Acute Sinusitis Clinical Presentation

Acute sinusitis is a clinical diagnosis; thus, an understanding of its presentation is of paramount importance in differentiating this entity from allergic or vasomotor rhinitis and common upper respiratory infections. No specific clinical symptom or sign is sensitive or specific for acute sinusitis, so the overall clinical impression should be used to guide management.

Risk factors include smoking, older age,  air travel, experiencing changes in atmospheric pressure, swimming, asthma, allergies, dental disease, and immunodeficiency.

A history of occupational or allergic rhinitis, vasomotor rhinitis, nasal polyps, rhinitis medicamentosa, or immunodeficiency should be sought in an evaluation for rhinosinusitis. Rhinosinusitis is more common in individuals with congenital defects that affect humoral immunity and ciliary motility, in those with cystic fibrosis, and in persons with AIDS.

Obtain a history of diabetes or organ transplant if invasive fungal sinusitis is being considered. Fungal infections are more common in people with diabetes and those who are immunocompromised. Clinicians should maintain a high index of suspicion for acute invasive fungal sinusitis in immunocompromised patients with orbital or CNS complications of rhinosinusitis.

Clinical findings may include the following:

• Pain over cheek and radiating to frontal region or teeth, increasing with straining or bending down

• Redness of nose, cheeks, or eyelids

• Tenderness to pressure over the floor of the frontal sinus immediately above the inner canthus

• Referred pain to the vertex, temple, or occiput

• Postnasal discharge

• A blocked nose

• Persistent coughing or pharyngeal irritation

• Facial pain

• Hyposmia

The duration of the condition should be determined. Suspect acute sinusitis in any patient with an upper respiratory tract infection that persists beyond 7-10 days, particularly if the infection is severe and is accompanied by high fever, purulent nasal discharge, or periorbital edema (ethmoid sinusitis).

The condition may start as an upper respiratory tract infection, and the patient may seem to be recovering; however, the condition becomes acutely worse around the seventh day of illness. This should be considered a red flag because most upper respiratory tract infections last 5-7 days. The natural history of rhinovirus infection, as described by Gwaltney et al, lasts from 1-33 days. One fourth of patients have symptoms that last longer than 14 days. ^[32]

Bacterial and viral sinusitis

During the course of a viral upper respiratory tract infection, 3 common clinical presentations should prompt the clinician to consider that the patient is experiencing an episode of acute bacterial sinusitis. These presentations are described as onset with persistent symptoms, onset with severe symptoms, or onset with worsening symptoms. What is meant by persistent symptoms, in the context of acute bacterial sinusitis, is respiratory symptoms that last more than 10 days but less than 30 days and which have not begun to improve. Such symptoms include nasal discharge (of any quality, eg, thick or thin, serous, mucoid or purulent) or daytime cough (which may be worse at night) or both.

A consensus statement published in 2007 in Otolaryngology-Head and Neck Surgery made strong recommendations that clinicians should distinguish between acute rhinosinusitis caused by bacterial causes and those episodes caused by viral upper respiratory infections and noninfectious conditions. ^[33]

The panel suggests that the diagnosis of acute bacterial sinusitis be entertained when (1) symptoms or signs of acute rhinosinusitis are present 10 days or more beyond the onset of upper respiratory symptoms, or (2) symptoms or signs of acute rhinosinusitis worsen within 10 days after an initial improvement. A history of purulent secretions and facial or dental pain are specific symptoms that may point to a bacterial etiology. In a patient in intensive care, acute sinusitis should be suspected in the presence of sepsis of unknown origin.

The consensus statement is in accordance with the AAAAI 2005 practice parameter for diagnosis and management of sinusitis, which states that upper respiratory tract infections persisting after 10-14 days are suspicious for acute bacterial sinusitis. The likelihood of bacterial disease increases if the infection history includes persistent purulent rhinorrhea, postnasal drainage, and facial pain. ^[4]

The 2007 guidelines ^[33] were updated in 2015 ^[34] based on evidence from 42 new systematic reviews. They included a new algorithm to clarify action statement relationships and expanded opportunities for watchful waiting (without antibiotic therapy) as initial therapy for acute bacterial rhinosinusitis. They strongly recommended that clinicians (1) distinguish presumed acute bacterial rhinosinusitis from acute sinusitis caused by viral upper respiratory infections and noninfectious conditions and (2) confirm a clinical diagnosis of chronic sinusitis with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography.

