Following a viral infection, the patient will usually complain of a dull
pain in the face, gradually increasing over a couple of days, exacerbated
by sudden motion of the head, or holding the head dependent, between
the knees, and perhaps radiating to the upper molar teeth (via the
maxillary antrum), or with eye movement (via the ethmoid sinuses).
Often there is a sensation of facial congestion and stuffiness. Children
with sinusitis often present with cough and fetid breath. Fever is only
present in half of patients with acute infection and is usually low grade.
A high fever usually indicates a serious complication such as meningitis
or another diagnosis altogether. Transillumination of sinuses in the ED
is usually unrewarding, but you may elicit tenderness on gentle
percussion or firm palpation over the maxillary or frontal sinuses or
between the eyes (ethmoid sinuses). Swelling and erythema may exist
and you may even see pus draining below the nasal turbinates, with a
purulent, yellow-green and sometimes foul-smelling or bloody discharge
from the nose or running down the posterior pharynx. The patient's
voice may have a resonance similar to that of a "stopped up" nose, and
he may complain of a foul taste in his mouth. Stuffy ears and impaired
hearing are common because of associated serous otitis media and
eustachian tube dysfunction.
What to do:
- Rule out other causes of facial pain or headache via history (did the
patient wake up with a typical migraine?) and physical examination
(palpate scalp muscles, temporal arteries, temperomandibular joints,
eyes, and teeth).
- Shrink swollen nasal mucosa (and thereby open the ostia draining the
sinuses) with 1% phenylephrine (Neo-Synephrine) or 0.05%
oxymetazoline (Afrin) nose drops. Drip 2 drops in each nostril, have
the patient lie supine 2 minutes, and then repeat the process (this allows
the first application to open the anterior nose so the second gets farther
back). Have the patient repeat this process every 4 hours, but for no
more than three days (to avoid rhinitis medicamentosa).
- Examine the nose for purulent drainage before and after shrinking the
nasal mucosa with topical vasoconstrictor.
- Add systemic sympathomimetic decongestants (e.g., pseudephedrine
(Sudafed) 60mg q6h or phenylpropanolamine (Entex LA) 75mg q12h).
- If there is fever, pus, heat, or any other sign of a bacterial
superinfection, add antibiotics (e.g., amoxicillin, trimethoprim plus
sulfamethoxazole, amoxicillin plus clavulinate, erythromycin plus
sulfasoxazole, cefuroxime). First-line antibiotic therapy is amoxicillin,
or, for patients with penicillin allergy, Bactrim or Sulfa. If the patient
has been recently treated with these medications or if the infection
appears to be serious, then treat with a second-line drug like Ceftin or
- Provide pain relief, when necessary (e.g., ibuprofen, naproxyn,
acetaminophen, oxycodone, hydrocodone)
- Recommend symptomatic relief with hot water vapor inhalation using
a simple teakettle or hot shower or, if available, a steam vaporizer or
home facial sauna device.
- Sinusitis can sometimes be demonstrated on x rays, and you can
usually get adequate visualization of maxillary, frontal, and ethmoid
sinuses with one upright Water's view. Chronic sinusitis appears as
thickened mucosa; acute as an air-fluid level or complete opacification.
Films are usually not necessary, however, on an emergency basis. If
symptoms and physical findings of sinusitis are classic, plain sinus
radiographs need not be obtained before treatment. If an acute attack
does not resolve with medical treatment, or the diagnosis of sinusitis is
in doubt, plain films are helpful as the primary imaging study.
- Arrange for followup within 1-7 days.
What not to do
- Do not ignore signs of an orbital cellulitis with swelling erythema,
decreased extraocular movements and possible proptosis. These patients
require consultation and admission for intravenous antibiotics.
- Do not ignore the toxic patient with marked swelling, high fever,
severe pain, profuse drainage, or other signs and symptoms of a serious
infection. See potential complications below. These patients require
immediate consultation and intervention.
- Do not prescribe antihistamines, which can make mucous secretions
dry and thick, and interfere with necessary drainage. Antihistamines
only cure sinusitis on television, or when it is due to allergic rhinitis.
- Do not allow patients to use decongestant nose drops more than 3
days, thereby allowing their nasal mucosa to become habituated to
sympathomimetic medication. When they stop the drops they will suffer
a rebound nasal congestion (rhinitis medicamentosa) which requires
time, topical steroids, and reeducation to resolve.
- Do not prescribe topical or systemic sympathomimetic decongestants
to a patient who suffers from hypertension, tachycardia or difficulty
initiating urination, all of which may be exacerbated.
The paranasal sinuses drain through tiny ostia under the nasal
turbinates which, if occluded, allow secretions and pressure differences
to build up, resulting in pressure and pain of acute sinusitis, and the
air-fluid levels sometimes visible on upright x rays. Sinus infections are
relatively common and complications relatively rare, but the bony walls
of the paranasal sinuses are so thin that bacterial infections can spread
through them. Most sinusitis begins with mucosal swelling from a viral
upper respiratory infection. Other causes include dental infection,
allergic rhinitis, barotrauma from flying, swimming or diving, nasal
polyps and tumors and foreign bodies, including nasogastric and
endotracheal tubes in hospitalized patients. Abscessed teeth can be the
source of a maxillary sinusitis. If there is tenderness to percussion of
the bicuspids or molars, arrange for dental referral.
Complications such as orbital cellulitis, osteomyelitis, epidural
abscell, meningitis, cavernous sinus thrombosis and subdural empyema
can be devastating and therefore patients must be instructed to get early
follow up when signs and symptoms worsen or do not improve in 48-72
hours, or if there is any change in mentation. Frontal sinusitis has the
greatest potential for serious complications, particularly in adolescent
males, the group at greatest risk for intracranial complications.br
Computerized tomographic scanning of the sinuses is more
accurate than plain x rays, particularly when evaluating the ethmoid or
sphenoid sinuses, but CT scans are needed from the ED only in unusual
circumstances. Most patients can have initial treatment begun on the
basis of history and physical findings alone. Anyone who has facial
pain, headache, purulent nasal discharge and nasal congestion persisting
for more than ten days, with or without a fever, should probably be
treated empirically for sinusitis.
Many patients have been conditioned by the advertising of
over-the-counter antihistamines for "sinus" problems (usually meaning
"allergic rhinitis"), and may relate a history of "sinuses" which, on
closer questioning, turns out to have been rhinitis.
- Williams JW, Simel DL: Does this patient have sinusitis?
Diagnosing acute sinusitis by history and physical examination. J Am
Med Assoc 1993;270:1242-1246.
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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD