Sinusitis

Definition

Sinusitis is inflammation of the sinuses, which are air-filled cavities in the skull. The etiology
can be infectious (bacterial, viral, or fungal) or noninfectious (allergic) triggers. This
inflammation leads to blockade of the normal sinus drainage pathways (sinus ostia), which in
turn leads to mucus retention, hypoxia, decreased mucociliary clearance, and predisposition to
bacterial growth.

Figure 1: Click to Enlarge

Sinusitis can be divided into the following categories: 1

1. Acute sinusitis is defined as symptoms of less than 4 weeks' duration (Fig. 1 );

2. Subacute sinusitis is defined as symptoms of 4 to 8 weeks' duration;
3. Chronic sinusitis is defined as symptoms lasting longer than 8 weeks' duration (Fig. 2 );
4. Recurrent acute sinusitis is often defined as three or more episodes per year, with each
episode lasting less than 2 weeks' duration.

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Prevalence

The prevalence of acute sinusitis is on the rise, based on data from the National Ambulatory
Medical Care Survey (from 0.2% of diagnoses at office visits in 1990 to 0.4% of diagnoses at
office visits in 1995 2 ). In 2001, sinusitis represented 13.6 million outpatient visits according to
the U.S. Centers for Disease Control and Prevention. 3 Approximately 40 million Americans are
affected by sinusitis every year, with 33 million cases of chronic sinusitis reported annually to
the U.S. Centers for Disease Control and Prevention. 4
Figure 2: Click to Enlarge

When sinusitis is considered together with commonly associated comorbid conditions such as
allergic rhinitis, asthma, and chronic bronchitis, exacerbation of these diseases affects more than
90 million people—nearly one in three Americans. 5 The socioeconomic impact of this translates
to more than $5.8 billion dollars spent on the treatment of sinusitis. 6

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Pathophysiology

The most common cause of acute sinusitis is an upper respiratory tract infection (URTI) of viral
origin. The viral infection may lead to inflammation of the sinuses that usually resolves without
treatment in less than 14 days. If symptoms worsen after 3 to 5 days or persist for longer than 10
days and are more severe than normally experienced with a viral infection, a secondary bacterial
infection is diagnosed. The inflammation may predispose to the development of acute sinusitis
by causing sinus ostial blockage. Although inflammation in any of the sinuses can lead to
blockade of the sinus ostia, the most commonly involved sinuses in both acute and chronic
sinusitis are the maxillary and the anterior ethmoid sinuses. 7 The anterior ethmoid, frontal, and
maxillary sinuses drain into the middle meatus, creating an anatomic area known as the
“ostiomeatal complex” (Fig. 3).
The nasal mucosa responds to the virus by producing mucus and recruiting mediators of
inflammation, such as white blood cells, to the lining of the nose, which cause congestion and
swelling of the nasal passages. The resultant sinus cavity hypoxia and mucus retention cause the
cilia—that move mucus and debris from the nose—to function less efficiently, creating an
environment for bacterial growth.

If the acute sinusitis does not resolve, chronic sinusitis may develop from mucus retention,
hypoxia, and blockade of the ostia. This promotes mucosal hyperplasia, continued recruitment of
inflammatory infiltrates, and the potential development of nasal polyps. However, other factors
may predispose to sinusitis ( Table 1 ). 8

When bacterial growth occurs in acute sinusitis, the most common organisms include
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. 9 In chronic
sinusitis, these organisms, plus Staphylococcus aureus, coagulase-negative Staphylococcus
species, and anaerobic bacteria, are the most likely involved organisms. Organisms isolated from
patients with chronic sinusitis increasingly are showing antibiotic resistance. In fact, penicillin
resistance rates for S. pneumoniae are as high as 44% in parts of the United States. 10 These
resistant organisms commonly occur in patients who have received two or more recent courses of
antibiotics.
Table 1: Conditions That Predispose to Sinusitis

Allergic rhinitis Hormonal conditions (e.g., progesterone-induced Cystic fibrosis

congestion of pregnancy, rhinitis of
Nonallergic rhinitis hypothyroidism) Primary ciliary
dyskinesia
 Gastroesophageal reflux
Anatomic factors:
Primary immune deficiency:
 Septal deviation
 Paradoxical middle  Selective IgA deficiency
turbinate  Common variable Immune deficiency
Kartagener's
 Ethmoid bulla
syndrome
hypertrophy Acquired Immune deficiency
 Choanal atresia
 Adenoid  Human immunodeficiency virus
hypertrophy  Transplantation
 Chemotherapy

