Sinusitis

Chronic and recurrent sinusitis management

1st line = topical nasal steroids: - prescribed for >3 months, particularly if suspicion of allergic cause - formulation prescribed depends on age Refractory cases or severe concurrent allergies may benefit from oral steroids. No clear evidence supporting the use of long-term antibiotics - an ENT opinion is recommended when considering their use and if started, treatment is usually for 3-4 weeks. Smoking cessation. Good dental hygiene. Manage any underlying conditions.

What is recurring sinusitis?

>3 significant acute episodes in a year lasting >= 10 days with no intervening symptoms.

When to refer someone with chronic or recurrent sinusitis?

>=3 exacerbations requiring antibiotics in the last year. Same conditions for which you would refer someone with acute sinusitis.

When infection occurs in chronic sinusitis, what are the most common responsible organisms?

Anaerobes. Gram =ve bacteria. Staph. aureus. Coagulase -ve staphylococci.

Main fungi causing fungal sinusitis

Aspergillus. Mucor.

Management of Pott's puff tumour

CT scan. Surgical drainage, IV antibiotics.

Percussion of the sinuses

Can theoretically be percussed for dullness but the area to percuss is small and their sizes vary from person to person. Not reliable. Frontal: percuss forehead. Maxillary: percuss just below inferior orbital margin. However, does elicit tenderness.

Translumination of the sinuses

Darkened room + torch with a sheath that can be drawn up around the light source. Frontal: 1) draw the sheath up around the light source so that light is only emitted from the tip 2) place under the medial orbital roof, just posterior to the rim 3) direct light superomedially and press gently so that no light leaks into the room 4) look for a reddish glow just above the eyebrow Maxillary: 1) pull the sheath back so that light is transmitted circumferentially from the end of the torch 2) place torch in the patient's mouth with the instruction to seal the lips around the torch but to leave the jaw open 3 ) direct light superiorly 4) look for red glow in malar areas Cannot transluminate the ethmoidal and sphenoidal sinuses.

Chronic sinusitis investigations

Diagnosed the same way as acute sinusitis but symptoms last >12 weeks. Assess for nasal polyps. Cranial nerve examination in the elderly. Exam ear to rule out middle ear fluid. Rule out underlying problems: - allergic rhinitis - asthma - immunosuppression - chronic dental infection - nasal foreign body - aspirin sensitivity - Wegener's granulomatosis - Churg-Strauss syndrome

Diagnosis of fungal sinusitis

Diagnosis usually made following ENT referral. Allergic fungal sinusitis: serum total fungus-specific IgE concentrations may be elevated. Microbiology and histology provide final diagnosis.

Acute sinusitis investigations

Diagnosis usually made on above symptoms and further investigations generally not required.

How to palpate the sinuses for tenderness

Frontal sinus: press upward beneath the medial side of the supraorbital ridge. Maxillary sinus: press against the anterior wall, below the inferior orbital margin. Ethmoidal: press medially against the medial wall of the orbit. Sphenoidal: cannot be palpated for tenderness.

What are the paranasal sinuses?

Frontal, maxillary, sphenoidal and ethmoidal sinuses.

Refer the following with acute sinusitis

Hospital admission: - severe systemic disease - suspicion of intracranial spread e.g. severe frontal headache, frontal swelling, signs of meningitism, focal neurological signs - suspicion of spread to orbit e.g. orbital cellulitis - consider referral for high-risk patients e.g. immunocompromised. ENT referral: - unilateral symptoms e.g. mass, bloodstained discharge, crusting, non-tender facial pain, facial swelling, nasal polyps - not on antibiotics and symptoms worsen within 72 hrs - on antibiotics and symptoms do not resolve within 72 hrs Consider referral to ENT for recurrent infections.

What is subacute sinusitis?

Inflammation lasting 4-12 weeks.

What is sinusitis?

Inflammation of the membranous lining of >=1 of the sinuses, leading to sinus cavity obstruction. Generally also involves inflammation of the nasal mucosa, hence it is sometimes called rhinosinusitis.

Chronic sinusitis epidemiology

Less common than acute sinusitis but still reasonably common. More likely to have underlying problem.

Acute sinusitis management once referred

May involve: - microbiological investigation - IV antibiotics - sinus puncture + irrigation - endoscopic sinus surgery if severe infection + post-operative intranasal steroids, saline douching and careful nasal toileting

Acute sinusitis symptoms and signs

Most commonly present with a non-resolving cold (>1 week or worsening symptoms over 4-5 days) which may have a biphasic character i.e. the initial viral infection (rhinitis) appears to begin settling and is then followed by further malaise due to subsequent sinusitis. May be: - pain or pressure over affected sinus (not sensitive or specific sign, often unilateral and worse when bending forward) - pyrexia - nasal obstruction leading to mouth-breathing - purulent and discoloured nasal discharge or postnasal drip - decreased or absent sense of smell - headache - halitosis - fatigue - dental pain - chronic cough due to postnasal drip - feeling of pressure/fullness in ears Suggested by poor response to nasal decongestants.

