, and itchy eyes and nose.
• Cases of viral rhinosinusitis are often difficult to differentiate from acute bacterial rhinosinusitis.⁵ The latter usually presents with a high fever, acute facial pain, swelling or erythema, sinus tenderness, symptoms of sinusitis lasting greater than 10 days, or symptoms that worsen after initial improvement.³

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 maxillary or frontal sinuses may be seen on transillumination.
• Partial opacification is a nonspecific finding, and it is not as reliable.

Causes

• The most common culprits in acute viral rhinosinusitis are rhinovirus, influenza virus, and parainfluenza virus.
• Community-acquired acute bacterial rhinosinusitis (ABRS) is usually due to a single pathogen, though 2 pathogens can be isolated in up to 25% of cases.³ Streptococcus pneumoniae and Haemophilus influenzae are the organisms most commonly found in adult patients diagnosed with ABRS.
• In chronic sinusitis, the infecting organisms vary, and a higher incidence of anaerobic organisms is seen (eg, Bacteroides, Peptostreptococcus, and Fusobacterium species).⁶
• In children, similar organisms are seen, with the addition of Moraxella catarrhalis. In older children and young adults, Staphylococcus aureus is an occasional culprit.
• Nosocomial sinusitis presenting as fever of unknown origin can be seen in patients with prolonged intensive care unit stays or intubation.³ These patients are at risk of infection with gram-negative organisms including Pseudomonas aeruginosa, Klebsiella pneumoniae, Enterobacter species, Proteus mirabilis, and Serratia marcescens. Gram-positive cocci such as S aureus can also be seen.
• Acute invasive fungal rhinosinusitis can be caused by Candida, Aspergillus, and Phycomycetes species. Risk factors include diabetes mellitus, cancer, hepatic disease, renal failure, burns, extreme malnutrition, and other immunosuppressive diseases.

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