Acute bacterial rhinosinusitis is commonly overdiagnosed. In fact, acute bacterial rhinosinusitis is the correct diagnosis in only 40-50% of cases in which a primary care physician initially classifies a patient as likely having the condition. ^[35]

Although diagnostic criteria for acute rhinosinusitis have been proposed, ^[36] no single sign or symptom has strong diagnostic value for bacterial rhinosinusitis. ^[37] As noted, however, acute bacterial rhinosinusitis should be suspected in patients who exhibit symptoms of viral upper respiratory tract infection that do not improve after 10 days or that worsen after 5-7 days.

Symptoms of acute bacterial rhinosinusitis include the following:

• Facial pain or pressure (especially unilateral)

• Hyposmia/anosmia

• Nasal congestion

• Nasal drainage

• Postnasal drip

• Fever

• Cough

• Fatigue

• Maxillary dental pain

• Ear fullness/pressure

A change in the color or characteristic of the nasal discharge is not a specific sign of bacterial rhinosinusitis. A previous diagnosis of rhinosinusitis is not a predictor of acute bacterial rhinosinusitis. ^[37]

Anterior rhinoscopic examination, with or without a topical decongestant, is important to assess the status of the nasal mucosa and the presence and color of nasal discharge. Predisposing anatomical variations can also be noted during anterior rhinoscopy.

Endoscopic examination may reveal the origin of the purulent discharge from the middle meatus and may provide information about the nature of ostiomeatal obstruction. The use of endoscopy may also aid in the etiologic diagnosis of acute sinusitis by allowing the careful attainment of purulent secretions from the sinus ostia for culture. Purulent secretions in the middle meatus (highly predictive of maxillary sinusitis) may be seen using a nasal speculum and a directed light. Purulence can occur with and without any sinus bacterial infection, and is often present in those with nasopharyngitis. ^[38]

Fever is seen in fewer than 2% of individuals with sinusitis. Sinus transillumination and palpation are of little predictive value. 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. A basic evaluation of ocular and neurological function is also necessary to rule out potential complications.

The following may be noted:

• Purulent nasal secretions

• Purulent posterior pharyngeal secretions

• Mucosal erythema

• Periorbital edema

• Tenderness overlying sinuses

• Air-fluid levels on transillumination of the sinuses (60% reproducibility rate for assessing maxillary sinus disease)

• Facial erythema

Evaluation of the pediatric patient

Sinusitis and upper respiratory tract infections are common pediatric problems. As many as 10% of upper respiratory tract infections can be complicated by acute sinusitis. Untreated chronic sinusitis can lead to life-threatening complications.

Physical examination findings may not be helpful in making a diagnosis of acute bacterial sinusitis in a child because the findings are almost identical to those of a child with viral rhinosinusitis. The presence of pus in the middle meatus suggests involvement of maxillary, frontal, or ethmoid sinuses; pus in the superior meatus suggests involvement of sphenoid or posterior ethmoid cells.

According to a study by Mcquillan et al in which pediatricians were asked how they diagnose and manage nonsevere acute sinusitis in children, on the basis of age group, pediatricians reported first considering acute sinusitis at the following rates: ages 0-5 (6%), 6-11 (17%), 12-23 (36%), 24-35 (21%), and 36 months or older (20%). ^[39]

In the Mcquillan study, symptoms thought to be very important included prolonged symptom duration (93%), purulent rhinorrhea (55%), and nasal congestion (43%); 60% reported that symptom duration is more important than symptom combination. Symptom duration before considering the diagnosis were 1-6 days (3%), 7-9 days (17%), 10-13 days (37%), 14-16 days (38%), and 17 or more days (6%).

