This study provides a comprehensive overview of sinusitis, detailing its pathophysiology, clinical manifestations, diagnostic criteria, and management strategies. Sinusitis, characterized by inflammation of the paranasal sinuses, can be acute, subacute, recurrent, or chronic, with distinct clinical presentations and treatment approaches. Diagnosis relies on clinical evaluation, imaging studies, and occasionally nasal endoscopy. Treatment encompasses both pharmacologic and non-pharmacological interventions, including antibiotics for bacterial cases and intranasal corticosteroids to reduce inflammation. Surgical interventions like functional endoscopic sinus surgery may be required for refractory cases. Emerging therapies, such as biologics and minimally invasive procedures, offer promising alternatives to traditional management approaches.
Key points
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The most common etiology for sinusitis is a viral infection. Bacterial cases are associated with an antecedent viral upper respiratory tract infection with persistent symptoms lasting more than 10 days, worsening symptoms after initial improvement, or fever greater than 39 C (102.2 F).
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For patients with chronic sinusitis who have failed antibiotic trials and nasal saline irrigation, otolaryngology referral is recommended for evaluation with nasal endoscopy and consideration of surgical options such as adenoidectomy and endoscopic sinus surgery.
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Decongestants, antihistamines, and nasal irrigation are ineffective for children with acute bacterial sinusitis.
Introduction
Definitions
The paranasal sinuses are a group of 4 paired air-filled spaces: the maxillary, frontal, ethmoid, and sphenoidal sinuses, as demonstrated in Fig. 1 . Sinusitis results from impaired mucociliary clearance and subsequent inflammation of the paranasal sinuses due to infection, allergies, or mechanical obstruction. In cases of rhinosinusitis, the inflammation extends to the nasal mucosa.
Types of sinusitis, depending on the duration, include
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Acute infections : up to 4 weeks
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Subacute : 4 to 12 weeks
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Chronic : lasts more than 12 weeks
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Recurrent infection : involves 3 or more distinct episodes of sinusitis per year, with symptom-free intervals between episodes.
While the most common etiology is a viral infection, bacterial cases are associated with antecedent viral upper respiratory tract infections that have persistent symptoms lasting more than 10 days, worsening symptoms after initial improvement, or fever greater than 39 C (102.2 F).
Epidemiology
In 2018, the Centers for Disease Control (CDC) reported 28.9 million adults diagnosed with sinusitis, resulting in 2.7 million visits to physician offices and 234,000 visits to emergency departments, with chronic sinusitis as the primary diagnosis. In adults, the paranasal sinuses are a group of 4 paired air-filled spaces: the maxillary, frontal, ethmoid, and sphenoidal sinuses. In children, only the ethmoid and maxillary sinuses are present at birth.
Pathogenesis
Sinusitis results from impaired mucociliary clearance and subsequent inflammation of the paranasal sinuses due to infection, allergies, or mechanical obstruction. In cases of rhinosinusitis, the inflammation extends to the nasal mucosa. While viral causes like rhinovirus, influenza, and parainfluenza are the most common, bacterial causes are prominent as well. Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis represent 60% to 70% of bacterial causes. Immunocompromised patients are susceptible to fungal infections caused by Aspergillus and Mucor species (for detailed infectious causes, see Table 1 ).
| Viruses | Bacteria | ||
|---|---|---|---|
| Adults | Most common | Rhino Influenza parainfluenza | Streptococcus pneumoniae , Haemophilus influenzae , Moraxella catarrhalis , Streptococcus pyogenes , Staphylococcus aureus , Other anaerobic bacteria |
| Less common | Fusobacterium nucleatum Prevotella and Porphyromonas Peptostreptococcus species (spp) | ||
| Children | Most common | Rhino Influenza parainfluenza | Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis |
| Less common | Staphylococcus aureus alpha-hemolytic streptococci | ||
Clinical signs and symptoms
Sinusitis, characterized by inflammation of the paranasal sinuses, presents with a range of symptoms depending on the affected sinus and underlying cause. Common manifestations include facial pain, cough, congestion, postnasal drip, ear pain, halitosis, hyposmia or anosmia, purulent nasal drainage, and nasal congestion or obstruction.
