Sinusitis is inflammation of the mucous membranes lining the paranasal sinuses.
The term is most commonly used to describe bacterial rhinosinusitis, which is a clinical diagnosis made by the presence of upper respiratory tract symptoms that have not improved in 10 days or have worsened after 5 " 7 days. Diagnosis of sinusitis should be considered based on persistence and/or severity of symptoms.
Classification based on duration of symptoms:
Acute: persistent nasal and sinus symptoms for 10 " 30 days; worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement; or concurrent high fever and purulent nasal discharge for the first 3 " 4 days of an acute upper respiratory tract infection (URI)
Subacute: clinical symptoms for 30 " 90 days
Chronic: symptoms lasting >90 days
Recurrent: acute sinusitis with complete resolution of 10 days between episodes; 3 episodes in 6 months or 4 episodes in 1 year
Classification by severity of illness:
Persistent: >10 " 14 days but <30 days; nasal discharge and/or daytime cough
Severe: temperature of ≥39 °C (102.2 °F) with concurrent purulent nasal discharge for ≥3 days and/or facial pain, headache, or periorbital edema
General Prevention
Avoid allergen exposure and treat allergies if present.
Improve mucociliary clearance by increasing ambient humidity with a humidifier.
Pathophysiology
Normal sinus function depends on patency of paranasal sinus ostia, function of the ciliary apparatus, and secretion quality.
A buildup of secretions is due to ostial obstruction, reduction in ciliary function, and overproduction of secretions.
Viral URIs and/or allergic rhinitis often precede an acute bacterial infection.
Etiology
Viral pathogens (e.g., rhinovirus, parainfluenza virus) have been recovered in respiratory isolates, but their significance is unknown.
Most illnesses of short duration (<7 days) are thought to be from viral infections and should not be treated with antibiotics.
Chronic sinusitis often secondary to allergic rhinitis, cystic fibrosis, environmental pollutants, or gastroesophageal reflux
Bacterial pathogens: with an increasing prevalence of penicillin resistance
Most common pathogens:
Haemophilus influenzae, nontypeable
Streptococcus pneumoniae
Moraxella catarrhalis
Other pathogens:
Group A streptococci
Group C streptococci
Peptostreptococci
Other Moraxella species
Streptococcus viridans
Eikenella corrodens
Staphylococcus aureus
Pseudomonas aeruginosa (in patients with cystic fibrosis)
Anaerobic organisms
Polymicrobial
Fungal pathogen: Aspergillus
Diagnosis
History
Previous sinusitis, previous antibiotic use, allergies, child care attendance
Key symptoms to differentiate from viral URI:
Duration of symptoms >10 days or worsening of symptoms after initial improvement
Onset of fever, especially with a duration of ≥3 " 4 days, facial pain, purulent discharge at onset
Some or all of the following may be present:
Nasal discharge: consistency, color. In older patients, nasal discharge may not be the primary complaint, but concurrent rhinitis is a common feature.
Postnasal drainage, nasal congestion
Fever
Recent history of a URI
Sore throat from mouth breathing due to nasal obstruction
Cough present during the day; may be worse at night
Malodorous breath
Hyposmia/anosmia
Maxillary dental pain
Facial swelling
Ear pressure or fullness
Headache and facial pain are uncommon in young children with sinusitis but may be seen in older children and adolescents.
Fatigue
Irritability
Snoring
Hyponasal speech
Physical Exam
Fever may be present.
Nasal-sounding voice may be present.
Malodorous breath may be noted but is not a specific indicator of sinusitis.
Purulent drainage in the nose and/or oropharynx may be appreciated.
Nasal mucosa may be erythematous, pale, and/or boggy, but these are nonspecific findings.
Frontal, maxillary, and ethmoid areas may be tender to palpation/percussion.
Headache and/or facial pain may change with position, increasing in intensity as the patient leans forward.
Transillumination is not a reliable aid in diagnosis.
Proptosis, eye swelling, and impaired extraocular movements suggest orbital infection.
Diagnostic Tests & Interpretation
Lab
Gold standard is culture from sinuses via direct aspiration/ endoscopy; not indicated for diagnosis of acute, uncomplicated sinusitis
For chronic or recurrent sinusitis, consider
Sweat chloride test to rule out cystic fibrosis
Immunoglobulin levels, IgG subclass levels, complement levels, and testing for human immunodeficiency virus (HIV) infection
Mucosal biopsy to assess ciliary function
Imaging
Imaging is not recommended in uncomplicated cases of sinusitis.
Sinus radiographs are of limited value with the exception of the Waters (occipitomental) view for identifying maxillary sinusitis.
Plain radiographs do not adequately identify ethmoid sinusitis.
Findings suggestive of sinusitis include complete sinus opacification, mucosal thickening ≥4 mm, and air " fluid levels.
