What is sinusitis?
inflammation of the mucosal linings of the nasal passage and paranasal sinuses.
What are the three types of acute rhinosinusitis? And what are the causative organisms of each type of acute rhinosinutis?
- Viral rhinosinusitis
- Most commonly caused by rhinoviruses and coronaviruses.
- Post-viral rhinosinusitis – residual mucosal inflammation following a viral infection that produces ongoing symptoms.
- Bacterial rhinosinusitis – usually preceded by a viral infection, which predisposes the mucosa to bacterial infection
- Most common causative organisms are S. pneumoniae, H. Influenzae, M. catarrhalis, and S. aureus
What are the main risk factors for acute rhinosinusitis?
- Cigarette smoke exposure (active or passive)
- Air pollution exposure
- Anatomical variations, such as septal deviation, nasal polyps, or sinus hypoplasia
- Anxiety or depression
- Asthma or diabetes
What are the symptoms of acute rhinosinusitis?
- Nasal obstruction
- Discoloured nasal discharge (either anterior or posterior discharge)
- Facial pain or pressure (usually unilateral over the maxillary or frontal sinus)
- Altered sense of smell
What symptoms suggest a bacterial cause of acute rhinosinusitis?
- Severe local pain
- Fever
- Discoloured discharge
- Worsening after an initial improvement (post-viral)
How is acute rhinosinusitis diagnosed?
- Clinically
- Imaging, such as a CT scan may be required if complications are suspected.
- Skin prick testing for allergy might be appropriate in patients with recurrent episodes and symptoms suggested of allergic rhinitis.
How is acute rhinosinusitis managed?
- Most cases of acute rhinosinusitis cases can be managed in the community, and do notrequire treatment with antibiotics.
- For patient with symptoms up to 5 days (or >5 days but improving), symptomatic treatment with analgesia and nasal decongestants will suffice.
- For cases of >10 days or worsening after 5 days, topical nasal steroids and oral antibioticsare indicated.
- If there is no improvement after 7-14 days of treatment or the presence of red-flag symptoms, referral to ENT services should be considered.
What are the red flag symptoms for when referral to ENT services should be considered.
- Eye signs, including periorbital swelling or erythema, displaced globe, visual changes, ophthalmoplegia.
- Severe unilateral headache, bilateral frontal headache, or frontal swelling.
- Neurological signs or reduced conscious level.
What are the complications of acute rhinosinusitis?
- Preseptal cellulitis, orbital cellulitis, or abscesses (sinusitis is the commonest cause of orbital cellulitis and abscesses)
- Osteomyelitis (infection invading the bone can eventually lead to penetration into the skull vault causing intracerebral complications)
- Pott’s puffy tumour (osteomyelitis of the frontal sinus can result in a soft boggy swelling over the overlying tissue on the forehead
- Intracranial abscesses
- Venous sinus thrombosis
What is the specialist management for acute rhinosinusitis?
- An ENT specialist will perform nasal endoscopy, to identify any abnormal anatomy or pathology. A culture of any nasal discharge may be warranted for atypical infections.
- A CT scan of the paranasal sinuses would show the extent of the disease, as well as identifying complications and any underlying anatomical abnormalities.
- For severe infections or complications, admission might be necessary for treatment with oral steroids, intravenous antibiotics, and the consideration of surgery.
What is the difference between acute and chronic rhinosinusitis?
symptoms lasting longer than 12 weeks = chronic
symptoms lasting less than 12 weeks = acute
What are the main risk factors for chronic rhinosinusitis?
- Asthma or atopy
- Aspirin sensitivity
- Ciliary impairment (e.g. cystic fibrosis or primary ciliary dyskinesia)
- Smoking
- Immunosuppression
What are the signs and symptoms of chronic rhinosinusitis?
- Nasal obstruction
- Discoloured nasal discharge (either anterior or posterior discharge)
- Facial pain or pressure (usually unilateral over the maxillary or frontal sinus)
- Altered sense of smell
- Rhinoscopy will reveal generalised mucosal swelling, mucopurulent (green/yellow) discharge, and/or polyps; nasal polyps are overgrowths of swollen mucosa which prolapse into the airway or sinuses.
What are the types of sinusitis with regards to location?
- Maxillary - pain/presure in the maxillary cheek area and tooth aches or headaches
- Ethmoidal - pain or pressure between the eyes, the sides of the upper part of the nose and headaches
- Frontal - pain or pressure in the forehead, above the eyes and headache
- Sphenoidal - pain/pressure behind the eyes often felt in the top of the head over the mastoid processes or the back of the head
What are the sign and symptom of sinusitis?
- Thick naal nasal mucous
- headaches
- pain on leaing forward
- pain on touching the sinus
- cough
- malaise
- fever
- sore throat
- plugged nose
What are the symptoms of chronic sinusitis?
halitosis
post nasal drip
How should suspected sinusitis be investigated?
clinically
assume viral if <10 days
assume bacterial is >10days or if it gets worse
if complicated = CT scan
How should sinusitis be managed?
- Watch and wait
- Abx if >4weeks
- Nasal irrigation
- Nasal steroids
- Naproxen
- Anti-histamines
- Steam inhalation
- Decongestants
What are the possible complications of sinusitis?
osteomyelisits
infection fo the eye socket - loss of eyesight
otitis media
vertigo
cerebral abscess
meningitis
How is chronic rhinosinusitis managed?
- The treatment of chronic rhinosinusitis is dependant on the severity of symptoms.
- This can be assessed via a severity Visual Analogue Score (VAS) score, in addition to examination of the nasal cavity.
- Mild disease (VAS 0-3 with no significant mucosal disease) – treated with nasal saline douching and topical steroid spray or drops.
- Moderate to severe disease (VAS >3 with significant mucosal disease) – requires long term antibiotics with topical steroids and a CT imaging of the sinuses
- Refractory cases should be considered for surgical intervention (FESS). After surgery, it is important that topical treatments are continued.
