Sinusitis

By Emilie Watson

Sinuses

• What are they for?

….several theories

• Lightening the weight of the head • Humidifying and heating inhaled air • Increasing the resonance of speech• Serving as a crumple zone to protect vital

structures in the event of facial trauma

What is sinusitis?• Inflammation of the lining of the sinuses• Mucosal oedema, mucus retention (which may become

infected. Polyps and septal deviation can lead to poor drainage.

• Acute (Usually follows URTI but 10% due to tooth infection)

• Chronic (often due to structural or drainage problems)

• Can be – viral, bactierial, fungal, and have contributing factors such as trauma

Signs and Symptoms• Major Factors• Thick colored post nasal

drainage ordischarge becoming yellowish to yellow-green

• Congested nasal passages• Sneezing• Reduction or loss of sense of

smell• Facial pain• Facial pressure or fullness• Fever - only with additional

symptoms• Pus in the nose upon physical

exam

• Minor Factors• Fever• Fatigue• Halitosis• Hoarseness• Headache• Ear pain• Irritability• Dental pain• Persistent cough• Blocked feeling/clicking in ears

Investigations

• Thorough examination – important to rule out any factors that may be causing the sinusitis

• CT (usefull pre-surgergy)• MRI (useful differentiating fungal vs tumour)• XRAY – not much use• Allergy and immune testing• Nasal endoscopy• Sinus culture• Biopsy and wash out

DD

• Migraine,• TMJ dysfunction• Neuralgias• Cervical spine disease• Temporal arteritis• Herpes Zoster• Dental pain

Treatments

??? Antibiotics???

When should I prescribe an antibiotic for acute sinusitis?

• Antibiotics are not required for most people presenting with acute sinusitis; instead the mainstay of treatment is symptomatic relief.

• Admit if the person is suspected of having a serious localized or systemic illness that requires further assessment or administration of intravenous antibiotics (for example, if there is evidence of peri-orbital or intracranial complications).

• Consider an immediate antibiotic prescription only if it is not appropriate to admit the person and they are:

• Systemically unwell, or• At high risk of complications because of a pre-existing comorbidity.• Consider a delayed prescribing strategy for all other people, especially if

symptoms are causing significant discomfort (such as marked pain or profuse, purulent discharge).

• If an antibiotic is required, prescribe according to local protocols where available:• Amoxicillin is a good first-line choice. Prescribe the maximum oral dose (1 g three

times a day) for 1 week.• Doxycycline (not in children less than 12 years of age) or a macrolide

(erythromycin or clarithromycin for 1 week) are options if the person has a known allergy to penicillin (consider erythromycin for pregnant women).

When to referimmediate referral to an ENT for suspected complications (e.g. periorbital infection)urgent referral to an ENT for suspected sinonasal tumour (persistent unilateral symptoms, such as bloodstained discharge, crusting, or facial swelling)consider ENT referral for:

– if there is recurrent or chronic sinusitis– progressive or unremitting facial pain– children with persistent sinusitis after two antibiotic courses

dental review– if the infection is suspected to be of dental origin, then refer patient

for dental review. Initiate antibiotic treatment, with the addition of antibiotics to cover anaerobic bacteria (e.g. metronidazole)

• Surgery – functional endoscopic sinus surgery, removing polyps

• Side effects – muco or pyocoeles, orbital cellulitis/abscess, osteomyelitis

…. Can be serious

Can cause•Meningitis•Encephalitis•Cerebral abscess •Cavernous sinus thrombosis

Frontal sinusitis with pus draining from frontal sinus

Polyp causing chronic sinusitis

Chronic – atrophic changes