Acute Rhinosinusitis

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It is the inflammation of the mucosal lining of the nose and paranasal sinuses of not more than 12  weeks’ duration. In sinusitis of dental origin, anaerobic bacteria are often found. 

Acute Purulent Rhinosinusitis   

• Bacterial infection with pus accumulation in one or more of the paranasal sinuses 

Clinical presentation 

• Nasal discharge (watery or purulent)
• Nasal congestion
• Post nasal dripping
• Headache worsening on bending forward and more in the morning
• Fever
• Facial pain
• Ear pain and blockage
• Anterior rhinoscopy - water/purulent nasal discharge occasionally foul smelling
• Nasal congestion
• Plain paranasal sinuses X-ray (Water's, Caldwell views)
• Mucosal thickening; air fluid levels

Pharmacological Treatment: 

B: azithromycin (PO) 500mg 24hourly for 3days. Children: 10mg/kg 24hourly for 3days 

OR 

B: amoxicillin+clavulanic acid (PO) 625mg 8hourly for 7days Children: 375mg 12hourly for 7days

OR 

C: clarithromycin (PO), 500mg 12hourly for 7-14days. Children ≥ 6 months: 15mg/kg/day  in 2divided doses for 7-14days 

OR 

B: ceftriaxone (IV) Adults: 1-2g 12hourly for 7 days. Children: 50 to 100mg/kg once for 7 days

OR 

S: cefixime (PO) Adults: 400mg 24hourly for 7-14 days. Children ≥ 6 months to 12years (weight below 45kg): 8mg/kg 24hourly for 7-14days  

AND (for fungal rhinosinusitis) 

D: itraconazole (PO) Adults: 200mg 24hourly for 30days

OR 

S: amphotericin B (IV) Adults: Test dose of 1mg IV infused over 20-30minutes. Loading dose of 0.25-0.5mg/kg IV infused over 2 to 6 hourly. Maintenance dose of 0.25-1mg/kg  24 hourly for 3-6 weeks. For children: Test dose of 0.1mg/kg not to exceed 1mg infused over 20-60minutes. Loading dose of 0.25mg/kg infused over 2-6 hours. Maintenance dose of 0.25mg/kg 24hourly to ensure a total dose of 30-40mg/kg is given over 3-6weeks 

AND 

B: ephedrine (0.5% and 1%) nasal drop, Adults and children above 12years: Instill 1 to 2 drops in each nostril, not more than 4 times a day for 3 to 5days      

OR 

S: xylometazoline (0.05% and 0.1%) nasal drops/spray, Adults and children above 6years: instill  2  to  3drops  in  each  nostril  8hourly  for  3  to  5days  or 1  to  2sprays  in  each  nostril  8hourly for 3 to 5days 

OR 

D:  fluticasone propionate (50mcg/spray) nasal spray, Adults and adolescents more than 12years: 2sprays in each nostril 24hourly as needed. Children 4-11years: 1spray in each  nostril 24hourly as needed 

OR 

S: mometasone nasal spray, Adults and adolescents from 12years: 1spray in each nostril 24hourly as needed. Children 6-11years: 1spray in each nostril 24hourly as needed. 

AND 

A: paracetamol (PO) Adults: 500mg to 1g 4-8hourly as needed. Children ≤ 10kg: 10mg/kg 4-8hourly as needed. Children >10kg: 15mg/kg 4-8hourly as needed

OR 

A: diclofenac (IM) Adults: 75mg 8hourly as needed 

OR 

C: diclofenac (PO) Adults: 50mg 4-8 hourly as needed 

OR 

C:  ibuprofen  (PO)  Adults:  200-400mg  4-8  hourly  as  needed.  Children  ≥  6  months:  5-10mg/kg 4-8hourly as needed 

Non-pharmacological management 

• Saline nasal wash
• Steaming with or without Vicks

Note: Treatment periods shorter than ten days increase the risk of treatment failure

Referral: To ENT Specialists:

• Children with ethmoiditis presenting as an acute periorbital inflammation or orbital cellulitis must be hospitalized immediately (ophthalmology consultation should be sought)
• Adults with pronounced symptoms despite treatment
• If sinusitis of dental origin is suspected
• Recurrent sinusitis (>3 attacks in a year) or chronic sinusitis (duration of illness of >12 weeks)

Surgical management   

Surgery  if  associated  with  complications  eg  orbital/periobital  abscess,  pottys  puffy  tumour,  brain  abscess and nasal polyposis etc. 

• Frontal Trephination
• Open ethimoidectomy
• Functional Endoscopic Sinus Surgery (FESS)