SINUSITIS

I. Anatomy & pathophysiology

  1. Maxillary, frontal, ethmoid, and sphenoid
  2. Connected to nasal cavity via narrow (1-3mm) ostia
  3. Sinusitis usually precipitated by occlusion of ostia or alteration of ciliary function
  4. Precipitants include
  1. Infections (viral or bacterial)
  2. Allergens
  3. Nonallergic irritants (smoke, perfume, chemical fumes)
  4. Anatomic abnormalities (deviated septum, polyps, tumors, foreign bodies, ciliary dysfunction, etc.)
  1. Asthma or immunodeficient states can further predispose
  2. Bugs
  1. Pneumococcus & H. Flu make up 70% in all age groups; Moraxella catarrhalis is more common in kids than adults
  2. Chronic sinusitis can include anaerobes
  3. 30% of symptomatic pts with abnormal x-rays have negative cx of sinus puncture aspirates (J. Gen. Int. Med. 9:38, 1994, cited in AAFP review)
  4. GNR's and fungal can occur in immunocompromised pts, pts with diabetes, and pts with cystic fibrosis

II. Complications

  1. Most common with frontal and ethmoid sinusitis b/c of their deep position in the cranium
  2. Intracranial abscesses, meningitis, osteomyelitis, orbital cellulitis, orbital abscesses

III. Diagnosis

  1. Can be difficult to distinguish from viral URI or allergic rhinitis
  2. "Acute" = 10d-3wks; "Chronic" = 3wks-3mos
  3. Significant clinical signs for dx of acute maxillary sinusitis: (BMJ 311:233, 1995)
  1. Preceding URI
  2. Unilateral facial pain
  3. Unilateral tenderness
  4. Maxillary toothache
  5. Elevated ESR & CRP
  1. "Red Streak" sign
    1. In a study in 73 pts with nasal sx, all of whom underwent sinus CT, a "red streak sign" (a red streak visible in the oropharyngeal mucosa) had positive and negative likelihood ratios or 2.11 and 0.44, respectively, for air-fluid levels on CT (J. Gen. Int. Med. 21:986, 2006--AFP)
  2. AAFP brochure says mentions the following, often following a 5-7d URI:
  1. Purulent nasal discharge
  2. Purulent pharyngeal drainage
  3. Periorbital edema
  4. Nasal congestion
  5. Headache
  6. Facial pain or pressure
  7. Tooth pain
  8. Foul breath
  9. Fever
  10. Red, swollen nasal mucosa (as opposed to pale mucosa of allergic rhinitis)
  1. Majority of pts with sinusitis feel no pain on percussion!
  2. Chronic sinusitis
    1. Diagnosis: smoldering purulent postnasal drip and cough, fould breath, facial pain, HA, nasal congestion, malaise; cobblestone pharyngeal appearance
    2. In children, diagnosis is less clear; purulent nasal d/c the hallmark but not specific
  3. Diagnostic imaging
  1. X-ray: useful for confirming frontal, ethmoid, and maxillary sinusitis; see mucosal thickening, air-fluid levels; NOT HIGHLY SENSITIVE
  2. CT: 30-40 pts with positive CT findings will have no sx; NOT HIGHLY SPECIFIC; "primary role is to validate a diagnosis prior to surgery" (AAFP brochure)
  3. MRI: Not specific; in one series of 257 asymptomatic pts who had MRI's for suspected intracranial disease, 42% had sinus abnormalities, most commonly mucosal thickening of maxillary sinuses; sig. more frequent in those > 50yo (Arch Oto. 123:602, 1997-abst)
  4. Ultrasound: highly variable results

IV. Treatment

  1. Intranasal steroids to restore ventilation of sinus
  1. No evidence that they cause adrenal suppression (except for dexamethasone, so don't use it) or growth retardation in kids
  2. Preparations: beclomethasone, budesonide, flunisolide, fluticasone propionate, tramcinolone
  3. Shown to slightly reduce sx scores in one randomized study of 407 pts also tx'd with amox-clavulanic acid x 3wks (J. All. Clin. Immunol. 106:630, 2000--JW)
  4. Fluticasone intranasal 2 puffs (200ug total dose) QD x 21d vs. placebo added to a regimen of 3d of intranasal xylometazoline + cefuroxime axetil 250mg PO BID x 10d ass'd with sig. more rapid time to "clinical success" c/w placebo (median 6d vs. 9.5d w/placebo, sig.) in a randomized trial of 95 pts with h/o recurrent or chronic sinusitis and acute sinusitis dx'd by X-ray or nasal endoscopy) (JAMA 286:3097, 2001--Abst)
  1. Can use oral steroids with very significant nasal inflammation (20-30mg/d taper over 5-7d suggests AAFP brochure)
  2. Antibiotics
  1. AAFP brochure recommends 2-3wks for acute sinusitis; chronic can require 3wks or longer
  2. One trial looked at shorter course (JAMA 273:1015, 1995)
  1. 80 adult pts with acute maxillary sinusitis and sx < 1mo; positive x-ray; randomized to Bactrim DS BID x 3d (+ placebo x 7d) vs. Bactrim DS BID x 10d
  2. All got Afrin BID x 3d
  3. 77% of both groups had resolution of sx at 14d
  4. No sig. diff in sx scores
  5. Recc'd long course of broad-spectrum abx for nonresponders and then ENT referral for endoscopy
  1. 2000 Guidelines by Sinus & Allergy Health Partnership (in collaboration w/CDC) recc'd considering abx only in the case of the following (Otolaryngol Head Neck Surg 123:5, 2000)
    1. Typical sx, not improving after 10d or worsening after 5-7d
    2. Specific sx: nasal drainage, nasal congestion, facial pressure or pain, postnasal drainage, fever, cough, fatigue, dental pain and pressure in the ears
  1. Which abx to use
    1. Amoxicillin good first line (trimethoprim/sulfamethoxazole for PCN-sensitive pts)
    2. If concerned about beta-lactamase producing organisms (based on local epidemiologic considerations) consider Augmentin, cefuroxime, etc.
  1. Note that clinical utility of antibiotics may not be significant
  1. 214 adults with x-ray confirmed acute maxillary sinusitis randomized to amoxicillin 250 TID x 7d vs. placebo. After 2 weeks, 83% of amox group and 77% of placebo group had greatly reduced sx; 65% and 53% respectively were cured; relapses had occurred at 1y in 21% and 17%, respectively; all nonsignificant differences (Lancet 349:683, 1997-JW)
  1. Antihistamines, mucolytics (e.g. guaifenesin, potassium iodide): little proven benefit
  2. Tx of sinusitis in children
    1. In a randomized trial in 161 children 1-18yo with clinical dx of acute sinusitis (URI sx x 10-28d; excluded if T > 39'C, facial pain, or facial swelling), randomized to Amoxicillin (40mg/kg/d divided TID), Augmentin (45 mg/kg/d divided BID), or placebo, f/u @ 2wks showed no sig. diff. in sx, functional ststus, days missed from school or child care, or recurrence of sx (Peds. 107:619, 2001--JW)

V. Prevention

  1. Sinus irrigation
    1. In a randomized trial in76 pts with h/o frequent sinusitis randomized to daily nasal irrigation with 150mL 2% buffered NaCl (1 pint tap water, 1 "heaping teaspoon" of canning salt, and 1/2 tsp baking soda) x 6mos using the "SinuCleanse" nasal cup system vs. no such treatment, mean sx scores improved more in active-tx c/w control group; the active-tx group also reported less antibiotic use during the 6mos of the trial (J. Fam. Prac. 51:1049, 2002--abst)