© 2004 The Cleveland Clinic Foundation

A distinct entity, allergic fungal sinusitis (AFS), occurs in immunocompetent patients and results
from an immunologic reaction to fungi that colonize the sinuses. 11 Most people tolerate exposure
to mold spores in the air because they are ubiquitous in our environment. However, people with
AFS develop a hypersensitivity reaction involving an intense eosinophilic inflammatory response
to the fungus that has colonized the sinuses. Common fungi associated with this syndrome
include Bipolaris specifera and Aspergillus, Curvularia, and Fusarium species. 11 This is an
allergic noninvasive response to the fungus that should be distinguished from invasive fungal
sinusitis, which is more common in diabetic and immunocompromised patients. The diagnostic
criteria for AFS include findings of chronic sinusitis on computed tomography (CT) of the
sinuses (such as mucosal thickening, opacification, polyps, and high-intensity signaling from the
high protein content in the mucus) or low signaling of fungal concretions in sinus cavities on
MRI. On sinus culture, fungi can be isolated with associated “allergic mucin,” which is mucus
loaded with degranulated eosinophils. Allergy skin testing can verify that these patients have an
IgE-mediated reaction to molds.

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Signs and symptoms

Acute bacterial sinusitis in adults most often manifests with more than 7 days of nasal
congestion, purulent rhinorrhea, postnasal drip, and facial pain and pressure, alone or with
associated referred pain to the ears and teeth. There may be a cough, frequently with a worsening
at night. 12 Children with acute sinusitis may not be able to relay a history of postnasal drainage or
headaches, so cough and rhinorrhea are most commonly reported symptoms. 13 Other symptoms
may include fever, nausea, fatigue, impairments of smell and taste, and halitosis.

Chronic sinusitis may cause more indolent symptoms that persist for months. Nasal congestion
and postnasal drainage are the most common symptoms of chronic sinusitis. Chronic cough that
is described as worse at night or on awakening in the morning is also a frequently described
symptom of chronic sinusitis. Clinical evidence of chronic sinusitis may be subtle and less overt
than in acute sinusitis unless the patient is having an acute sinusitis exacerbation. Because this
diagnosis may be more difficult to make in the primary care setting or in a setting without
radiographic or rhinoscopic capabilities, Lanza and Kennedy have proposed 14 a major and minor
classification system to define chronic sinusitis by the manifesting symptoms ( Table 2 ).
Table 2: Symptoms Associated with the Diagnosis of Chronic Sinusitis

Facial pain/pressure
Facial congestion/fullness
Nasal obstruction/blockage
Nasal discharge/purulence/postnasal drip
Hyposmia/anosmia
Headache
Fever
Halitosis
Fatigue
Dental pain
Cough
Ear pain/pressure/fullness
Reprinted from Otolaryngology—Head and Neck Surgery, Vol 117, Donald C. Lanza, MD and David K. Kennedy, MD, Adult rhinosinusitis defined, pp S1-S7.
Copyright 1997, with permission from the American Academy of Otolaryngology—Head and Neck Surgery Foundation, Inc.

Physical Findings

Typical physical signs include bilateral nasal mucosal edema, purulent nasal secretions, and
sinus tenderness (however, this is not a sensitive or specific finding). The location of sinus pain
depends on which sinus is affected. Pain on palpation of the forehead over the frontal sinuses can
indicate that the frontal sinuses are inflamed; however, this is also a very common area for
tension headaches. Infection in the maxillary sinuses can cause upper jaw pain and tooth
sensitivity, with the malar areas tender to the touch. Because the ethmoid sinuses are between the
eyes and near the tear ducts, ethmoid sinusitis may be associated with swelling, tenderness, and
pain in the eyelids and tissues around the eyes. The sphenoid sinuses are more deeply recessed
and may manifest with more vague symptoms of earaches, neck pain, and deep aching at the top
of the head.

However, in most patients with a suspected diagnosis of sinusitis, pain or tenderness is found in
several locations, and their perceived area of pain usually does not clearly delineate which
sinuses are inflamed. Purulent drainage may be evident on examination as anterior rhinorrhea or
visualized as posterior pharyngeal drainage with associated clinical symptoms of sore throat and
cough.

