Snapshot A 14-year-old boy presents with recurrent nasal congestion and left suborbital pain of 2 weeks duration. 1 week prior to the onset of these symptoms, he described having a "cold." On physical exam, there is pain over the left maxillary sinus. A CT of the head is shown.(Left maxillary sinusitis) Introduction Infection of the paranasal sinus due to undrained collection of pus maxillary sinuses most commonly involved but can involve any sinus can be bacterial (acute or chronic), or fungal Risk factors Kartagener disease cystic fibrosis Wegener's granulomatosis smoking impairs ciliary function Acute sinusitis < 1 month Sudden onset most commonly caused by S. pneumoniae H. influenzae Moraxella cattarrhalis usually precipitated by an acute viral respiratory tract infection which is thought to lead to reduced clearance of mucus Inflammation can cause swelling of the mucosa of the nose or sinuses causing occlusion or obstruction of the sinus ostia mucociliary transport is reduced Chronic sinusitis > 12 consecutive weeks The role of bacteria is not well supported and the diagnosis criteria revolve around inflammation which predispose to ostia obstruction, further inflammation and infection Associated bacteria include S. aureus, anaerobs and gram-negatives Other risks include systemic disease, anatomic anomalies, mucociliary dusfunciton, trauma, noxious chemicals such as pollutants or smoke, medications. Invasive Fungal Rhinosinusitis Risks: immunosuppressed, diabetes, steroid use most commonly due to aspergillus followed by mucormycosis Suspect with fever, localization symptoms such as orbital swelling, changes in vision or significant facial pain or numbness, nasal bleeding. Endoscopy may show mucosal necrosis (indicative of mucormycosis). Mucormycosis grows rapidly and can invade vasculature causing ischemia. Noninvasive Fungal Rhinosinusitis fungus ball in sinuses Cuased by allergic or non-allergic reaction to fungus Presentation Symptoms fever facial pain headache that can radiates to the upper teeth purulent rhinorrhea congestion loss of smell Physical exam Classically, facial tenderness with palpation over the involved sinus Evaluation/Diagnosis Primarily a clinical diagnosis Imaging Plain radiographs have fallen out of favor due to poor sensitivity CT Nasal Endoscopy Invasive fungal rhinosinusitis Diagnosed with biopsy/histology. CT can be obtained to evaluate extent of disease. Fungal Ball appear dark, crumbly, possible sporulation histology (tangled hyphae) Allergic fungal rhinosinusitis histology shows inflammatory cells, eosinophils and charcot-leyden crystals, hyphae Treatment Acute sinusitis supportive therapy for 7 days analgesia (tylenol), nasal saline irrigation, decongestants, adequate hydration no antibiotics unless no clinical improvement during observation period or temperature >38.3 C antibiotic for 10-14 days amoxicillin-clavulanate is first line Chronic sinusitis Treatment in general is unclear. Some studies suggest improvement with antibiotics (such as macrolides) and topical or oral steroids. surgery if not responsive to antibiotic therapy to improve ventilation and drainage maxillary sinusotomy, ethmoidectomy, or sphenoid sinusotomy Invasive fungal rhinosinusitis If possible, reversal of immunocompromised state early aggressive medical (amphotericin B) and surgical debridement Fungus ball endoscopic removal Allergic fungal rhinosinusitis endoscopic removal of nasal polyps and inspissated muci prednisone taper Complications osteomyellitis mucocele meningitis epidural abcess cerebral abscess orbital/periorbital cellulitis cavernous sinus thrombosis Prognosis Generally good in acute bacterial sinusitis can be fatal in diabetic or immunocompromised patients with invasive fungal disease