CT scan with contrast of the paranasal sinuses: useful in complicated, recurrent, and chronic sinusitis and/or history of polyposis
CT scan of the head with contrast: indicated when sinusitis is accompanied by signs of increased intracranial pressure, meningeal irritation, proptosis, toxic appearance, limited extraocular movements, or focal neurologic deficits or in patients being considered for sinus-related surgery
MRI of the sinuses: reserve for complicated cases and in immunocompromised patients in which fungal infection is suspected; will show mucosal thickening and fluid
MRI with contrast of the head, as an alternative or adjunct to CT with contrast, when intracranial complications are suspected
Pitfalls
Sinus radiographs may be abnormal in asymptomatic children or those with mild URIs.
Studies have shown a relatively high incidence of sinus abnormalities on CT scan in asymptomatic children, especially in infants <12 months of age. The significance of opacified sinuses in asymptomatic children is not well understood.
Up to 1/3 of patients with symptoms of chronic sinusitis may have normal CT scans.
Differential Diagnosis
Infection: viral URI with or without mucopurulent rhinitis
Environmental: allergic rhinitis
Drug-induced: rhinitis medicamentosa
Tumors
Nasal polyps
Hypertrophied adenoids
Neoplasms
Trauma: foreign body (e.g., bead, cotton, tissue paper)
Congenital
Septal deviation
Unilateral choanal atresia
Dysmotile cilia syndrome
Dental disorder
Other: vasomotor rhinitis
Treatment
General Measures
New guidelines support the option of observing children with persistent symptoms, but not those with worsening or severe symptoms, for 3 days before treating with antibiotic therapy.
If orbital or CNS infection is suspected by history and examination, antibiotics should be started immediately, and emergency CT studies should be performed.
Pitfalls
Diagnosis of sinusitis is being made with increasing frequency and may result in overtreatment, given that up to 50% will have spontaneous resolution.
With widespread antibiotic use, there are increasing numbers of resistant organisms.
Medication
Antibiotics
Appropriate drug choice depends on local resistance patterns.
High-risk children include age <2 years, hospitalization, antibiotic use within 3 months of diagnosis, and child care attendance.
1st-line treatment: amoxicillin 45 mg/kg/day or 80 " 90 mg/kg/24 h of amoxicillin if high risk, local pneumococcal resistance >10%, severe symptoms or comorbidity, divided twice daily with a max of 2 g/dose
For non " type I penicillin allergy (late or delayed, >72 hours) or type I allergy (anaphylaxis) in children age 2 years and older, cefdinir (14 mg/kg/day), cefpodoxime (10 mg/kg/day), or cefuroxime axetil (30 mg/kg/24 h divided twice daily) may be used.
For type I penicillin allergy in children age <2 years, consider clindamycin combined with cefixime to cover resistant bacteria.
Macrolides and trimethoprim-sulfamethoxazole are not recommended due to high resistance rates.
Duration of treatment should be for 10 (minimum) to 28 days (and until 7 days beyond symptom resolution).
Consider changing antibiotic coverage and/or obtaining a culture if symptoms do not improve after 3 " 5 days of antibiotics, especially in a hospitalized patient.
Complicated sinusitis (CNS or orbital involvement) or children with toxic appearance: IV antibiotics and hospitalization; ceftriaxone 100 mg/kg/24 h in 2 doses) or ampicillin-sulbactam (200 " 400 mg ampicillin component/kg/day in 4 divided doses); cefotaxime 100 " 200 mg/kg/day divided every 6 hours or, if no other alternative, levofloxacin 10 " 20 mg/kg/day divided every 12 " 24 hours
If a hospitalized, ill child is not improving on the IV antibiotics listed above, consider adding vancomycin (60 mg/kg/24 h divided into 4 doses) for penicillin-resistant S. pneumoniae +/ ’ metronidazole (30 mg/kg/24 h divided into 4 doses) for anaerobic coverage.
Chronic sinusitis: consider broad-spectrum antibiotic (amoxicillin/clavulanate [80 " 90 mg/kg/24 h of amoxicillin divided in 2 doses]) for at least 3 weeks and use of adjuvants such as saline irrigation or intranasal steroids; consider culture if no resolution after 1 week of treatment.
Other pharmaceuticals:
Decongestants and antihistamines are not recommended due to side effects and lack of evidence of clinical improvement with use.
Mucolytics, such as guaifenesin, may improve mucous clearance.
