LMCC/Sinusitis

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

Etiology[edit]

  • 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[edit]

  • 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[edit]

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

Acute Sinusitis Score[edit]

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[edit]

  • 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[edit]

  • 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[edit]

  • acute: 40% will recover spontaneously

Pharmacology[edit]

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

Adjunct therapy[edit]

  • 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[edit]

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

References[edit]

Toronto Notes 2005