Acute rhinosinusitis results from an impairment of mucociliary clearance and subsequent inflammation of the paranasal sinuses, due to infection, allergies, or mechanical obstruction. Sinusitis typically occurs in conjunction with inflammation of the nasal mucosa. The most common etiology is a viral infection; most bacterial cases are associated with antecedent viral upper respiratory tract infection.
Maxillary sinusitis (most common) is associated with paranasal facial, retroocular, or maxillary dental pain, purulent rhinorrhea, and conjunctivitis. Ethmoid sinusitis, more common in children, produces a low-grade fever and periorbital pain. Frontal sinusitis can cause a severe supraorbital headache, which is exacerbated by leaning forward; a low-grade fever; upper lid edema; and rhinorrhea. Sphenoid sinusitis is rare, and patients typically complain of a vertex headache and retro-ocular pain. Sphenoid sinusitis can involve cranial nerves, most commonly the abducens nerve, the pituitary gland, and the cavernous sinus. Involvement of all sinus cavities is referred to as pansinusitis. Important complications of sinusitis include periorbital and orbital cellulitis, cavernous sinus thrombosis, and intracranial abscess.
Pott’s puffy tumor, a rare osteomyelitis of the cranium from direct extension of a frontal sinusitis, presents as a boggy, tender swelling overlying the frontal sinus.
H influenzae and S pneumoniae together represent 60% to 70% of bacterial causes. Immunocompromised patients are susceptible to fungal infections, including Aspergillus and Mucor species.
Sinusitis. Purulent drainage from the maxillary sinus ostium in a patient with maxillary sinusitis. Drainage may not always be apparent, since the ostium may be occluded from swelling and inflammation. (Photo contributor: Robin T. Cotton, MD.)
Sinusitis. Bone windows of a sinus CT demonstrating bilateral maxillary sinus disease. (Photo contributor: Lawrence B. Stack, MD.)
Pansinusitis—Pott’s Puffy Tumor. Forehead and right periorbital edema in a patient with pansinusitis suggests osteomyelitis of the anterior table of the frontal sinus. (Photo contributor: Lawrence B. Stack, MD.)
Management and Disposition
Most patients can be treated with oral or intranasal decongestants and analgesics alone. Humidified air, steam, or saline nasal sprays also facilitate drainage. If symptoms persist beyond 7 days, consider antibiotics.
Sinusitis—Pott’s Puffy Tumor. Marked swelling and erythema over the central forehead in a patient with sinusitis indicating osteomyelitis of the anterior table of the frontal sinus. (Photo contributor: Lawrence B. Stack, MD.)
Parenteral steroids are not used in acute or recurrent sinusitis. Intranasal steroids may have a role in allergic and chronic sinusitis. CT is the most sensitive and specific imaging modality.