Sinusitis

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IntroductionInflammation 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 mg/kg 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