Running head: SINUSITIS

Acute and Chronic Sinusitis

Jessica Baucom
University of North Carolina at Charlotte

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Acute and Chronic Sinusitis

Sinusitis is one of the most common diagnoses in family practice. Usually precipitated by
a viral upper respiratory infection, sinusitis is an inflammatory process in the paranasal sinuses
(Buttaro, 2013). The cause is usually viral but can be bacterial, fungal, or allergen-related
(Domino & Baldor, 2015). Because of its economic impact, $5.8 billion in health care expenses
and 61.2 million lost work days, it is an illness that bears discussion and requires appropriate
treatment (Buttaro, 2013). This paper will discuss the etiology, pathophysiology, signs and
symptoms, clinical findings, differential diagnoses, and treatment for both acute sinusitis (ARS)
and chronic sinusitis (CRS).
Etiology
Although the cause of ARS is frequently viral, the most common bacterial pathogens are
Streptococcus pneumoniae, Haemophilus influenza, and Moraxella catarrhalis (Buttaro, 2013).
Other, less common, pathogens include Chlamydia pneumoniae, Streptococcus pyogenes, and
fungi (Buttaro, 2013). Usually these less common pathogens are seen in immunocompromised
patients (i.e. uncontrolled diabetics, chronic corticosteroid use, nosocomial infections) (Buttaro,
2013).
Less commonly seen, CRS occurs as a result of a prolonged sinus infection (>12 weeks)
or recurrent acute infections that never completely resolve due to inadequate treatment (Buttaro,
2013). Gram-negative or anaerobic pathogens are often present in these cases (Buttaro, 2013).
The placement of nasogastric tubes or nasal intubation may introduce gram-negative bacteria,

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and identification of gram-negatives and anaerobes is vital to appropriate treatment and prevent
spreading from the sinuses to the brain (Buttaro, 2013).
Pathophysiology
When the sinuses are inflamed due to a cold virus or influenza, swelling and excess
mucus result, which creates a good medium for bacterial growth (Buttaro, 2013). Cytokines from
the inflammatory response damage the mucosal surfaces of the sinuses (Domino & Baldor,
2015). In addition, obstruction of a sinus ostium can impair normal sinus drainage and lead to
ARS (Hamilos, 2015). In patients with impaired cilia (i.e. CF, smokers), thick mucus places them
at higher risk for sinusitis.
In the case of CRS, believed to result from an unresolved ARS, inadequate sinus drainage
leads to the chronic inflammatory state (Hamilos, 2015). An anatomic abnormality, such as septal
deviation, can hinder normal sinus drainage and mucous clearance and prevent a full recovery
(Hamilos, 2015). According to Domino & Baldor (2015), risk factors for both ARS and CRS
include: allergic rhinitis, asthma, cigarette smoking, dental infections, and immunodeficiency.
Signs and Symptoms
Patients with ARS characteristically present with nasal congestion, facial and/or dental
pain, postnasal drainage, headache, fever, and yellow/green nasal discharge (Buttaro, 2013).
Domino and Baldor (2015) suggest using an assemblage of symptoms and not one hallmark sign
or symptom to differentiate between bacterial and viral ARS. Some symptoms that may suggest a
bacterial etiology are: exacerbation of symptoms after > 5-7 days after initial improvement,
symptoms continuing for >10 days, continual purulent nasal discharge, one-sided upper dental or
facial pain, one-sided maxillary sinus tenderness, and fever (Domino & Baldor, 2015). Both

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Buttaro (2013) and Domino and Baldor (2015) conclude that other associated symptoms can
include cough, sore throat related to postnasal drainage, frequent throat clearing, halitosis,
hyposmia, retro-orbital pain, and gastrointestinal symptoms from the swallowing of mucus. Of
note, symptoms that are indicative of advanced infectious process and require physician
consultation are: visual disturbances (especially diplopia), altered mental status, and periorbital
cellulitis (Domino & Baldor, 2015). Regarding pediatrics, diagnosis can be more difficult
because children usually have more subtle symptoms (Domino & Baldor, 2015). Since children
have several colds per year they are at risk for sinusitis.
Symptoms of CRS may vary, but usually include one or more ARS symptoms, most
commonly: thick yellow/green nasal discharge and congestion, and a cough lasting more than 30
days (Buttaro, 2015). Any pain is usually a dull headache or pressure along the forehead and/or
midface, and cough is related to postnasal drip (Buttaro, 2013). According to Buttaro (2015), the
patient with CRS may have an exacerbation of asthma or allergy symptoms.
Physical Exam Findings
While obtaining the patients history, a general survey for facial asymmetry and
periorbital cellulitis should be considered in ARS (Buttaro, 2013). Take into account any fever or
abnormal vital signs. Upon inspection of the nasal tract, there may be purulent discharge, edema
and erythema of the nasal mucosa, septal deviation, or polyps (Domino & Baldor, 2015).
Purulent discharge may also be present in the oropharynx, and it is important to examine the
teeth due to the relationship of maxillary sinusitis and dental infections (Buttaro, 2013). The
sinuses may be tender to palpation. Infections in the maxillary sinuses produce pain and/or
erythema over the cheek (Buttaro, 2013). Frontal sinus infections cause pain in the forehead,
elicited by palpating the orbital roof just below the eyebrows (Buttaro, 2013). Finally, rarely seen