The nose should be examined for a deviated nasal septum, nasal polyps, and epistaxis. Foreign
bodies and tumors may mimic symptoms of sinusitis and should be in the differential diagnosis,
especially if the symptoms are unilateral. The ears should be examined for signs of associated
otitis media and the chest for the presence of asthma exacerbation, a common comorbid
condition.
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Diagnosis

In a primary care setting, a good history and physical examination to detect the presence of most
or all of the commonly manifesting signs and symptoms can provide a reliable diagnosis of acute
sinusitis. The presence of purulent secretions has the highest positive predictive value for
clinically diagnosing sinusitis.

Differentiating it from a common viral URTI is most important. Mucus in URTIs is typically not
described as persistently purulent. Nasal congestion is a predominant symptom without persistent
or worsening head congestion, headache, or facial pain or fatigue. URTI symptoms would be
expected to peak on about day 3 to 5 and resolve within 7 to 10 days. Most other diagnostic
modalities, described later, aid in the differential diagnosis of persistent nasal symptoms.

Radiographic Evaluation

The two modalities most commonly used include the plain radiograph and CT scan. Plain
radiography does not adequately represent the individual ethmoid air cells, the extent of mucosal
thickening in chronic sinusitis, or visualization of the ostiomeatal complex. Magnetic resonance
imaging can be considered for evaluation of suspected tumors but is not recommended for acute
sinusitis because it does not distinguish air from bone. For these reasons, CT scanning of the
sinuses is the imaging procedure of choice (Fig. 4). In many centers, the cost is similar to that of
plain radiographs because of the availability of limited coronal views (usually comprising
approximately six coronal views of the maxillary, ethmoid, sphenoid, and frontal sinuses) that
are optimally sufficient for ruling out sinusitis. More detailed coronal slices are useful for
viewing the ostiomeatal complex and for surgical mapping.

Figure 4: Click to Enlarge

Transillumination

A common practice before plain radiographs and CT scans were widely available, it is of limited
use, with a high rate of error.

Ultrasonography
This method has not been proved accurate enough to substitute for a radiographic evaluation.
However, it may be considered to confirm sinusitis in pregnant women, for whom radiographic
studies may pose a risk.

Nasal Smear

By examining the cellular contents of the nasal secretions, one may find polymorphonuclear cells
and bacteria in sinusitis. In a viral infection, these would not be found, and in allergic disease,
one would expect eosinophils.

Sinus Puncture

The most accurate way to determine the causative organism in sinusitis is a sinus puncture. After
anesthetization of the puncture site, usually in the canine fossa or inferior meatus, the contents of
the maxillary sinus are aspirated under sterile techniques, and bacterial cultures are performed to
identify the organism. Culture specimens obtained from nasal swabs correlate poorly with sinus
pathogens found by puncture because of contamination of the swab with normal nasal flora.
However, because sinus puncture is an invasive procedure, it is not routinely performed. More
recently, studies have shown a close correlation between organisms found by sinus puncture and
by endoscopically guided aspiration of the sinus cavities through the middle meatus. Although
this needs to be done by an otolaryngologist trained in the procedure, it may be necessary for
defining the pathogenic organism when standard therapy has failed or in an
immunocompromised patient who is at high risk for sequelae of untreated sinusitis, such as
orbital or central nervous system complications.

Summary

 Differentiating bacterial sinusitis from a common viral URTI is most important.

 The presence of purulent secretions has the highest positive predictive value for clinically
diagnosing sinusitis.
 CT of the sinuses is the imaging procedure of choice.

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Therapy

Treatment of Acute Sinusitis

Antibiotics, such as amoxicillin for 2 weeks, have been the recommended first-line treatment of
uncomplicated acute sinusitis. The antibiotic of choice must cover S. pneumoniae, H. influenzae,
and M. catarrhalis. Because rare intracranial and orbital complications of acute bacterial sinusitis
are caused by S. pneumoniae (most commonly in the immunocompromised host), adequate
coverage for this organism is important. Amoxicillin-clavulanate (Augmentin) is also an
appropriate first-line treatment of uncomplicated acute sinusitis. The addition of clavulanate, a
beta-lactamase inhibitor, provides better coverage for H. influenzae and M. catarrhalis. 15
Because of S. pneumoniae resistance, higher doses of amoxicillin (90 mg/kg/day to maximum of
2 gm/day) should be considered. These higher doses are effective against S. pneumoniae because
resistance is related to alteration in penicillin-binding proteins, a mechanism distinct from the
beta-lactamase enzymatic inactivation of H. influenzae and M. catarrhalis.

