GP - Sinusitis

Question 1

How many paranasal sinuses does one have? What are they?

Answer 1

4 paranasal sinuses: Frontal, Maxillary, Ethmoidal, and Sphenoid

Question 2

What is the timescale for acute sinusitis and chronic sinusitis?

Answer 2

Acute sinusitis: sinusitis that lasts < 12 weeks

Chronic sinusitis: sinusitis that last > 12 weeks

Question 3

What is uncomplicated sinusitis?

Answer 3

Uncomplicated sinusitis refers to sinusitis where inflammation does not spread outside the paranasal sinuses and nasal cavity

Question 4

What usually causes acute sinusitis?

Answer 4

Usually caused by a viral infection in the upper respiratory tract (e.g. rhinovirus, respiratory synctial virus, parainfluenza and influenza), which can be followed by a secondary bacterial infection (Streptococcus pneumoniae and Haemophilus influenzae)

Question 5

How does a viral infection in the upper respiratory tract cause a secondary bacterial infection in the paransal sinuses?

Answer 5

Sinus mucosal oedema, obstruction of sinus ostia, and reduction in mucociliary action allow secretions to stagnate in the sinuses –> bacterial colonisation –> infection

Question 6

What factors/ conditions are associated with acute sinusitis?

Answer 6

Asthma

Allergic rhinitis

Smoking

Ciliary impairment (e.g. cystic fibrosis)

(same as for chronic sinusitis)

Question 7

What bacteria predominate in chronic sinusitis?

Answer 7

Staphylococcus aureus

Pseudomonas aeruginosa

Question 8

What age group does acute sinusitis commonly affect?

Answer 8

Adults

Less common in children because their sinuses are not fully developed

Question 9

What are the possible complications of acute sinusitis?

Answer 9

Think of the danger triangle of the face!

• Orbital complications - orbital cellulitis, cavernous sinus thrombosis
  
  • Infections can spread from the ethmoid sinus across the thin ethmoid bone into the orbit –> orbital cellulitis
• Intracranial complications - meningitis, encephalitis, brain abscess
• Bony complications - osteomyelitis
• Chronic sinusitis

Question 10

What are the clinical features of acute sinusitis?

Answer 10

Presentations:

• Acute sinusitis usually follows a common cold, so symptoms of a cold (sneezing, coughing, runny nose)
• Nasal congestion (mouth breathing), nasal discharge (anterior/ posterior nasal drip), facial pain/ pressure that gets worse when bending forward, headache, reduced sense of smell
  
  • Discharge maybe purulent
• Altered speech secondary to nasal congestion
• Redness and swelling over where the paranasal sinuses are

Question 11

Which paranasal sinus is most commonly affected in acute sinusitis? and why?

Answer 11

The maxillary sinus as it drains superiorly

Question 12

What examinations can a GP carry out for acute sinusitis?

Answer 12

• Inspect and palpate maxillofacial area to elicit swelling and tenderness
• Anterior rhinoscopy to look for nasal inflammation, purulent nasal discharge, and mucosal oedema
• Take pulse rate, BP, and temperature if the person is systemically unwell

Question 13

What are some clinical features that suggest acute bacterial sinusitis?

Answer 13

Suspect acute bacterial sinusitis when several of the following features are present:

• Symptoms that last more than 10 days
• Discolored/ purulent nasal discharge
• Fever > 38 degree C
• Severe local pain (usually one side more painful than the other)
• Marked deterioration after an initial milder form of the illness

Question 14

What are the clinical features of chronic sinsuitis?

Answer 14

Presentations are the same as acute sinusitis, but last longer than 12 weeks

Same examinations as for acute sinusitis

(please see previous slides)

Question 15

Give 3 differential diagnoses for acute sinusitis

Answer 15

• Common cold
• Allergic rhinitis
• Migraine

Question 16

What management would you do, as a GP, to treat a patient with acute sinusitis?

Answer 16

Management:

• If a person has had symptoms for 10 days or less:
  
  • Do NOT offer Abx
  • Advise that acute sinusitis is usually caused by virus and is only complicated by bacteria in 2% cases. It takes 2-3 weeks to resolves on its own, and most people will recover without Abx
  • Advise to take paracetamol or ibuprofen for pain and fever
  • Advise to seek medical advice if symptoms worsen rapidly or significantly i.e. do not improve after 3 weeks or become systemically very unwell
• If a person has had symptoms for > 10 days
  
  • High-dose intranasal corticosteroids
  • Consider no Abx prescription or a back-up Abx prescription (only use it if symptoms worsen significantly, or do not improve within 7 days)
• Give Abx only if it’s complicated sinusitis, i.e. if systemically unwell
  
  • GIve Phenoxymethylpenicilllin if no life-threatening symptoms (if allergic, give doxycycline), OR, Co-amoxiclav if systemically unwell/ high risk of complications

Question 17

How long does it take for acute sinusitis to resolve on its own?

Answer 17

2-3 weeks

Question 18

If an antibiotic is needed and patient shows no life-threatening symptoms, what Abx will you prescribe?

Answer 18

Phenoxymethylpenicillin (if allergic, doxycycline)

Question 19

What are the indications for referral? and who do you refer to?

Answer 19

Referral to ENT:

• Frequent recurrent episodes (> 3 a year)
• Treatment failure despite Abx use
• Resistant bacteria
• Anatomical abnormalities causing nasal obstruction e.g. nasal polyp, deviated nasal septum
• Immunocompromise

Question 20

When should you admit patient?

Answer 20

• If systemically unwell, has symptoms and signs of a more serious illness, or is at high risk of complications:
  
  • Severe systemic infection
  • Orbital complications, Intracranial complications, Bony complications

Question 21

What management would you give to a patient with chronic sinusitis?

Answer 21

• Advise that chronic sinusitis may last months
• If they have an associated disorder e.g. asthma or allergic rhinitis, advise them that good control of these will benefit their sinusitis symptoms
• Advise the person to avoid allergens, stop smoking, practise good dental hygiene, and avoid underwater diving
• Nasal irrigation with saline to relieve nasal congestion and discharge
• Intranasal corticosteroids for 3 months. esp if there is an allergic cause

Question 22

Give 5 predisposing factors and associated conditions of chronic sinusitis