LMCC/Sinusitis

• inflamation of mucous membranes in the nasal cavity and paranasal sinuses
• fluid within these cavities or the underlying bone

Etiology

• divided into
  • acute: < 4 weeks
  • recurrent: 4 or more episodes per year lasting at least 10 days
  • chronic: > 12 weeks
• common pathogens are S. pneumoniae, H.influenza, M.catarrhalis

Risk Factors

• medical conditions: respiratory infections, allergic rhinitis cystic fibrosis or immunodeficiency
• anatomic: deviated septum, polyps, adenoid hypertrophy, tumour
• irritants: environmental, tobacco smoke, air pollution, chlorine
• iatrogenic: topical decongestant overuse, cocaine, trauma

History

• recent URTI
• nasal congestion/discharge
• fascial pain/swelling
• maxillary toothache
• fever
• headache worse with bending over
• poor response to decongestants

Acute Sinusitis Score

1 point each for:

• Maxillary toothache
• history of purulent nasal discharge
• poor response to decongestants
• abnormal transillumination
• purulent secretions
  • 0-1 sinusitis unlikely
  • 2-3 order x-ray (Water's view)
  • 4-5 likely sinusitis, no x-ray needed, treat with antibiotics

Physical

• swelling and erythema over symptomatic area
• tenderness on palpation of paranasal sinuses
• periorbital swelling
• nasal speculum exam: hyperemia, edema, crusts, purulence, polyps
• tranillumination
  • to evaluate frontal and maxillary sinuses
  • of no diagnostic value in children, marginal in adults
  • 55% with +'ve radiologic findings have abnormal transillumination
  • must be in complete darkness

Investigations

• radiography only when diagnosis of sinusitis is in doubt
• all patients with pronounced frontal headaches should have radiograph performed
• CT scans are not routineley used for diagnosis

Management

• acute: 40% will recover spontaneously

Pharmacology

• 1st line: amoxicillin x 10 days or TMP-SMX if penecillin allergy
• 2nd line: Amoxil/clavulin, clarithromycin, ceflacor, cefixime

Adjunct therapy

• saline nasal spray with humidification
• topical or systemic decongestants; for short term use only
• antihistamines are contraindicated
• nasal corticosteroid spray for chronic sinusitis

Referal to ENT

• failure of 2nd line therapy
• >3 episodes/year
• development of complications (ie. mucoceles, orbital extension, meningitis, intracranial abscess, venous sinus thrombosis)

References

Toronto Notes 2005