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Sinusitis
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Sinusitis

The terms rhinosinusitis and sinusitis are synonymous as inflammation of the sinuses is always accompanied by inflammation of the nasal cavity

Acute and chronic rhinosinusitis are independent clinical entities with different underlying pathophysiological mechanisms

Examination (this is identical for all types of sinusitis)

1. Anterior rhinoscopy - always performed with a headlight and thudicum speculum NOT with an otoscope
- look for mucopurulence, oedema, erythema and polyps
2. Flexible nasendoscopy

Acute rhinosinusitis

Up to 4 weeks of purulent nasal discharge accompanied by nasal obstruction, facial pain, facial pressure or fullness

Aetiology and History

Both viral and bacterial sinusitis are usually preceded by an URTI

Viral:
Symptoms of acute rhinosinusitis are present less than 10 days
Symptoms do not worsen

Bacterial:
10 days+ beyond onset of URTI symptoms
Symptoms worsen within 10 days after initial improvement
Common bacteria that cause sinusitis are the same as for otitis media:

Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis

Purulent rhinorrhea, facial pain/pressure and nasal obstruction strongly suggest a bacterial cause

Management

Antibiotics: amoxicillin + clavulanate (Co-amoxiclav) for 7 days

Sinus rinse can be helpful

Further investigation and surgery may be indicated for recurrent or persistent sinusitis and complications

Chronic rhinosinusitis

Aetiology

The pathophysiology of CRS is multifactorial and forms a large part of the research that the University of Auckland ENT department performs
Factors include:

Immunology - intramucosal B and T cells
Microbiology - intramucosal S. aureus
Anatomy - sinus ostia obstruction (outlet of sinus)

History and Diagnosis

12 weeks or longer of 2+ of the following:
Mucopurulent discharge (anterior, posterior or both)
Nasal obstruction (congestion)
Facial pain/pressure/fullness
Decreased sense of smell

and inflammation as seen by:
Purulent mucus or oedema in the middle meatus or ethmoid region
Polyps
Imaging - CT

Ethmoid sinusitis

Management

1. Antibiotics
- ideally culture-directed; duration 3-4 weeks

2. Anti-inflammatory
- intranasal and oral steroids
- allergy management (if previous allergy known)

3. Mechanical
- nasal saline irrigation

4. Surgery - performed if symptoms remain despite maximal medical therapy for 4 - 6 weeks
- Functonal endoscopic sinus surgery (FESS)

Complications

Complications of sinusitis are rare in the antibiotic era

Orbital infection
This represents a progression of the infection

Periorbital oedema
Orbital cellulitis
Subperiosteal abscess
Orbital abscess
Cavernous sinus thrombosis

Intracranial complications
Meningitis
Epidural abscess
Pott's Puffy tumour (osteomyelitis of frontal bone with subperiosteal abscess)

Complication

Pott's Puffy tumour

A CT of the head showing:

Maxillary sinusitis (full arrow)
Periorbital oedema +/- cellulitis (empty arrow)

Sagittal and axial MRI cuts show fluid in the frontal sinus communicating with the subperiosteal abscess
through a defect in the anterior table of the sinus.

Patients present with a tender doughy soft tissue swelling that causes pitting edema over the frontal bone

Allergic rhinitis

This is one of the most common ENT diseases and a differential diagnosis for sinusitis

It is the inflammation of the nasal mucous membranes caused by an IgE-mediated reaction to one or more allergens

History

Patients may be atopic and complain of:

- clear and watery nasal discharge
- itching of nose, eyes and throat
- nasal congestion

Seasonal symptoms may include exposure to pollen or cats

Management

Mainstay:
1. Antihistamines
2. Intranasal corticosteroids

Others:
3. Systemic corticosteroids - if intractable symptoms
4. Decongestants - be aware of rebound effects

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