Sinusitis in Adults
Gita Pensa, MD, and Mel Herbert, MD
- 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).
- Frontal, maxillary, ethmoid, sphenoid
- Maxillary is most common; can also have odontogenic spread
- Acute: <4 weeks
- Subacute: 4-12 weeks
- Chronic: >12 weeks
- Recurrent: 4×/year (without intervening symptoms)
- 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
- 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
- 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
- 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).
- 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
- 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
- Pain with eye movement
- Cranial nerve palsies
- Altered mental status
- Neck stiffness or other meningeal signs
- Papilledema or other sign of increased intracranial pressure
Wyler B, Mallon WK. Emerg Med Clin North Am. 2019;37(1):41-54. doi: 10.1016/j.emc.2018.09.007. PMID: 30454779