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Sinusitis

Inflammation of the paranasal sinuses may be acute, subacute, chronic, allergic, or hyperplastic. Acute sinusitis usually results from the common cold; in about 10% of patients, it lingers in subacute form. Chronic sinusitis follows persistent bacterial infection, generally occurring when a cold spreads to the sinuses.

Allergic sinusitis accompanies allergic rhinitis. Hyperplastic sinusitis is a combination of purulent acute sinusitis and allergic sinusitis or rhinitis. For all types, the prognosis is good.

Causes

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Signs and Symptoms

A patient with acute sinusitis typically complains of nasal congestion that preceded a gradual buildup of pressure in the affected sinus. He may state that for 24 to 48 hours after onset, a nasal discharge was present and later became purulent. He may also list a sore throat, a localized headache, and a general feeling of malaise.

The patient may point to pain specific to the affected sinus: in the cheeks and upper teeth (maxillary sinusitis); over the eyes (ethmoid sinusitis); over the eyebrows (frontal sinusitis); or behind the eyes, over the occiput, or at the top of the head (sphenoid sinusitis, a rare condition).

The patient also may report purulent nasal drainage that continues longer than 3 weeks after an acute infection subsides, which usually suggests subacute sinusitis. The patient with chronic sinusitis may report continuous and mucopurulent discharge. In the acute form, the patient may complain of a stuffy nose, vague facial discomfort, edema, edematous nasal mucosa, fatigue, and a nonproductive cough.

Assessment of vital signs may reveal a low-grade fever of 99° to 99.5° F (37.2° to 37.5° C).

The areas over the sinuses may appear swollen (caused by bacterial growth on diseased tissue in hyperplastic sinusitis). Inspection also may reveal enlarged turbinates and thickening of the mucosal lining and mucosal polyps (hyperplastic sinusitis). Palpation may cause pain and pressure over the affected sinus areas. Transillumination may expose diminished areas of light, which indicate areas of purulent drainage that prevent the passage of light.

Diagnostic tests

Sinus X-rays reveal cloudiness in the affected sinus, air-fluid levels, or a thickened mucosal lining; ultrasonography and computed tomography scanning may uncover suspected complications, recurrent or chronic sinusitis, or unresolved and serious sinusitis.

Antral puncture promotes drainage and removal of purulent material. It also may be used to collect a specimen for culture and sensitivity identification of the infecting organism, but this test is rarely performed. Sinus endoscopy indicates purulent nasal drainage, nasal edema, and obstruction of ostia.

Treatment

Antibiotics are the primary treatment for acute sinusitis. Analgesics may be prescribed to relieve pain. Other appropriate measures include vasoconstrictors, such as epinephrine and phenylephrine, to decrease nasal secretions. Steam inhalation also promotes vasoconstriction and encourages drainage.

Antibiotic therapy - usually with amoxicillin or ampicillin - combats persistent infection. Local heat applications may help to relieve pain and congestion.

In subacute sinusitis, antibiotic therapy also is the primary treatment. As in acute sinusitis, vasoconstrictors may reduce nasal secretions.

Severe allergic symptoms may require treatment with corticosteroids and epinephrine.

In both chronic sinusitis and hyperplastic sinusitis, antibiotics and a steroid nasal spray may relieve pain and congestion. Antihistamines may be judiciously prescribed for symptom relief but are administered cautiously because they may thicken nasal secretions and prevent effective sinus drainage.

If a subacute infection persists, the maxillary sinus may be irrigated. The ethmoid and sphenoid sinuses can be drained indirectly with the Poetz displacement method - a technique that uses gravity to displace thick, purulent material with thin irrigating fluid. If these irrigating techniques fail to relieve symptoms, one or more sinuses may require surgery.



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