Mcquillan et al reported that CT scanning was used by 58% in making the diagnosis of acute sinusitis. Antibiotics were used frequently or always by 96% of the respondents. Adjuvants used frequently or always included saline washes (44%), systemic decongestants (28%), nasal corticosteroids (20%), and systemic antihistamines (13%).

In children younger than 6 years, the nasal examination usually consists of evaluating the anterior nasal cavity and middle meatus with anterior rhinoscopy using an otoscope and ear speculum. The superior meatus can never be observed with this technique and is difficult to observe with nasal endoscopy, rigid rhinoscopy, or both. Purulence running into the posterior nasal cavity and nasopharynx, observed only by rigid rhinoscopy, can indicate probable drainage from the sphenoethmoid recess, which drains the posterior ethmoids and sphenoid sinuses.

In persons with acute ethmoiditis, especially in infants and younger children, periorbital cellulitis with edema of the soft tissues and erythema of the overlying skin is not uncommon.

American Academy of Pediatrics (AAP) recommendations do not require imaging in the diagnosis of children aged 6 years or younger to make the diagnosis of uncomplicated acute bacterial sinusitis if they meet the criteria for the diagnosis.

Approximately 75% of orbital or periorbital infections are the result of extending sinusitis. Untreated, inadequately treated, or partially treated rhinosinusitis may lead to chronic rhinosinusitis, meningitis, brain abscess, or other extra-sinus complications. 

Local complications

Mucoceles are chronic epithelial cysts that develop in sinuses in the presence of either an obstructed sinus ostium or minor salivary gland duct. They have the potential for progressive concentric expansion that can lead to bony erosion and extension beyond the sinus.

Maxillary sinus mucoceles are usually found incidentally on sinus radiographs and are of little significance in the absence of symptomatology or infection. Frontoethmoidal and sphenoethmoidal mucoceles, on the other hand, tend to be symptomatic and have a high potential for bony erosion.

Osteomyelitis is a potential local complication most commonly occurring with frontal sinusitis. Osteomyelitis of the frontal bone is called a Pott puffy tumor and represents a subperiosteal abscess with local edema anterior to the frontal sinus. This can advance to form a fistula to the upper lid with sequestration of necrotic bone.

Orbital complications

Orbital complications are the most common complications encountered with acute bacterial sinusitis. Infection can spread directly through the thin bone separating the ethmoid or frontal sinuses from the orbit or by thrombophlebitis of the ethmoid veins.

Diagnosis should be based on an accurate physical examination, including ophthalmological evaluation and appropriate radiological studies. CT scanning is the most sensitive means of diagnosing an orbital abscess, although ultrasound has been found to be 90% effective for diagnosing anterior abscesses. ^[32] The classification by Chandler, which is based on physical examination findings, provides a reasonable framework to guide management. This classification consists of 5 groups of orbital inflammation ^[37] :

• Group 1 - Inflammatory edema (preseptal cellulitis) with normal visual acuity and extraocular movement

• Group 2 - Orbital cellulitis with diffuse orbital edema but no discrete abscess

• Group 3 - Subperiosteal abscess beneath the periosteum of the lamina papyracea resulting in downward and lateral globe displacement

• Group 4 - Orbital abscess with chemosis, ophthalmoplegia, and decreased visual acuity

• Group 5 - Cavernous sinus thrombosis with rapidly progressive bilateral chemosis, ophthalmoplegia, retinal engorgement, and loss of visual acuity; possible meningeal signs and high fever

Intracranial complications

Intracranial complications may occur as a result of direct extension through the posterior frontal sinus wall or through retrograde thrombophlebitis of the ophthalmic veins. Subdural abscess is the most common intracranial complication, although cerebral abscesses and infarction that result in seizures, focal neurological deficits, and coma may occur.

Systemic complications

Sinusitis can result in sepsis and multisystem organ failure caused by seeding of the blood and various organ systems. Reports of bacteremia, thoracic empyema, and nosocomial pneumonia have been documented in the intensive-care population with acute sinusitis, and the mortality rate in this group can be as high as 11%.