GP - Sinusitis Flashcards
How many paranasal sinuses does one have? What are they?
4 paranasal sinuses: Frontal, Maxillary, Ethmoidal, and Sphenoid
What is the timescale for acute sinusitis and chronic sinusitis?
Acute sinusitis: sinusitis that lasts < 12 weeks
Chronic sinusitis: sinusitis that last > 12 weeks
What is uncomplicated sinusitis?
Uncomplicated sinusitis refers to sinusitis where inflammation does not spread outside the paranasal sinuses and nasal cavity
What usually causes acute sinusitis?
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)
How does a viral infection in the upper respiratory tract cause a secondary bacterial infection in the paransal sinuses?
Sinus mucosal oedema, obstruction of sinus ostia, and reduction in mucociliary action allow secretions to stagnate in the sinuses –> bacterial colonisation –> infection
What factors/ conditions are associated with acute sinusitis?
Asthma
Allergic rhinitis
Smoking
Ciliary impairment (e.g. cystic fibrosis)
(same as for chronic sinusitis)
What bacteria predominate in chronic sinusitis?
Staphylococcus aureus
Pseudomonas aeruginosa
What age group does acute sinusitis commonly affect?
Adults
Less common in children because their sinuses are not fully developed
What are the possible complications of acute sinusitis?
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
What are the clinical features of acute sinusitis?
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
Which paranasal sinus is most commonly affected in acute sinusitis? and why?
The maxillary sinus as it drains superiorly
What examinations can a GP carry out for acute sinusitis?
- 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
What are some clinical features that suggest acute bacterial sinusitis?
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
What are the clinical features of chronic sinsuitis?
Presentations are the same as acute sinusitis, but last longer than 12 weeks
Same examinations as for acute sinusitis
(please see previous slides)
Give 3 differential diagnoses for acute sinusitis
- Common cold
- Allergic rhinitis
- Migraine
What management would you do, as a GP, to treat a patient with acute sinusitis?
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
How long does it take for acute sinusitis to resolve on its own?
2-3 weeks
If an antibiotic is needed and patient shows no life-threatening symptoms, what Abx will you prescribe?
Phenoxymethylpenicillin (if allergic, doxycycline)
What are the indications for referral? and who do you refer to?
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
When should you admit patient?
- 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
What management would you give to a patient with chronic sinusitis?
- 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
Give 5 predisposing factors and associated conditions of chronic sinusitis
