What is acute sinusitis?
Symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal sinuses, where clinical symptoms have been present for 4 weeks or less.
What pathogens cause acute sinusitis?
- Most common cause of acute sinusitis is a viral infection.
- The three most common bacteria are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.
How can viral and bacterial acute sinusitis be differentiated?
- Viral= symptoms <10 days
- Bacterial= symptoms >10 days but <4 weeks
What risk factors are associated with acute sinusitis?
- Viral upper respiratory tract infection
- Allergic rhinitis
What are the signs of acute sinusitis?
- Oedematous turbinate
What are the symptoms of acute sinusitis?
- Purulent nasal discharge (cloudy or discoloured nasal mucus)
- Nasal obstruction (congestion, stuffiness, or blockage)
- Facial pain or pressure
- Cough
- Myalgia
- Sore throat
What investigations should be ordered for acute sinusitis?
- Clinical diagnosis
- Nasal endoscopy
- CT sinuses (non-contrast)
Why investigate using nasal endoscopy? And what may this show?
- Recommended in selected patients (e.g., patient refractory to empirical antibiotic therapy, concern for antibiotic resistance, patient immunocompromised) as it can provide excellent visualisation of the nasal cavity and sinuses.
- Mucosal erythema and purulent discharge.
Why investigate using CT (non-contrast)? And what may this show?
- Ordered if complications are suspected, or if further investigation is required (e.g., with recurrent episodes, suspected anatomical abnormalities) to rule out alternative diagnoses.
- Identifies extent of sinus disease, abnormal anatomical structures.
Briefly describe the treatment for acute sinusitis
The goals of treatment are to relieve symptoms, eradicate infection, and prevent complications. Management varies depending on whether the aetiology is viral or bacterial, and should involve shared decision-making with the patient. In most cases the diagnosis is made presumptively.
How is viral acute sinusitis treated?
- Supportive therapy
- Analgesia and antipyretics
- Decongestants
- Intranasal corticosteroids
- Topical anticholinergics (e.g., ipratropium)
- Intranasal saline irrigations and sprays
How is bacterial acute sinusitis treated?
- Antibiotic therapy or watchful waiting dependent on the number of days
- Analgesia and antipyretic
- Decongestant
- Intranasal corticosteroid
- Intranasal saline
What is the antibiotic of choice in acute sinusitis?
- If no life-threatening symptoms: phenoxymethylpenicillin
- If systemically very unwell, symptoms or signs of a more serious illness or condition are present, or there is a high risk of complications: co-amoxiclav
Briefly describe the guidelines for prescribing antibiotics for acute bacterial sinusitis
- If a person has had symptoms for 10 days or less: do not offer an antibiotic prescription.
- If a person has had symptoms for around 10 days or more with no improvement: consider antibiotic prescription.
Under what conditions may a patient be refferred to an ENT specialist with acute sinusitis?
- Frequent recurrent episodes (more than three episodes requiring antibiotics a year).
- Treatment failure after extended courses of antibiotics.
- Unusual or resistant bacteria.
- Anatomic defect(s) causing obstruction.
Immunocompromise. - A suspected allergic or immunological cause.
- Comorbidities complicating management such as nasal polyps.
What complications are associated with acute sinusitis?
- Chronic sinusitis
- Bacterial meningitis
- Subdural abscess
- Peri-orbital or orbital cellulitis
What differentials should be considered for acute sinusitis?
- Allergic rhinitis
- Non-allergic rhinitis
- Migraine
How does acute sinusitis and allergic rhinitis differ?
- Signs and symptoms: ocular and/or nasal pruritus, sneezing and rhinorrhoea. Headache, purulent discharge, and facial pain/pressure are less common.
- Investigations: allergen skin-prick testing and in vitro-specific IgE determination.
How does acute sinusitis and non-allergic rhinitis differ?
- Signs and symptoms: heterogeneous group of nasal diseases that has nasal obstruction or rhinorrhoea as common factors. History of pregnancy, barometric changes, food-associated symptoms, or hypothyroidism.
- Investigations: diagnosis in clinical (no differentiating tests).
How does acute sinusitis and migraine differ?
- Signs and symptoms: patient reports a history of ‘recurrent sinus infection’ in which moderate-severe headache is the most prominent symptom. Sensitivity to light or noise, aura, symptoms decrease if sitting/lying in a quiet, dark room. Absence of purulent nasal discharge.
- Investigations: diagnosis is clinical (no differentiating tests). Radiological tests may exclude features of acute bacterial sinusitis.
