Sinusitis

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Introduction

• Inflammation of the mucosal lining of the paranasal sinuses
• May be acute or chronic and affect one or more of the sinuses
  • Most commonly the maxillary sinus or antrum (in very young children the ethmoidal sinuses)
• Acute sinusitis is often sequel to acute rhinitis
  • Common organisms are streptococcus, pneumococcus, and haemophilus
  • Chronic sinusitis is more insidious
  • May be associated with chronic rhinitis and allergy but other factors such as air pollution, smoking, dental sepsis and poor general health may be contributory
• Bacteriology is mixed: sometimes Gram negative and fungal organisms

Clinical features

• Rhinorrhoea
• Nasal obstruction
• Fever with pain over affected sinus in acute cases
• Less dramatic symptoms in chronic sinusitis
  • Intermittent nasal obstruction and discharge over a long period
  • Little pain
  • Mucopurulent postnasal discharge ("drip")

Differential diagnoses

• Acute rhinitis (coryza)
• Allergic rhinitis
• Vasomotor rhinitis

Complications

• Orbital cellulitis (complicating ethmoidal sinusitis)
• Cavernous sinus thrombosis (sphenoidal sinusitis)
• Intracranial infection
  • Subdural abscess
• Meningitis
• Cerebral abscess
• Dural vein thrombophlebitis
• Osteomyelitis of frontal or maxillary bones
• Chronic pharyngotonsillitis
• Chronic laryngitis and bronchitis

Investigations

• Nasal swab for microscopy, culture and sensitivity
• X-ray of sinuses: four-view
• Antrum roof puncture/lavage: specimen for culture
• CT scan in complicated cases
• MRI

Treatment goals

• Control and eradicate infection
• Restore adequate drainage of sinuses

Non-drug treatment

• Antrum wash-out/lavage
• Trephining of frontal sinus
• Radical surgery for non-responsive cases
  • Intranasal antrostomy
  • Caldwell-Luc operation
  • Fronto-ethmoidectomy
• Functional Endoscopic Sinus Surgery (FESS)

Drug treatment

• Antibiotics
  • Amoxicillin
  • Adult: 500 mg - 1 g orally every 8 hours for 5 - 7 days
  • Child:40 mg/kg orally every 8 hours for 5 - 7 days
• Or:
  • Amoxicillin/clavulanic acid
  • Adult: 500/125 mg orally every 12 hours
  • Child: 0.25 mL/kg of 125/31 mg suspension orally every 8 hours; dose doubled in severe infections
    • 1 - 6 years: 5 mL of 250/62 mg suspension every 8 hours; dose doubled in severe infections
    • 6 - 12 years: 5 mL of 250/62 mg suspension every 8 hours; dose doubled in severe infections
    • 12 - 18 years: one 250/125 mg strength tablet every 8 hours, daily increased in severe infection to one 500/125 strength tablet every 8 hours daily
• Or:
  • Cotrimoxazole
  • Adult: 960 mg orally 12 hourly
  • Child
    • 6 weeks to 5 months: 120 mg orally 12 hourly;
    • 6 months - 5 years: 240 mg 12 hourly;
    • 6 - 12 years: 480 mg every 12 hours
  • Ceftriaxone
  • Adult: 1 g intravenously or intramuscularly 12 hourly for 7 days for patients with severe or nosocomial disease
  • Child:
    • Neonates: 20 - 50 mg/kg by intravenous infusion over 60 minutes once daily, or by deep intramuscular injection, or by intravenous injection over 2 - 4 minutes, or by intravenous infusion
    • 1 month - 12 years (body weight under 50 kg) 50 once daily, up to 80 mg/kg in severe infections

• Decongestant
  • Psuedoephedrine tablets
  • Adult: 60 mg orally twice daily until congestion clears
  • Child
    • 2 - 6 years: 15 mg orally 3 - 4 times daily;
    • 6 - 12 years: 30 mg 3 - 4 times daily;
    • 12 - 18 years: 60 mg 3 - 4 times daily
• Analgesic
  • Paracetamol
  • Adult: 500 mg -1 g orally 4 - 6 hourly (maximum of 4 g daily) for 5 - 7 days
  • Child over 50 kg: same as adult dosing
    • 6 - 12 years: 250 - 500 mg;
    • 3 months - 5 years: 125 - mg taken orally every 4 - 6 hours for 5 - 7 days

Supportive measures

• Steam inhalations with menthol
• Treat contributory nasal pathology as appropriate
  • Allergy, nasal polyps, septal deviations, dental pathology, etc

Notable adverse drug reactions, contraindications, and caution

• Amoxicillin
  - minor gastrointestinal disturbance
• Cotrimoxazole
  - Fixed drug eruption
  - Nausea and vomiting
  - Erythema multiforme
  - Steven-Johnson syndrome
  
  

Prevention

• Avoid airway irritants, smoking, and alcohol
• Avoid air pollution
• Maintain good general health and nutrition