Background
- Acute rhinosinusitis is inflammation of mucosal lining of nasal passage and paranasal sinuses <4 weeks in duration
- causes
- viruses identified in <10% of childhood sinus infections
- acute bacterial sinusitis is rhinosinusitis complicated by bacterial infection, such as
- Streptococcus pneumoniae
- Nontypeable Haemophilus influenzae
- Moraxella catarrhalis
- uncommon bacterial agents in acute sinusitis include
- Staphylococcus aureus (unless orbital or intracranial complication)
- respiratory anaerobes (unless dental infections)
- fungal sinusitis (such as Aspergillus species) if immunocompromised or diabetic
- common, possibly affecting 6% to 7% of children attending medical care for respiratory symptoms
- risk factors
- exposure to tobacco smoke or other irritants
- underlying conditions such as
- anatomic abnormalities of nasal passages and sinuses
- immunodeficiencies
- cystic fibrosis
- primary ciliary dyskinesia
- pathogenesis
- usually follows URIs or allergic rhinitis
- mucosal edema, decreased mucus transport, and obstruction of ostiomeatal complex lead to stagnation of secretions
- stagnation of secretions, decreased pH, and lowered oxygen tension within sinus promotes bacterial or viral overgrowth
- age of pneumatization of paranasal sinuses based on MRI in 1,452 children with no history of sinus disease
- at birth for maxillary and ethmoid sinuses
- age 9 months for sphenoid sinus
- age ≥5 years for frontal sinus
- viruses identified in <10% of childhood sinus infections
- acute bacterial sinusitis is rhinosinusitis complicated by bacterial infection, such as
- Streptococcus pneumoniae
- Nontypeable Haemophilus influenzae
- Moraxella catarrhalis
- uncommon bacterial agents in acute sinusitis include
- Staphylococcus aureus (unless orbital or intracranial complication)
- respiratory anaerobes (unless dental infections)
- fungal sinusitis (such as Aspergillus species) if immunocompromised or diabetic
- exposure to tobacco smoke or other irritants
- underlying conditions such as
- anatomic abnormalities of nasal passages and sinuses
- immunodeficiencies
- cystic fibrosis
- primary ciliary dyskinesia
- usually follows URIs or allergic rhinitis
- mucosal edema, decreased mucus transport, and obstruction of ostiomeatal complex lead to stagnation of secretions
- stagnation of secretions, decreased pH, and lowered oxygen tension within sinus promotes bacterial or viral overgrowth
- age of pneumatization of paranasal sinuses based on MRI in 1,452 children with no history of sinus disease
- at birth for maxillary and ethmoid sinuses
- age 9 months for sphenoid sinus
- age ≥5 years for frontal sinus
Evaluation
- ISDA criteria for diagnosis of acute sinusitis includes presence of at least 2 major or 1 major plus ≥2 minor symptoms.
- Major symptoms include
- nasal congestion or obstruction
- facial congestion or fullness
- facial pain or pressure (may be unilateral, above or below eyes on leaning forward)
- purulent anterior nasal discharge
- purulent or discolored posterior nasal discharge
- hyposmia or anosmia
- fever
- Minor symptoms include
- Headache
- ear pain, pressure, or fullness
- halitosis
- dental pain
- cough
- fatigue
- percussion of sinuses may elicit tenderness but not useful to distinguish causes of rhinosinusitis
- signs favoring acute bacterial sinusitis include
- signs or symptoms lasting ≥10 days without clinical improvement
- worsening signs or symptoms following initial improvement (“double sickening”)
- severe symptoms including fever ≥39 degrees C (102 degrees F) and purulent nasal discharge lasting ≥3 consecutive days
- symptoms suggestive of noninfectious rhinitis include
- pruritis of eyes, nose, mouth, palate, ears
- watery rhinorrhea
- sneezing
- nasal congestion
- postnasal drip
- Major symptoms include
- differential diagnosis
- viral URI (may be indicated by absence of either disturbed sleep or green nasal discharge)
- allergic rhinitis
- migraine
- nasal foreign body
- dental disease
- testing
- blood tests and imaging studies are not
indicated to
- confirm uncomplicated acute bacterial sinusitis
- distinguish bacterial from viral causes
- Contrast-enhanced CT preferred over MRI to identify suppurative complications (such as orbital or intracranial extension of infection)
- obtain cultures by direct sinus aspiration rather than by nasopharyngeal swab if no response to first- and second-line antibiotics
- blood tests and imaging studies are not
indicated to