RHINOSINUSITIS

- refers to an inflammatory condition involving the nasal sinuses

o maxillary sinus is most commonly involved
o Next (in order of frequency): ethmoid, frontal, and sphenoid sinuses
- 5th leading diagnosis for antibiotics prescriptions
- Can be classified accor. To:
o Duration (acute or chronic)
o Etiology (infectious or noninfectious)
 If infectious, viral, bacterial, or fungal

Sinus
- Lined with respiratory epithelium that produces mucus
o Mucus is then transported to the nasal cavity via ciliary action through the sinus ostium
- Normal: no mucus, sterile

Disruption in ciliary clearance/Sinus ostia obstruction  retained secretions  inc. susceptibility to infection  sinusitis

ACUTE RHINOSINUSITIS
DEFINITION  sinusitis of <4 weeks  characterized by symptoms of sinus
 constitutes the vast majority of sinusitis cases inflammation lasting >12 weeks
 precedes viral URI
ETIOLOGY Ostial Obstruction  can arise from either infectious  commonly associated with bacteria or fungi
and noninfectious causes  chronic bacterial sinusitis
 due to the impairment of mucociliary
Noninfectious etiologies clearance from repeated infections
 allergic rhinitis rather than to persistent bacterial
 barotrauma infection
 exposure to chemical irritants  page 228

Viral (Uncommon):
 rhinovirus
 parainfluenza virus
 influenza virus

Bacterial:
 S. pneumoniae and nontypable Haemophilus
influenzae
 are the most common pathogens
 50–60% of all cases
 Moraxella catarrhalis
 20% in children but a lesser percentage of
adults

Anaerobes found in infections of the roots of

premolar teeth  spread to the adjacent maxillary
sinuses

Nosocomial:
 S. aureus
 Pseudomonas aeruginosa
 Serratia marcescens
 Klebsiella pneumoniae
 Enterobacter species

Fungal
 - immunocompromised patients and represent
invasive, life-threatening infections
- rhinocerebral mucormycosis caused by fungi
of the order Mucorales
CLINICAL  (+) Sinus inflammation
MANIFESTATION
S Common
 nasal drainage and congestion
 facial pain or pressure
 localized to the involved sinus
 worsens when pt bends over or is supine
 headache
 Thick, purulent or discolored nasal (both in viral
and bacterial)

Nonspecific:
 Cough
 Sneezing
 Fever

Those assoc. with bacterial sinusitis:

 Tooth pain (upper molars)
 Halitosis

Advanced frontal sinusitis can present with a

condition known as Pott’s puffy tumor, with soft
tissue swelling and pitting edema over the frontal
bone from a communicating subperiosteal abscess

Acute fungal rhinosinusitis  symptoms related to

pressure effects, particularly when the infection has
spread to the orbits and cavernous sinus

Signs such as orbital swelling and cellulitis, proptosis,

ptosis, and decreased extraocular movement are
common, as is retro- or periorbital pain
DIAGNOSIS  Timing is important esp. in discriminating sx from  CT of sinuses – radiographic study of choice
viral URI  determine the extent of disease
 Difficult to determine due to low  detecting an underlying anatomic
sensitivity and specificity of the common defect or obstructing process (e.g., a
clinical features polyp)
 assessing the response to therapy
Acute bacterial sinusitis – for patients with
“persistent” (>10 days in adults or >10–14 days in
children) accompanied by the three cardinal signs
of:
 purulent nasal discharge
 nasal obstruction
 facial pain

40-50% of those who met the criteria

have true bacterial sinusitis

 CT or sinus radiography – not recommended for

acute disease (<10 days)
TREATMENT  Improve without antibiotic therapy  clinical cure in most cases is very difficult
 aimed at symptom relief and facilitation  repeated courses of antibacterial agents and
of sinus drainage such as with: multiple sinus surgeries
 oral and topical decongestants  increase their risk of colonization with
 nasal saline lavage antibiotic-resistant pathogens and of
 nasal glucocorticoids - in patients surgical complications
with a history of chronic sinusitis
or allergies
 Antibiotic therapy
 considered for adult patients whose
condition does not improve after 10 days
and patients with more severe symptoms
(regardless of duration)
 Community-acquired sinusitis
 Empirical antibiotic therapy for adults
should consist of the narrowest-spectrum
agent active against the most common
bacterial pathogens, including S.
pneumoniae and H. influenzae 
amoxicillin or amoxicillin/ clavulanate
(with the decision guided by local rates of
β-lactamaseproducing H. influenzae)
 Patients who do not respond to initial
antimicrobial therapy  sinus aspiration and/or
lavage
 Antibiotic prophylaxis not recommended
 Surgery and IV antibiotic
 For severe cases with intracranial
complications like abscess
 Nosocomial sinusitis
 Broad spectrum antibiotics

Then it can be tailored to the results of

culture

COMPLICATIONS  Meningitis
 Epidural abscess
 Cerebral abscess