Topical nasal steroids: may reduce and prevent mucosal swelling, which can lead to ostial occlusion, in patients with allergic rhinitis
Other treatments:
Humidifier: may improve mucociliary clearance
Normal saline: Although there is no evidence to support its efficacy in acute sinusitis, saline irrigation and or spray is used by some for symptom relief; increases humidity and enhances mucociliary transport; vasoconstricts and improves drainage and ventilation
Surgery/Other Procedures
Maxillary sinus aspiration: if unresponsive to multiple antibiotics, severe facial pain, and orbital or intracranial complications; should be performed by a trained ear, nose, and throat (ENT) specialist
Surgery: performed as a last resort after medical therapy attempted and in patients with orbital or CNS complications
Ongoing Care
Prognosis
Spontaneous resolution in up to 50% of patients
Usually improves within 72 hours of initiation of antibiotics
Excellent for those who are otherwise healthy
Complications
Periorbital cellulitis
Orbital cellulitis
Orbital abscess
Subperiosteal abscess
Meningitis
Intracranial abscess
Optic neuritis
Cavernous or sagittal sinus thrombosis
Epidural, subdural, and brain abscess(es)
Osteomyelitis of the maxilla
Osteomyelitis of the frontal bone (Pott puffy tumor)
Patient Monitoring
Immediate referral is indicated if there are CNS symptoms, periorbital edema, visual changes, facial swelling, extraocular muscle involvement, or proptosis.
Radiographic soft tissue changes may last for up to 8 weeks; therefore, reimaging is of limited value.
Referral to an otolaryngologist (ENT specialist) when sinusitis is chronic and not responsive to medical therapy, recurrent, complicated, or when there is polyposis
Additional Reading
Brook I. Acute sinusitis in children. Pediatr Clin North Am. 2013;60(2):409 " 424. [View Abstract]
Chow AW, Benninger MS, Brook I, et al. IDSA Clinical practice guidelines for acute bacterial sinusitis in children and adults. Clin Infect Dis. 2012;54:1041 " 1045.
Leo G, Triulzi F, Incorvaia C. Diagnosis of chronic sinusitis. Pediatr Allergy Immunol. 2012;23(Suppl 22):20 " 26. [View Abstract]
Setzen G, Ferguson BJ, Han JK, et al. Clinical consensus statement: appropriate use of computed tomography for paranasal sinus disease. Otolaryngol Head Neck Surg. 2012;147(5):808 " 816. [View Abstract]
Shaikh N, Wald ER, Pi M. Decongestants, antihistamines and nasal irrigation for acute sinusitis in children. Cochrane Database Syst Rev. 2012;9:CD007909. doi:10.1002/14651858.CD007909.pub3. [View Abstract]
Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262 " e280. [View Abstract]
Codes
ICD09
473.9 Unspecified sinusitis (chronic)
461.9 Acute sinusitis, unspecified
461.1 Acute frontal sinusitis
461.0 Acute maxillary sinusitis
461.2 Acute ethmoidal sinusitis
461.8 Other acute sinusitis
472.0 Chronic rhinitis
ICD10
J32.9 Chronic sinusitis, unspecified
J01.90 Acute sinusitis, unspecified
J01.10 Acute frontal sinusitis, unspecified
J01.00 Acute maxillary sinusitis, unspecified
J01.91 Acute recurrent sinusitis, unspecified
J31.0 Chronic rhinitis
J01.20 Acute ethmoidal sinusitis, unspecified
SNOMED
36971009 Sinusitis (disorder)
15805002 Acute sinusitis (disorder)
40055000 Chronic sinusitis (disorder)
78737005 Frontal sinusitis
18643000 Ethmoidal sinusitis
311000119101 non-allergic rhinitis (disorder)
88348008 Maxillary sinusitis (disorder)
FAQ
Q: Are all of the sinuses present at birth?
A: No. The maxillary and ethmoid sinuses form during the 3rd and 4th gestational months and are present at birth. They continue to enlarge until the preteen years. The sphenoid sinuses are pneumatized by 5 years; isolated sphenoid sinusitis is rare. The frontal sinuses are present at age 7 " 8 years and are not completely developed until late adolescence.
Q: Does the nasal discharge seen with sinusitis have to be purulent and thick?
A: No. Although the nasal discharge is often described as purulent and thick, it may also be clear or mucoid or thick or thin. Multiple studies have shown that a change in color or consistency is not a specific sign of a bacterial infection.
Q: Are radiographic studies useful in the diagnosis of sinusitis?
A: There is evidence to suggest that plain radiographs (x-rays) have limited value in the diagnosis of sinusitis and are not recommended in cases of uncomplicated sinusitis. Mucosal thickening may be seen with viral URIs and allergic rhinitis. Studies have shown that x-rays do not correlate well with CT scans in the diagnosis of chronic sinusitis.
Q: Can one make the diagnosis of sinusitis based on CT scan results alone?
A: No. Up to 50% of patients who had CT scans performed for other reasons had soft tissue changes in their sinuses. Mucosal thickening and opacification on CT imaging have been seen in large numbers of asymptomatic patients. These findings seem to occur more frequently in infants younger than 12 months of age. Given the poor specificity of CT imaging of the paranasal sinuses, results must be used in the context of the patient 's clinical presentation.