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Updated: Dec 17 2021


  • 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
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