CHAPTER 40
Rhinosinusitis
(Sinusitis)
Presentation
After a viral infection or with chronic allergies, the patient may complain of a dull facial pain, which is usually unilateral, gradually increases over a couple of days, is exacerbated by sudden motion of the head or bending over with the head dependent, may radiate to the upper molar teeth (through the maxillary antrum), and may increase with eye movement (through the ethmoid sinuses). Often, there is a sensation of facial congestion and stuffiness. The child with sinusitis often has a cough, rhinorrhea, and fetid breath. The patient’s voice may have a resonance similar to that of an individual with a “stopped up” nose, and she may complain of a foul taste in her mouth or reduced sense of smell. Stuffy ears and impaired hearing are common because of associated otitis media with effusion and eustachian tube dysfunction. A colored nasal discharge is a particularly sensitive finding. Fever is present in only half of all patients with acute infection and is usually low grade. A high fever and severe headache usually indicate a serious complication, such as meningitis or another diagnosis altogether. Transillumination of sinuses in the acute care setting is usually unrewarding, but tenderness may be elicited on gentle percussion or firm palpation over the maxillary or frontal sinuses or between the eyes (ethmoid sinuses). Swelling and erythema may exist. Pus may be visible draining below the nasal turbinates (most often in the middle meatus) with a purulent yellow-green or chronic infection, sometimes with a foul-smelling discharge from the nose or running down the posterior pharynx.
What To Do:
Rule out other possible causes of facial pain or headache through the patient’s history and physical examination (palpate the scalp muscles, temporal arteries, temporomandibular joints, eyes, and teeth). Consider the diagnosis of viral or allergic rhinitis (see Chapter 39).
Shrink swollen nasal mucosa (and thereby provide symptomatic relief of nasal obstruction) with 1% phenylephrine (Neo-Synephrine) or 0.05% oxymetazoline (Afrin) nose drops. Instill 2 drops in each nostril, allow the patient to lie supine for 2 minutes, and then repeat the process. (Repeating the process allows the first applications to open the anterior nose so that the second dose gets farther back.) Have the patient repeat this process every 4 hours but for no more than 3 to 5 days (to avoid rhinitis medicamentosa).
Examine the nose for purulent drainage before and, when practical, after shrinking the nasal mucosa with a topical vasoconstrictor.
Antibiotics should be limited to patients who have symptoms lasting 7 or more days, with unilateral maxillary pain or tenderness of the face or teeth accompanied by purulent nasal secretions or to those patients who present initially with more severe symptoms.
Prescribe amoxicillin (Amoxil), 1 g tid × 10 days, 90 mg/kg/day divided bid or tid (suspension 125, 200, 250, and 400 mg/5mL). Studies have shown that the newer broad-spectrum antibiotics are no better than the older, less expensive narrow-spectrum ones.
If the patient has taken antibiotics within the past month or the prevalence of drug-resistant Streptococcus pneumoniae is greater than approximately 30% in the community, prescribe amoxicillin clavulanate (Augmentin XR), 2000/125 mg bid (prescribed as 2 tabs 1000/62.5 mg bid), or extra strength pediatric suspension, 90 mg amoxicillin component/kg/day divided bid × 10 days.
The best choice in penicillin-allergic patients is either trimethoprim-sulfamethoxazole (Bactrim) 1 PO bid × 7 days or azithromycin (Zithromax) 500 mg PO day 1 then 250 mg PO qd days 2 to 5.
The more expensive respiratory fluoroquinolones should be considered in adults only if penicillin-resistant S. pneumoniae is a major concern or for treatment failures.
Most cases of acute rhinosinusitis are viral in origin, and the clinical differentiation of viral from bacterial causes is difficult. Therefore, when a patient presents early in the course of his illness, unnecessary treatment with antibiotics can often be avoided by not starting a patient on antibiotics initially but, instead, writing a backup prescription that can be filled if symptoms persist for a total of 7 days.
Provide pain relief (e.g., ibuprofen, naproxen, acetaminophen, oxycodone, hydrocodone) when necessary.
If allergic rhinitis is suspected (see Chapter 39), a second-generation antihistamine is a logical addition to therapy, or an intranasal steroid may be helpful, but it may be difficult to distinguish viral from allergic sinus symptoms.
