A 39 year old woman attends your surgery with a four day history of unpleasant yellowish nasal discharge, blocked nose, and severe pain across her cheeks and between her eyes. One week ago she had had a “bad cold” and she thought she was getting better, but then this started.
What issues you should cover
Sinusitis, now termed rhinosinusitis, is inflammation of one or more of the paranasal sinuses. It is clinically defined by at least two of the following symptoms: blockage or congestion; discharge or postnasal drip; facial pain or pressure; reduction or loss of smell. In acute rhinosinusitis symptoms persist for up to 12 weeks, with complete resolution; in chronic rhinosinusitis symptoms persist for more than 12 weeks without complete resolution. Viruses (coryza, rhinovirus, or influenza, for example) cause mucosal swelling and obstruct the sinus openings into the nose. The symptoms result from increased mucus production, reduced drainage, ciliary paralysis, and stasis of secretions. Secondary bacterial infection can occur, commonly by Streptococcus pneumoniae, Haemophilus influenzae, or (in children) Moraxella catarrhalis. Atopy may also contribute to the development of rhinosinusitis, but evidence is lacking and its role is unclear.
Bacterial or viral?—Although the distinction between bacterial and viral rhinosinusitis is unclear, in acute rhinosinusitis secondary bacterial infection may be indicated by:
Duration longer than seven days
Purulent green or yellow nasal discharge
History of improvement, then deterioration in symptoms
Fever and general malaise
Facial pain and tenderness, particularly if unilateral or asymmetrical.
Is it something else?—Differential diagnosis may be:
Rhinitis—nasal congestion, rhinorrhoea, sneezing
Referred dental pain
Temporomandibular joint dysfunction
Tension headache
Migraine
Trigeminal neuralgia
Atypical facial pain
Neoplastic conditions.
Complications may be present:
Periorbital cellulitis—redness, oedema, pain, fever, chemosis
Orbital abscess—as above plus proptosis, ophthalmoplegia, diplopia, diminished visual acuity
Meningitis—headache, neck stiffness, drowsiness, photophobia
Osteomyelitis—frontal sinus osteitis and doughy oedema of the skin over the frontal bone producing a mass (Pott's puffy tumour)
Cerebral abscess—headache, altered conscious state, visual disturbance, unsteadiness, seizures, or other focal neurology.
What you should do
Depending on history, consider conservative treatment:
Reassurance
Steam inhalation daily—ensure that care is taken to avoid scalding injury
Possible medical treatments are:
Analgesia—stepwise paracetamol, ibuprofen, codeine as required in accordance with the WHO analgesic ladder
Decongestants:
- Oral (pseudephedrine)—can cause insomnia, anxiety, palpitations, and tachycardia (caution in certain groups, for example people with hypertension)
- Topical (xylometazoline)—prolonged use (>1 week) may cause rebound rhinitis
Intranasal corticosteroids—may be of benefit, particularly in chronic rhinosinusitis, recurrent acute rhinosinusitis, and rhinitis
Antibiotics—if history points toward bacterial cause. A prolonged course (2 weeks or more) may be required due to reduced drug delivery; follow local guidelines:
- First line—amoxicillin (trimethoprim or cefaclor if patient is allergic to penicillin)
- Second line—co-amoxiclav (clarithromicin if patient is allergic to penicillin)
If pus is present, take a swab for bacteriology before starting antibiotics. Delayed prescribing of antibiotics may have a role.
Useful reading
European Academy of Allergology and Clinical Immunology. European position paper on rhinosinusitis and nasal polyps. Rhinol Suppl 2005;(18):1-87. www.rhinologyjournal.com/EPOS.pdf
Williams JW Jr, Aguilar C, Cornel J, Chiquette ED, Makela M, Holleman DR, et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2003;(2):CD000243.
Lindbaek M, Hjortdahl P. The clinical diagnosis of acute purulent sinusitis in general practice—a review. Br J Gen Pract 2002;52:491-5.
Information for patients:
ENT UK. Sinus infection (sinusitis). www.entuk.org/patient_info/nose/sinisitis_html
Patient UK. Sinusitis. www.patient.co.uk/showdoc/23068821
Referral to ENT:
If complications are suspected, refer urgently
If patient is unresponsive to treatment consider immunocompromise (HIV infection, congenital immunodeficiency) or granulomatous disease (Wegener's granulomatosis, sarcoidosis, tuberculosis)
If symptoms last more than 12 weeks or recurrent acute rhinosinusitis develops:
No need to arrange investigations (e.g. imaging), specialist opinion is required
Specialist can perform nasendoscopy to confirm diagnosis
Plain x rays of the sinuses are no longer indicated; specialist may request computed tomography, generally as a precursor to surgical intervention