Acute Sinusitis

Question 1

What is sinusitis?

Answer 1

Inflammation of the mucous membranes of the paranasal sinuses

Question 2

Which sinuses are most commonly affected?

Answer 2

Maxillary

Question 3

Sinusitis is said to be acute if it lasts…

Answer 3

4-30 days

Question 4

How long does sinusitis last of it is subacute?

Answer 4

4-12 weeks

Question 5

Many people have a mild bout of sinusitis with..

Answer 5

A common cold

Question 6

Is severe acute sinusitis common?

Answer 6

No, most people only have 1 or 2 episodes in their life

Question 7

When do most people get acute sinusitis?

Answer 7

After a cold or flu
Virus causes mucosal oedema and reduced cilia action - impairing drainage of the sinuses into the nasal cavity ie there is stagnation of secretions in sinus = ideal for bacteria to grow

Question 8

Other than previous viral infection, what other risk factors are there that can predispose sinusitis?

Answer 8

Direct spread - dental root infection, swimming in infected water
Blockage to sinus drainage channels - polyps, septal deviation, foreign object, facial injury or surgery
Allergic rhinitis - swelling of tissues making sinuses more susceptible to infection
CF
Inflammatory disorders e.f sarcoidosis
Smoking
Immunocompromised

Question 9

What are the symptoms of acute sinusitis?

Answer 9

Facial pain - worse on benign forward 
Fever >38
Blocked nose
Discoloured discharge - yellow or green 
Double sickening (deterioration after mild phase of illness) 
Reduced sense of smell
Halitosis 
Headache 
Feeling of pressure or fullness in ears 
Malaise

Question 10

What is halitosis?

Answer 10

Bad breath

Question 11

The associated facial pain is typically worse when…

Answer 11

Bending forward

On pressure

Question 12

How is it diagnosed?

Answer 12

Clinically

Occasionally bloods taken - elevated ESR, CRP

Question 13

What are some differentials?

Answer 13

Non sinus pain- migraine, TMJ dysfunction, dental pain, neuropathic pain, temporal arteritis

Question 14

What are the most common infective agents to cause acute sinusitis?

Answer 14

Streptococcus pneumoniae
Haemophilius influenzae
Staphylococcus aureus
Moraxella catarrhalis

Question 15

In recurrent acute or chronic sinusitis what investigation can be done?

Answer 15

CT of paranasal sinsuses and nasal endoscopy- identify anatomical problems

Question 16

How is it managed if a person has symptoms for 10 days or less?

Answer 16

Do not offer antibiotics
Advise that: acute sinusitis is usually caused by a virus (and is only complicated by bacteria in about 2/100 cases)
Takes 2-3 weeks to resolve
Fever and pain can be managed with paracetamol, ibuprofen
Consider nasal decongestants or nasal saline, intra nasal corticosteroids may be considered if symptoms present for more than 10 days
Generally: drink lots of fluids, rest, avoid allergic triggers and not smoking
Medical advise sought if symptoms worsen, systemically unwell, or do not improve in 3w

Question 17

How do nasal decongestants work?

Answer 17

Reduce swelling of tissues and blood vessels that line nasal passageways
Should not use for more than 5-7 days as can cause rebound congestion in nose

Question 18

What complications can occur?

Answer 18

Orbital cellulitis/ abscess
Intracranial involvement - meningitis, cavernous sinus thrombus, cerebral abscess
Mucocoeles
Osteomyelitis

Question 19

If a person has had symptoms for 10 days or more with no improvement, how should they be managed?

Answer 19

Consider high dose nasal corticosteroid for 14 days
Consider no antibiotics or back up prescription

(Antibiotics advised if individual systemically unwell or sig comorbidities that pre dispose complications e.g COPD)
Corticosteroids may improve symptoms but not likely to affect how long they last

Question 20

If an antibiotic is indicated, what would you prescribe?

Answer 20

Penicillin V

Clarithromycin if penicillin allergy

Question 21

What factors may point towards bacterial cause?

Answer 21

Symptoms for more than 10 days
Discoloured or purulent nasal discharge
Severe, localised unilateral pain - particularly over teeth and jaw
Fever
Marked deterioration after initial milder phase