For symptomatic relief, recommend that the patient try hot facial compresses and hot water vapor inhalation using a simple teakettle, a hot shower, a steam vaporizer, or a home facial sauna device. Hot soups or teas can also be comforting. Plain saline nasal sprays and irrigations have been shown to lessen symptoms as well.
Arrange for follow-up within 1 to 7 days, depending on the severity of the initial findings. Specialist evaluation is appropriate when sinusitis is refractory to treatment or is recurrent.
Give the patient an explanation of the rationale for management and inform him about the signs and symptoms of worsening that should prompt him to seek immediate medical attention.
What Not To Do:
Do not ignore signs of orbital cellulitis (swelling, erythema, decreased extraocular movements, and possible proptosis). These patients require consultation and hospital admission for IV antibiotic therapy.
Do not ignore the toxic patient who has marked swelling, high fever, severe pain, profuse drainage, or other signs and symptoms of a serious infection. (See the potential complications described later.) These patients require immediate consultation and intervention.
Do not order routine radiograph or CT examinations. Reserve them for difficult diagnoses and treatment failures.
Do not prescribe first-generation antihistamines, which are sedating and can make mucous secretions dry and thick and can interfere with necessary drainage.
Do not allow the patient to use decongestant nose drops for more than 3 to 5 days; this will prevent the nasal mucosa from becoming habituated to topical sympathomimetic medication. If she uses the drops for more than 5 days, the patient may suffer rebound nasal congestion (rhinitis medicamentosa) when use of the drops is discontinued; resolution of this condition requires time, topical steroids, and reeducation.
Do not prescribe long-term topical or systemic sympathomimetic decongestants to a patient who suffers from increased intraocular pressure, hypertension, ischemic heart disease, tachycardia, or difficulty initiating urination, all of which may be exacerbated.
Do not prescribe antibiotics to patients with mild symptoms who do not have persistent maxillary facial or dental pain or tenderness or who do not have purulent nasal drainage. These patients are unlikely to have bacterial rhinosinusitis, regardless of duration of illness.
Discussion
The term rhinosinusitis is considered to be more accurate than sinusitis, because sinusitis is, in most instances, a continuum and eventual consequence of rhinitis (see Chapter 39). Acute sinusitis is defined as inflammation of the sinuses for less than 4 weeks.
Sinusitis is the most common health care complaint in the United States. The paranasal sinuses drain through tiny ostia under the nasal turbinates. Occlusion of these ostia allows secretions and pressure differences to build up, resulting in the pressure and pain of acute sinusitis and the air-fluid levels sometimes visible on radiographs. Early mild cases do not require treatment with antibiotics. However, congested sinuses can become a site for bacterial superinfection.
Most cases of rhinosinusitis begin with ostial obstruction caused by mucosal swelling associated with viral upper respiratory tract infection. Other causes include allergic rhinitis; barotraumas caused by flying, swimming, or diving; nasal polyps and tumors; and foreign bodies, including nasogastric and endotracheal tubes placed in hospitalized patients. Abscessed teeth can also be the source of maxillary sinusitis. If there is tenderness on percussion of the bicuspids or molars, arrange for dental consultation.
A CT scan of the sinuses is the study of choice for evaluating sinusitis but is needed urgently only with complicated cases or treatment failures. Radiologic studies performed within days of the onset of symptoms may lead to an incorrect conclusion that bacterial infection is present. Up to 40% of sinus radiographs and more than 80% of CT scans may be abnormal in viral sinusitis if obtained within 7 days of the onset of illness.
Most patients can receive initial treatment on the basis of the history and physical examination alone. Anyone who has moderate to severe unilateral facial or dental pain or purulent nasal discharge persisting for more than 7 days, with or without fever, should probably be treated empirically for acute bacterial rhinosinusitis. Be aware that most cases of milder acute bacterial rhinosinusitis will resolve without the need to prescribe antibiotics, and complications of untreated bacterial disease are rare.
Many patients have been conditioned by the advertising of over-the-counter antihistamines for “sinus” problems (usually meaning “allergic rhinitis”) and may relate a history of “sinuses,” which on closer questioning turns out to be uncomplicated rhinitis.
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