Classification of fungal sinusitis

Non-invasive: - 2 types: allergic fungal sinusitis AND sinus mycetoma Invasive: - presents as acute, fulminant sinusitis with 50% mortality rate even with aggressive management OR more slowly invading nature in diabetics - also a chronic granulomatous type almost exclusive to immunocompetent North Africans

What is Pott's puff tumour

Osteomyelitis of frontal bone. Rare. Boggy frontal swelling.

Clinical assessment of the sinuses

Palpation (most helpful). Percussion. Translumination. + nose examination (external and internal).

Signs and symptoms of sinus mycetoma

Presents like acute sinusitis. May complain of blowing gravel-like material from nose.

Complications of sinusitis

Rare and more common in children. Orbital cellulitis. Meningitis. Brain abscess. Osteomyelitis (Pott's puffy tumour when frontal bone affected). Mucocele formation. Cavernous sinus thrombosis. Chronic or recurrent: psychological problems associated with chronic pain and ill health. Children: adenoiditis, dacryocystitis, laryngitis.

Acute sinusitis management

Reassure that it is generally a viral infection similar to the common cold but will take about 2.5 weeks to resolve. For symptom relief: - pain/fever: paracetamol/ibuprofen/warm face packs - intranasal decongestant for max 1 week - nasal irrigation with warm saline solution - adequate fluids and rest Severe/prolonged infection or high risk of complications due to pre-existing comorbidity: antibiotics - 1st line = amoxicillin for 7 days - 2nd line = co-amoxiclav for 7 days or azithromycin for 3 days

Which symptoms of acute sinusitis predominate in children?

Rhinitis symptoms. Ear discomfort due to Eustachian tube blockage.

Further management for chronic or recurrent sinusitis upon referral

Same as for acute sinusitis.

Signs and symptoms of acute invasive fungal sinusitis

Severely ill with fever, cough, nasal discharge, headache and mental state changes. Rapid spread to orbit and CNS.

Sinusitis and children

Some controversy as to whether this diagnosis can be made in young children who have very poorly developed sinuses - radiographic evidence of sinuses is only visible from about 9 years of age. Current consensus is that it can occur in children >1 year old. Symptoms may vary a little from those of adults and can include irritability, lethargy, snoring, mouth breathing, feeding difficulty and hyponasal speech. Acute common. Chronic uncommon.

Most common bacteria causing secondary infection amounting to acute sinusitis

Strep.pneumoniae. Haemophilus influenzae. Moraxella catarrhalis. Staph aureus. Anaerobic bacteria.

Fungal sinusitis management

Surgical debridement of infected tissue. Invasive infection: + antifungals. Allergic fungal sinusitis: systemic steroids may be used postoperatively.

Signs and symptoms of chronic invasive fungal sinusitis

Symptoms of chronic sinusitis.

Signs and symptoms of allergic fungal sinusitis

Symptoms of chronic sinusitis. Often background of atopy.

What is chronic sinusitis?

Symptoms persist for > 12 weeks +/- acute exacerbations. May be caused by irreversible changes in the mucosal lining of the sinuses.

Symptoms and signs of chronic sinusitis

Symptoms: - similar to acute sinusitis but not as florid - facial pain and loss of smell more common than with acute sinusitis Signs: - dull ache on palpation - nasal mucosal inflammation - nasal purulence

Cause of acute sinusitis

Tends to arise as a result of viral infection which causes sinus drainage obstruction and subsequent secondary bacterial infection. About 90% of those with a viral URTI have some degree of sinus involvement but only 5% subsequently develop bacterial superinfection amounting to acute sinusitis.

Fungal sinusitis epidemiology

Traditionally thought to be uncommon but recent suggestions that it actually occurs in most cases of chronic sinusitis. Associated with DM and immunocompromisation.

Sinusitis risk factors

URTI. Allergy. Asthma. Smoking. Hormonal status e.g. pregnancy. Nasal dryness. DM. Nasal foreign body. Nasal obstruction. Previous nose/cheek trauma.. Irritant inhalation e.g. cocaine. Iatrogenic e.g. NG tubes, mechanical ventilation. Dental trauma or infection. Swimming, diving, high-altitude climbing. Immunocompromised.

Where can pathology from the maxillary sinus cause referred pain?

Upper jaw. Teeth. Skin of cheek.

Fungal sinusitis prognosis

Varying degrees of invasion and tissue erosion eventually occur in all types if left untreated. Orbit and CNS at high risk of invasion. All but acute invasive carry good prognosis. Relapses common during subsequent episodes of neutropenia so treatment with propylactic systemic antifungals indicated where this occurs.

What is acute sinusitis?

Viral or bacterial infection of the sinuses lasting 7-30 days and resolves completely with appropriate management. Very common.

3 types of chronic sinusitis

With polyps. Without polyps. Associated with fungal infection.