Other options include cephalosporins such as cefpodoxime proxetil (Vantin) and cefuroxime
(Ceftin). In patients allergic to beta-lactams, trimethoprim-sulfamethoxazole (Bactrim),
clarithromycin (Biaxin), and azithromycin (Zithromax) may be prescribed but may not be
adequate coverage for H. influenzae or resistant S. pneumoniae. 16 Penicillin, erythromycin
(Suprax) and first-generation cephalosporins such as cephalexin (Keflex, Keftab) are not
recommended for the treatment of acute sinusitis because of inadequate antimicrobial coverage
of the major organisms.

If treatment with one of these first-line agents has not shown a clinical response within 72 hours
of initial therapy, more broad-spectrum antibiotics should be considered. These include the
fluoroquinolones, gatifloxacin (Tequin), moxifloxacin (Avelox), and levofloxacin (Levaquin),
especially if amoxicillin-clavulanate, cefpodoxime proxetil, and cefuroxime were previously
prescribed.

Treatment of Chronic Sinusitis

Antibiotic therapy for chronic sinusitis is controversial and may be most appropriate for acute
exacerbation of chronic sinusitis. Medical therapy should include both a broad-spectrum
antibiotic and a topical intranasal steroid to address the strong inflammatory component of this
disease. Antibiotic therapy may need to be continued for 4 to 6 weeks. 12 The antibiotics of choice
include agents that cover organisms causing acute sinusitis but also cover Staphylococcus species
and anaerobes. These include amoxicillin-clavulanate, cefpodoxime proxetil, cefuroxime,
gatifloxacin, moxifloxacin, and levofloxacin. Currently used topical intranasal steroids such as
fluticasone (Flonase), mometasone (Nasonex), budesonide (Rhinocort AQ), triamcinolone
(Nasacort AQ) have a favorable safety profile as well as indications for the pediatric age group.
However, a short course of oral steroids may be used for extensive mucosal thickening and
congestion or nasal polyps.

Adjunctive Therapy

To temporarily alleviate the drainage and congestion associated with sinusitis, decongestant
nasal sprays oxymetazoline (Afrin) and phenylephrine hydrochloride (Neo-Synephrine) may be
used for 3 to 5 days. Long-term use of topical decongestants may cause “rhinitis
medicamentosa,” which is rebound congestion caused by vasodilatation and inflammation. Oral
decongestants (pseudoephedrine) may be a reasonable alternative if the patient has no
contraindication such as hypertension. Mucolytic agents (guaifenesin) can help to decrease the
viscosity of the mucus for better clearance and are often found in combination with
decongestants. Some mucolytics are now available over the counter. Saline spray or irrigation
may help clear secretions. Topical corticosteroids are not indicated for acute sinusitis but may be
helpful for chronic sinusitis, nasal polyps, and allergic and nonallergic rhinitis. Antihistamines
are not indicated for sinusitis but may be helpful for underlying allergic rhinitis.
Surgery

If medical therapy fails or if complications are suspected, an otolaryngology consultation is

warranted. This may begin with a nasal endoscopy for better visualization of the nasal cavity and
ostiomeatal complex. This may also allow for endoscopically guided sinus culture. If surgical
therapy is being contemplated, newer techniques of functional endoscopic sinus surgery are
performed to clear sinuses of chronic infection, inflammation, and polyps. This may be
combined with somnoturboplasty (i.e., shrinkage of the turbinate using radiofrequency waves).
Endoscopic sinus surgery is commonly performed on an outpatient basis using local anesthesia
and has less morbidity than traditional open surgery for chronic sinus disease. 1 Special
consideration should be given for patients who have chronic sinusitis and nasal polyps and who
also have aspirin-induced asthma. This is commonly referred to as the “aspirin triad” of aspirin
sensitivity, asthma, and polyposis. Although most of these patients undergo sinus surgery and
polypectomy, additional therapy with nasal steroids, leukotriene modifiers, and aspirin
desensitization, followed by 650 mg aspirin twice daily, should be considered. 17

Additional Evaluations

Laboratory Evaluation

This may be necessary to look for an underlying disorder that may predispose to sinusitis. The
evaluation may include a sweat chloride test for cystic fibrosis, ciliary function tests for immotile
cilia syndrome, blood tests for HIV, or other tests for immunodeficiency, such as
immunoglobulin levels.

Allergy Consultation

This should be done in any patient with recurrent acute or chronic sinusitis to rule out allergy to
dust mites, mold, animal dander, and pollen, which trigger allergic rhinitis. An allergy
consultation will provide immediate hypersensitivity skin testing to delineate which
environmental aeroallergens may exacerbate allergic rhinitis and predispose to sinusitis. Medical
management and environmental control measures are discussed. Treatment options such as
medications, immunotherapy, or both (“allergy shots”) are considered. Addition evaluation for
comorbid conditions such as asthma, sinusitis, and gastroesophageal reflux are addressed and
treated. Allergists are also trained in aspirin desensitization for treatment of patients with the
aspirin triad.

