SINUSITIS/ ACUTE SINUSITIS/ CHRONIC SINUSITIS/ SINUS INFECTION
Infection of the sinuses often follows a viral upper respiratory tract infection or allergic rhinitis. Symptoms of sinusitis include nasal congestion, purulent rhinorrhea (nasal discharge), postnasal drip, facial or tooth pain, headache, loss of the sense of smell, and cough. Most cases of clinically diagnosed sinusitis are the result of a viral upper respiratory tract infection (URI). Other conditions associated with sinusitis include bacterial sinusitis, fungal sinus infections, cystic fibrosis, Wegener’s granulomatosis, HIV infection, Kartagener’s syndrome, immotile cilia syndrome, tumors and foreign bodies. Sinusitis may be classified as acute (symptoms resolve within 12 weeks), acute recurrent (multiple episodes of sinusitis with intermittent periods without symptoms), and chronic (symptoms last greater than 12 weeks). Common physical findings include maxillary or frontal sinus tenderness, dark circles under the eyes, periorbital edema, and redness and swelling of the nasal mucosa. Nasal inspection may be performed with an otoscope with a large speculum. The nasal mucosa should be evaluated for the presence of septal deviation, polyps, tumors or foreign bodies. It is important to consider migraine as part of the differential as many patients with migraine develop rhinorrhea, nasal congestion, and lacrimation due to autonomic activation of the facial nerve. An empiric trial of a migraine therapy may help separate these patients from true sinusitis.
If the diagnosis appears reasonably clear from the history and physical exam, then supportive therapy (analgesics, nasal lavage, and possible decongestants) to keep the patient comfortable is all that is required since most cases are the result of an underlying viral URI. If symptoms persist greater than seven days or a bacterial infection is considered most likely after the initial evaluation, then an empiric trial of antibiotic therapy is warranted. However, if the diagnosis is in doubt, then radiography may be required. Coronal sinus CT scanning without contrast is the imaging modality of choice. However, imaging procedures are unnecessary for a single episode of sinusitis that responds to therapy. Imaging should be reserved for persistent, refractory or otherwise confusing or difficult cases. In pregnant patients A-mode ultrasound may be used to avoid radiation exposure. Fiberoptic rhinoscopy may be performed by ENT specialists to observe the anatomy such as the sinus ostia, sphenoethmoidal recess and eustachian tube ostia.
There are various forms of fungal sinus infections. Invasive forms include acute-fulminant invasive fungal sinusitis (rapidly fatal), chronic invasive fungal sinusitis (proves fatal after several weeks to months and is seen mostly in diabetics), and granulomatous invasive fungal sinusitis (an uncommon infection reported from Sudan that may be curable with surgery). AFS and mycetoma are the two noninvasive forms of sinus fungal infection. Mycetoma is a fungus ball that develops in a single sinus. Afflicted patients are usually immunocompetent and surgical removal often proves curative. The typical AFS patient is immunocompetent, and suffers from allergic rhinitis, nasal polyps, and asthma. These patients have often undergone multiple, unsuccessful courses of antibiotics, have radiographic evidence of sinusitis, allergic mucin contaminating affected sinuses, and evidence of fungal hyphae when mucin is stained with appropriate silver stains. Cultures are unreliable and often unrewarding. Associated laboratory findings include eosinophilia and an elevated serum IgE but there are not sensitive and nonspecific. Pathogens vary depending on the geographic location with Bipolaris spicifera noted in the Southwest, Curvularia lunata along the Gulf of Mexico, and Aspergillus fumigatus the primary pathogen in along the Atlantic coast. Recurrence is common following surgery although surgery is often necessary to obtain culture material to establish the diagnosis. Oral prednisone (10-20 mg QD x 2 weeks followed by a QOD schedule for approximately 2 weeks) followed by nasal corticosteroids is a therapeutic option that is often times successful. Patients are also instructed to perform daily nasal normal saline nasal lavage and are given allergy shots. Follow up includes regular rhinoscopy to monitor for and remove recurring obstruction. If infection continues despite the above therapy, oral itraconazole is an option.
Laboratory tests are necessary when an alternative diagnosis is suspect. Potential studies include nasal cytology, the sweat chloride test, ciliary function studies, HIV testing, urinalysis, C-ANCA, angiotensin-converting enzyme (ACE) level, and a white cell count with differential. A sample for cytology may be collected by having patients blow nasal secretions into wax paper or cellophane wrap, or by nasal laveage. Hansel stain will detect eosinophils present in the sample which indicate an allergic etiology. The sweat chloride test is used to diagnose cystic fibrosis. It is indicated when examination reveals nasal polyps or there is evidence of chronic nasal colonization with Pseudomonas species. An elevated ACE level may indicate sarcoidosis but it is not very specific. Infection may be indicated when there is an elevated WBC count with a left shift. Allergic rhinitis should be suspected when there is significant eosinophilia on the peripheral smear. When patients suffer recurrent infections of the upper (sinusitis, otitis) or lower (bronchitis or pneumonia) respiratory tract without an identifiable etiology, they should be evaluated further for primary hypogammaglobulinemia (common variable immune deficiency or selective IgA deficiency).
Therapy for acute uncomplicated sinusitis is with antibiotics. Choices include amoxicillin, amoxicillin-clavulanate, trimethoprim-sulfamethoxazole, azithromycin, clarithromycin, loraccarbef, ciprofloxacin, levofloxacin, gatifloxacin, cefpodoxime, cefuroxime, cefprozil, cefdinir, and moxifloxacin. It is prudent to first identify the epidemiologic profile in a specific medical community before deciding on an empiric antibiotic. Antibiotic therapy for acute disease should continue for at least 14 days. If symptoms do not lessen within 5 days of the initiation of therapy, then switching to a different antibiotic agent may be prudent. Chronic sinusitis may be secondary to an anaerobic pathogen. Therefore, antibiotic choices in chronic disease include penicillin, amoxicillin-clavulanate, clindamycin, or metronidazole and they should be continued for 3 to 6 weeks. In refractory cases consider a broad spectrum antibiotic plus either clindamycin or metronidazole. In addition to antibiotic therapies, antihistamines, topical decongestants, topical corticosteroids, saline sprays, or propylene/polyethylene glycol are useful adjunctive therapies. Of note, topical decongestants (phenylephrine and oxymetazoline) should be used for no more than 3 to 5 days or they may induce rebound congestion (rhinitis medicamentosa). Chronic, refractory cases may require referral to an ENT specialist for evaluation with flexible rhinolaryngoscopy and for possible surgery.