Sinusitis in Adults

Sinusitis in Adults

Gita Pensa, MD, and Mel Herbert, MD 

Background

• Sinusitis is common in adults AND kids, but this segment focuses on adults.
• The US total annual health care expenditure related to sinusitis was estimated at $43.4 BILLION in a 2019 paper, most of which was spent on prescription medication and imaging.
• Sinusitis can be categorized by location of symptoms, duration, and etiology (eg, infectious, inflammatory, allergic).

Location

• Frontal, maxillary, ethmoid, sphenoid
• Maxillary is most common; can also have odontogenic spread 

Duration

• Acute: <4 weeks
• Subacute: 4-12 weeks
• Chronic: >12 weeks
• Recurrent: 4×/year (without intervening symptoms)

Etiology

• Allergic, inflammatory, or infectious
  • Allergic: antihistamines, nasal steroids, decongestants
  • Infectious: acute is most often viral
  • If bacterial, same bacteria as nasopharyngeal infections and otitis media
  • Rarely fungal, but we won’t discuss here

Diagnosis

• The gold standard for diagnosis of bacterial sinusitis is antral sinus puncture and mucus aspirate culture, which is not a procedure we do. 
• The American Academy of Otolaryngology’s clinical guidelines for diagnosis of acute bacterial sinusitis include
  • Purulent nasal discharge
  • Nasal obstruction
  • Facial pain
  • Facial pressure lasting >10 days without improvement
  • Symptoms worsening within 10 days after initial improvement

Important points to ask about in history

• Fever
• Immunosuppression
• Previous sinusitis history or other recent infections
• Characteristics of headache, neck pain
• Other accompanying symptoms
• Allergies: red itchy eyes etc
• Cough, conjunctivitis, other signs pointing to viral 
• COVID risk factors
• Visual changes

Physical exam 

• A thorough exam, including neurologic, is important.
• Facial tenderness is not specific but good to note.
• Look at the face for swelling or erythema.
• Document the neurologic exam, including extraocular muscles.
• Neck exam may reveal stiffness and adenopathy.
• If your exam does not suggest anything but uncomplicated sinusitis, no tests or imaging are typically needed (maybe COVID in certain settings).

Imaging

• Can’t distinguish between viral and bacterial
• Computed tomography (CT) more specific/sensitive than plain X-rays
• Only need imaging when have suspicion of complications

Treatment of uncomplicated sinusitis

• Uncomplicated: symptomatic care × 7 days
• Treat if worsening after initial improvement, escalating/severe symptoms, or ongoing >7 days
• If no follow-up, consider treatment or tell them to come back to UC if worsening
  • Antibiotic choices:
    • First line: amoxicillin or augmentin
    • If patient has a penicillin allergy, consider doxycycline or third-generation cephalosporin like cefixime or amoxicillin-clavulanate

Complications to be aware of

• Periorbital cellulitis
  • Periorbital pain, redness, swelling
• Orbital cellulitis
  • Above plus eye pain, +/- pain with extraocular movement, proptosis, diplopia, fever
• Subperiosteal abscess
  • Collection of pus in the space between the periorbital and the lamina papyracea 
  • All of the above plus marked proptosis
• Sinus bone osteomyelitis
  • Gradual onset, dull pain worsening, overlying swelling, erythema
  • Pott’s puffy tumor
    • Complication of frontal sinusitis
    • Osteomyelitis of frontal bone associated with subperiosteal abscess
    • Swelling/puffiness of forehead
• Meningitis
• Brain abscess
  • Tricky diagnosis – global headache progresses to fever, altered mental status, etc
• Septic cavernous sinus thrombosis
  • Also tricky – headache, possibly fevers; may not be seen on plain CT

Urgent referral/transfer if these signs/symptoms are present:

• Severe and persistent headache
• Periorbital edema, inflammation, or erythema
• Vision changes (double vision or impaired vision)
• Abnormal extraocular movements
• Proptosis
• Pain with eye movement
• Cranial nerve palsies
• Altered mental status
• Neck stiffness or other meningeal signs
• Papilledema or other sign of increased intracranial pressure

REFERENCES:

Sinusitis update
Wyler B, Mallon WK. Emerg Med Clin North Am. 2019;37(1):41-54. doi: 10.1016/j.emc.2018.09.007. PMID: 30454779

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