Acute rhinosinusitis

Question 1

Definition

Answer 1

Acute inflammation in the mucous membranes of the paranasal sinuses.

Question 2

Causes

Answer 2

Acute rhinosinusitis is most commonly caused by a viral infection (i.e. the common cold).

About 5% of URTIs are complicated by an acute sinusitis,

• which is mainly viral initially
• while secondary bacterial infection commonly follows.

Any factor that narrows the sinus openings into the nasal cavity (the ostia) will predispose to acute sinusitis.

Question 3

clinical presentations

Answer 3

1) an URTI persisting for longer than 10 days

2) URTI that is unusually severe with pyrexia and a
purulent nasal discharge

Question 4

Clinical features of acute sinusitis

Answer 4

Facial pain and tenderness

Toothache

Purulent postnasal drip

Nasal discharge

Nasal obstruction

Rhinorrhoea

Cough (worse at night)

Fever

Epistaxis

Suspect bacterial cause if high fever and purulent nasal discharge.

Question 5

Measures & Treatment

Answer 5

• Increased fluids
• Saline insufflation or steam inhalation (a very important adjunct)
• Nasal decongestants (oxymetazoline-containing nasal drops or sprays) 5 for 5–10 days only if congestion
• Simple analgesics for pain, e.g. paracetamol, and fever
• Nasal saline irrigation
• Pseudoephedrine tabs
• If swollen and inflamed: corticosteroid spray
• Antihistamines and mucolytics are of no proven value.

Question 6

indication for oral antibiotics

Answer 6

Usually no indication for oral antibiotics unless
in severe cases with at least three of the following:

• facial pain
• persistent mucopurulent nasal discharge (>7–10 days)
• poor response to decongestants
• tenderness over the sinuses, esp maxillary
• tenderness on percussion of maxillary, molar and
premolar teeth that cannot be attributed to by a single tooth

Question 7

Guidelines for antibiotic treatment

Answer 7

If bacterial sinusitis (high fever, purulent nasal discharge):

1. Exclude dental root infection
2. Control predisposing factors
3. Use appropriate antibiotic therapy.
4. Establish drainage by stimulation of mucociliary flow and relief of obstruction

Question 8

Antibiotics (first choice):

Answer 8

• amoxycillin 500 mg (o) tds for 7 d or
• (if sensitive to penicillin) doxycycline 200 mg (o)
statim then 100 mg daily for 7 d or
• cefaclor 375 mg (o) bd for 7 d or
• amoxycillin clavulanate 875/125 mg (o) tds for 7 d

In complicated or severe disease, use intravenous cephalosporins or flucloxacillin

If superinfected: mupirocin 2% nasal ointment

If poor response to above agents—indicates resistant H. influenzae

Question 9

Persistent cases management

Answer 9

If severe and persistent, surgical drainage may be necessary by atrial lavage or frontal sinus trephine.

Question 10

Inhalations for sinusitis, what do you need?

Answer 10

The old method of towel over the head and inhalation bowl can be used, but it is better to direct the vapour at the nose.

Equipment needed is a container, which can be an old disposable bowl, a wide-mouthed bottle or tin, or a plastic container.

For the inhalant, several over-the counter preparations are suitable such as;

1. Friar’s Balsam (5 mL)
2. Vicks VapoRub (1 teaspoon), or menthol (5 mL).

The cover can be made from a paper bag (with its base cut out)

Cone of paper or a small cardboard carton (with the corner cutaway).

Question 11

Method of Inhalations for sinusitis

Answer 11

Add 5 mL or 1 teaspoon of the inhalant to 0.5 L (or 1 pint) of boiled water in the container.

Place the paper or carton over the container.

Get the patient to apply nose and mouth to the opening and breathe in the vapour deeply and slowly through the nose, and then out slowly through the mouth.

Perform for 5–10 minutes, TDS, esp before retiring.

After inhalation, upper airway congestion can be relieved by autoinsufflation.