Sinusitis

Question 1

Definition of sinusitis

Answer 1

Symptomatic inflammation of the paranasal sinuses. Can also be referred to as rhinosinusitis since inflammation of the nasal cavities usually accompanies sinus inflammation.

Question 2

Classification of sinusitis (according to disease course)

Answer 2

• Acute sinusitis refers to sinusitis that completely resolves within 12 weeks
• Recurrent acute sinusitis refers to four or more annual episodes of sinusitis without persistent symptoms in the intervening periods
• Chronic sinusitis refers to sinusitis that causes symptoms that last for more than 12 weeks
• Uncomplicated sinusitis refers to sinusitis where inflammation does not extend outside the paranasal sinuses and nasal cavity to involve nervous or ophthalmologic structures, or soft tissue

Question 3

Causes of sinusitis

Answer 3

• Acute sinusitis is usually triggered by a viral URTI (rhinovirus, RSV, parainfluenza, influenza) which may be followed by a bacterial infection- stagnation of secretions due to obstruction of the sinus ostia allows bacteria to grow.
• Chronic sinusitis is more likely to be inflammatory rather than an infectious process, it is also associated with different causative bacteria.

Question 4

Risk factors for sinusitis

Answer 4

Asthma, allergic rhinitis, anatomical or mechanical obstruction, impaired ciliary motility (CF), immunocompromise and genetic susceptibility (for chronic sinusitis)

Question 5

Complications of sinusitis

Answer 5

Can lead to orbital complications (orbital cellulitis, abscess), meningitis, encephalitis, osteomyelitis. Chronic sinusitis can influence development.

Question 6

Presentation of sinusitis

Answer 6

• Nasal blockage (obstruction/ congestion) or discoloured nasal discharge (anterior/posterior nasal drip) with fascial pain/ pressure and/or cough
• Acute sinusitis usually follows a common cold, and is defined as an increase in symptoms after 5 days, or persistence of symptoms beyond 10 days, but less than 12 weeks (chronic is same but for >12 weeks)
• May get associated nasal inflammation, mucosal oedema and purulent nasal discharge

Question 7

When should a child be referred to hospital with sinusitis

Answer 7

• Severe systemic infection
• Intraorbital or periorbital complications, including oedema or cellulitis, double vision, reduced visual acuity opthalmoplegia
• Intracranial complications, including swelling over the frontal bone, symptoms or signs of meningitis, severe frontal headache, or focal neurological signs

Question 8

How should sinusitis be managed if present for less than 10 days

Answer 8

• Do NOT offer an antibiotic prescription
• Advise that it is unlikely to be a bacterial cause (complicated by bacterial infection in 2 in 100 cases), it usually takes 2-3 weeks to resolve and will resolve without Abx
• Symptoms can be managed with self-care, including paracetamol/ibuprofen for fever
• Medical advice should be sought if symptoms worsen rapidly or significantly, do not improve after 3 weeks, or they become systemically very unwell

Question 9

How should sinusitis be managed if present for more than 10 days (less tan 12 weeks)

Answer 9

• Consider high-dose nasal corticosteroid for children >12 years (mometasone). This may improve symptoms, though it is unlikely to affect illness duration (could cause systemic side effects)
• Consider NO antibiotic prescription or back-up prescription
• Antibiotics are unlikely to change the course of the illness (withholding is unlikely to lead to complications)

The back-up prescription should be used if symptoms get considerably worse of it is still has not improved by 7 days
* 1st line= Phenoxymethylpenicillin
* Co-amoxiclav if systemically unwell, symptoms or signs of a more serious illness
* If allergic to penicillin give doxycycline

Question 10

How can chronic sinusitis be managed

Answer 10

Consider intranasal corticosteroids and nasal irrigation