Sinusitis

Sinusitis is a disease causing an inflammation of the mucosal cells lining the sinus and nasal cavities. After ongoing speculation, the term sinusitis has been replaced by the more specific term rhinosinusitis. Rhinosinusitis can occur in children or adults and is frequently seen in the offices of primary care physicians. Rhinosinusitis most commonly develops within the paranasal sinuses following a viral upper respiratory infection. As fluid collects and stagnates within the sinus cavities, greater inflammation develops and obstructs outward fluid passage, encouraging normal microbial flora to overgrow.

Given the predisposition to occur post viral illness, it is not uncommon for a patient with rhinosinusitis to report having cold symptoms that initially resolved but later returned. Rhinosinusitis can cohabitate with other conditions such as allergic rhinitis or asthma, thus clinical distinction is important for proper treatment. Patients often complain of a wide array of symptoms ranging from headache, foul-smelling nasal discharge, halitosis, ear fullness, or cough.

Most recent guidelines govern treatment based upon symptom severity and duration. Symptoms are categorized as major or minor while duration is classified as acute, subacute, or chronic. The more prominent major factors include facial pain/pressure, nasal congestion/obstruction, and thick, yellow nasal discharge. Minor criteria include dental pain, halitosis, headache, or a cough not due to any other cause. Moreover, symptom durations are independent of the prior viral respiratory infection. Acute symptoms last for less than four weeks, while chronic symptoms last for more than three months. Subacute illness lasts between four weeks and three months.

Acute symptoms of sinusitis last for less than four weeks, while chronic symptoms last for more than three months.

Risk factors for rhinosinusitis include anatomical abnormalities (i.e., deviated septum, polyps) or the presence of another chronic respiratory disease (i.e., cystic fibrosis). Although most causes of rhinosinusitis are viral, there exists an opportunity for normal bacterial flora to take advantage of an already overstressed, occupied immune system and cause rhino-sinusitis directly after a viral respiratory illness. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common bacteria in such cases. In diabetics or immunocompromised individuals, fungal causes should also be considered.

Diagnosing rhinosinusitis begins with a thorough account of the disease course from the patient. Subsequently, a physical exam with close attention to the head and neck regions are performed. The diagnosis of rhinosinusitis is usually evident following the history and physical exam; however, in complicated or immunosuppressed cases, the physician may seek an imaging modality. General radiographs of the sinuses offer a poor yield for results and are nonspecific toward determining a bacterial etiology. A computed tomography (CT) scan of the sinuses is more accurate for visualizing fluid but is also nonspecific to diagnose a microbial etiology. The only gold standard, and rarely performed, diagnostic test to distinguish a microbial presence is sinus puncture. Sinus puncture entails a fluid sample being directly drawn from the sinus cavity and sent to the laboratory for analysis.

Current treatment guidelines favor use of antibiotics only when symptoms are severe, last beyond seven days, or include prominent yellow nasal discharge. The optimal antibiotic regimen should be narrow spectrum and targeted toward the most likely bacterial agents previously mentioned. Three most common first-line medications include amoxicillin, doxycycline, and trimethoprim/sulfamethoxazole. Although many studies are unclear in the duration of antibiotic use, most agree employing medication beyond three to five days does not impact overall effectiveness or shorten the remaining illness course. Intranasal [Page 1547]steroids offer mild relief in symptoms, but also have not been proven to effectively alter the course of the disease. Similarly, oral or intranasal decongestants containing pseudoephedrine or oxymetazoline, respectively, tend to shrink inflamed nasal passages and encourage fluid drainage. However, prolonged use beyond five days is discouraged as a rebound effect involving increased nasal congestion is likely to ensue. The most promising intranasal remedy is to utilize a hypertonic nasal saline irrigation daily to improve symptoms, and decrease the need for other intranasal medications.

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