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sphenoid sinusitis can cause pain behind the eyes and facial pain (Buttaro, 2013).
Transillumination of the sinuses to confirm the presence of fluid is only helpful if the sinusitis is
asymmetric (Domino & Baldor, 2015). Testing for CRS may include a nasal endoscopy and a
sinus CT scan (Rudmik & Soler, 2015). An MRI may be required if a mass lesion is suspected
(Buttaro, 2013).
Differential Diagnoses
Other illnesses can present as sinusitis. Dental abscesses, trigeminal neuralgia, optic
neuritis, the common cold, and migraines can all result in facial pain (Buttaro, 2013). CRS can
be a complication of CF, syphilis, HIV infection, neoplasm, Wegener granulomatosis, and
Kartagener syndrome (Domino & Baldor, 2015). A thorough history, and detailed physical exam
can rule out these etiologies.
Treatment, Referral, and Health Promotion
As with most community-acquired infections, handwashing to prevent spread of viruses
is vital. Most cases of ARS will resolve with supportive care to treat pain and nasal symptoms,
whether viral or bacterial, although bacterial cases improve slightly quicker with antibiotics
(Domino & Baldor, 2015). Due to the ongoing rise of microbial resistance to antibiotics,
antibiotics use should be withheld unless symptoms continue for >10 days, onset with severe
symptoms (i.e. high fever, facial pain, purulent nasal discharge) for 3-4 consecutive days, or
worsening symptoms after initial improvement (Domino & Baldor, 2015). Buttaro (2013) and
Domino & Baldor (2015) state general supportive measures should include: analgesics, NSAIDs,
saline irrigation, steam inhalation, oral hydration, avoiding alcohol and caffeine, avoiding
cigarette smoke, over-the-counter decongestants and cough suppressants.

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If an antibiotic is needed, Augmentin is preferred and should be started as soon as a

diagnosis of bacterial ARS is made; however, for children, amoxicillin alone is recommended for
uncomplicated bacterial sinusitis, reserving Augmentin for more severe illness or children in
daycare (Domino & Baldor, 2015). Patients with recalcitrant ARS, failure of two antibiotics, and
in need of CRS evaluation should be referred to an otolaryngologist (Domino & Baldor, 2015).
If allergy-related and refractory, referral to an allergist is indicated (Buttaro, 2013). Sinus surgery
and sinus irrigation may be necessary if medical treatment fails (Domino & Baldor, 2015).
Surgery, physician referral, and hospitalization are required for orbital abscesses, spread of
infection to soft tissues, meningitis, brain abscesses, invasive or fungal sinusitis, suspected
obstructive tumor, and CSF rhinorrhea (Domino & Baldor, 2015).
Conclusion
From the information presented in this paper, it is apparent that ARS and CRS are
illnesses commonly seen in family practice. Proper management of these illnesses is vital to
containing antimicrobial resistance and assisting in reducing their economic impact. To achieve
these goals, proper diagnosis and treatment of viral versus bacterial sinusitis is imperative.
Furthermore, after two appropriate attempts at bacterial ARS treatment, refractory sinusitis calls
for further evaluation of other systemic causes versus CRS, and may require physician referral
and further testing.

References

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Buttaro, T. M. (2013). Primary care: A collaborative practice. St. Louis, Mo: Elsevier/Mosby.
Domino, F. J., & Baldor, R. A. (2015). The 5-minute clinical consult 2016 (24th ed.).
Philadelphia, Pa.: Wolters Kluwer Health/Lippincott Williams & Wilkins.
Hamilos, D.L. (2015). Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and
diagnosis. In: D.S. Basow (Ed.), UpToDate. Retrieved from
http://www.uptodate.com/contents/chronic-rhinosinusitis-clinical-manifestationspathophysiology-and-diagnosis?
source=search_result&search=chronic+rhinosinusitis&selectedTitle=2%7E120
Rudmik, L., & Soler, Z. M. (2015). Adult chronic sinusitis. JAMA: Journal of the American
Medical Association, 314(9), p. 964.