LMCC/Sinusitis


 * inflamation of mucous membranes in the nasal cavity and paranasal sinuses
 * fluid within these cavities or the underlying bone

Etiology

 * divided into
 * acute: < 4 weeks
 * recurrent: 4 or more episodes per year lasting at least 10 days
 * chronic: > 12 weeks
 * common pathogens are S. pneumoniae, H.influenza, M.catarrhalis

Risk Factors

 * medical conditions: respiratory infections, allergic rhinitis cystic fibrosis or immunodeficiency
 * anatomic: deviated septum, polyps, adenoid hypertrophy, tumour
 * irritants: environmental, tobacco smoke, air pollution, chlorine
 * iatrogenic: topical decongestant overuse, cocaine, trauma

History

 * recent URTI
 * nasal congestion/discharge
 * fascial pain/swelling
 * maxillary toothache
 * fever
 * headache worse with bending over
 * poor response to decongestants

Acute Sinusitis Score
1 point each for:
 * Maxillary toothache
 * history of purulent nasal discharge
 * poor response to decongestants
 * abnormal transillumination
 * purulent secretions
 * 0-1 sinusitis unlikely
 * 2-3 order x-ray (Water's view)
 * 4-5 likely sinusitis, no x-ray needed, treat with antibiotics

Physical

 * swelling and erythema over symptomatic area
 * tenderness on palpation of paranasal sinuses
 * periorbital swelling
 * nasal speculum exam: hyperemia, edema, crusts, purulence, polyps
 * tranillumination
 * to evaluate frontal and maxillary sinuses
 * of no diagnostic value in children, marginal in adults
 * 55% with +'ve radiologic findings have abnormal transillumination
 * must be in complete darkness

Investigations

 * radiography only when diagnosis of sinusitis is in doubt
 * all patients with pronounced frontal headaches should have radiograph performed
 * CT scans are not routineley used for diagnosis

Management

 * acute: 40% will recover spontaneously

Pharmacology

 * 1st line: amoxicillin x 10 days or TMP-SMX if penecillin allergy
 * 2nd line: Amoxil/clavulin, clarithromycin, ceflacor, cefixime

Adjunct therapy

 * saline nasal spray with humidification
 * topical or systemic decongestants; for short term use only
 * antihistamines are contraindicated
 * nasal corticosteroid spray for chronic sinusitis

Referal to ENT

 * failure of 2nd line therapy
 * >3 episodes/year
 * development of complications (ie. mucoceles, orbital extension, meningitis, intracranial abscess, venous sinus thrombosis)