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3.11 Sinusitis


Presentation

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:

What not to do

Discussion

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.

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Craig Feied, MD
Mark Smith, MD
Jon Handler, MD
Michael Gillam, MD