Treatment of Complications of Sinusitis

Orbital extension of sinus disease is the most common complication of acute sinusitis. This
complication is more common in children. Immediate management includes broad-spectrum
intravenous antibiotics, a CT scan to determine the extent of disease, and possibly surgical
drainage of the infection if there is no response to antibiotics. Extension to the central nervous
system can also occur. The most common intracranial complications are meningitis (usually
from the sphenoid sinus, which is anatomically located closest to the brain) and epidural abscess
(usually from the frontal sinuses).
Treatment of Allergic Fungal Sinusitis

Because of the extent of sinus blockage and the strong association with polyps, surgery is usually
indicated to remove the inspissated allergic mucin and polyps, followed by systemic
corticosteroids to decrease the inflammatory response. 7 Treatment guidelines are based on the
use of systemic steroids in allergic bronchopulmonary aspergillosis, in which steroids are tapered
to daily or every-other-day dosing to control the disease. Commonly, nasal steroids are also
added for topical treatment. Studies are currently being conducted to establish the role of
antifungal agents or inhalant allergen immunotherapy for the treatment of AFS.

Summary

 The antibiotic of choice for acute sinusitis must cover S. pneumoniae, H. influenzae, and
M. catarrhalis.
 The antibiotics of choice for chronic sinusitis include agents that cover organisms causing
acute sinusitis but that also cover Staphylococcus species and anaerobes.
 Medical therapy for chronic sinusitis should include a topical intranasal steroid to address
the strong inflammatory component of this disease.
 Allergy consultation should be considered in any patient with recurrent acute or chronic
sinusitis to rule out allergy as a contributing factor for sinusitis.
 If medical therapy fails or if complications are suspected, an otolaryngology consultation
is warranted.

Outcomes

URTIs of viral origin should run their course, with gradual improvement in symptoms daily until
complete resolution of symptoms occurs by day 7 to 10, with supportive treatment only and no
antibiotics.

When a secondary bacterial infection is suspected and antibiotics are given for acute sinusitis,
the expected clinical outcome would be resolution of the infection and associated symptoms.
This was shown in a study by Wald, in which symptoms resolved in 79% of patients who had
clinically and radiographically diagnosed sinusitis and who had been treated with amoxicillin or
amoxicillin plus clavulanic acid. 18

The data on outcomes of medical management of chronic sinusitis are showing that we can
control symptoms to a degree, although with a high rate of recurrence. Hamilos reported a
retrospective series of patients treated medically for chronic sinusitis. Treatment included
systemic steroids for 10 days, antibiotic coverage for aerobic and anaerobic organisms for 4 to 6
weeks, nasal saline irrigation, and topical steroid nasal spray. There were symptomatic and
radiographic improvements in 17 of 19 patients, but 8 of 19 had persistent ostiomeatal complex
abnormalities. In addition, relapse of sinusitis has been significantly associated with nasal
polyposis and a history of prior sinus surgery. 7

Overall, we have many treatment options for the sinusitis patient: antibiotics for the bacterial
infection; steroids, systemic or topical, for the inflammatory component; and surgery for the
anatomic and structural abnormalities that may predispose to sinusitis. Although these have
helped with initial improvement, we still see a high rate of recurrence of sinus disease. This
forces us to address the role of comorbid conditions such as allergic rhinitis, environmental
irritants (e.g., cigarette smoke), or the need for newer and better treatment modalities for this
disease.

What is Sinusitis?

Sinusitis is caused by an inflammation or infection of your sinus cavities.  These cavities are
located around the nose and behind the eyes. Inflammation is your body's way of reacting to
irritants; this reaction produces redness, swelling, mucus, and pain.
There are two types of sinusitis:

Acute sinusitis - an infection that usually lasts for about 3 weeks. It is often triggered by the flu or cold.
The flu or cold virus attacks your sinuses causing them to swell and become narrow. Your body responds
to this virus by producing mucus. When the sinuses become blocked and are filled with mucus, viruses,
fungi or bacteria can grow and cause infections.  That causes more mucus build-up, pressure and intense
headache, toothache or bad breath.

Chronic sinusitis - an infection that lasts for more than 3 weeks and can continue indefinitely if not
treated. It is commonly caused by allergies, fungal infections or
weakened immune system.