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Maxillary sinusitis: This type of sinusitis is often associated with paranasal facial pain, retro-orbital discomfort, or maxillary dental pain. Patients may also experience purulent rhinorrhea and conjunctivitis, particularly in acute cases.
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Ethmoid sinusitis: More prevalent in children, ethmoid sinusitis typically presents with periorbital pain and tenderness, often accompanied by nasal congestion and purulent discharge.
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Frontal sinusitis: Patients with frontal sinus involvement commonly report a supraorbital headache, upper lid edema, and persistent rhinorrhea.
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Sphenoid sinusitis: Although rare, sphenoid sinusitis can cause headaches and retro-orbital pain, often leading to diagnostic challenges due to its less frequent occurrence.
In one study evaluating clinical diagnosis of sinusitis compared to computed tomography (CT), several symptoms had significant correlation seen on CT scan: preceding common cold, pain bending forward, purulent rhinorrhea, nasal voice, hyposmia or anosmia, unilateral frontal pain, double sickening, but only 2 signs correlated significantly: swollen nasal mucosa (98% sensitivity, 16% specificity) and purulent secretion (60% sensitivity, 89% specificity).
Diagnosis and criteria
The diagnosis of acute rhinosinusitis (ARS) in primary care is based on established clinical criteria. According to the 2015 otolaryngology guidelines, ARS is suspected when patients present with up to 4 weeks of purulent nasal drainage (not clear) accompanied by nasal congestion andfacial pain, pressure, or fullness.
Distinguishing between viral and bacterial etiologies is crucial in management. Disease duration (>10 days) and worsening of symptoms before 10 days (double worsening sign) are key factors in this differentiation, guiding appropriate treatment strategies. The “double worsening sign” is defined as acute sinusitis symptoms as above worsening within the first 10 days, rather than improving. Effectively their symptoms start off distressing, improve for a short time, then become worse again.
Pediatric Considerations
The ethmoid and maxillary sinuses are present at birth and are the most involved in sinusitis in children. Sphenoid sinuses form at the age of 3 to 5 years and begin to pneumatize at the age of 5 years but do not fully develop until the age of 20 to 30 years. Frontal sinuses do not appear until the age of 7 to 8 years and remain incompletely pneumatized until late adolescence. Predisposing factors for acute bacterial sinusitis are diffuse mucositis secondary to viral rhinosinusitis in about 80% and allergic inflammation in about 20%. Less common predisposing factors include nonallergic rhinitis, cystic fibrosis, dysfunctional or insufficient immunoglobulins, ciliary dyskinesia, and anatomic abnormalities.
Physical examination
Diagnosis of rhinosinusitis is best supported by a thorough history and physical examination. Clinical findings that best rule in the diagnoses are purulent secretions in the middle meatus (positive likelihood ratio [LR+] 3.2) and the overall clinical impression of the clinician (LR+ 3.0), which impresses upon the clinician the role of experience and seeing many cases of sinusitis and other inflammatory and infectious diseases of the upper respiratory tract. Four specific signs and symptoms have a high likelihood ratio and were independently associated with acute sinusitis: “double worsening sign,” purulent rhinorrhea, purulent secretions, and erythrocyte sedimentation rate (ESR) greater than 10 had the highest likelihood ratios associated with acute sinusitis. A combination of at least 3 of these 4 symptoms and signs gave a specificity of 81% and a sensitivity of 66%. The clinical findings that best rule out rhinosinusitis are the overall clinical impression (LR ˗0.37), normal transillumination (LR 0.55), the absence of preceding respiratory tract infection (LR˗ 0.48), any nasal discharge (LR˗ 0.49), and lack of purulent nasal discharge (LR ˗0.54).
Diagnostic tests
While diagnostic testing is often not needed after a clinical diagnosis of sinusitis, one study found the prevalence of bacterial growth on cultures from patients clinically diagnosed with sinusitis was only about 52.5% to 61.1% (Smith 34) that demonstrates that clinical evaluation may overdiagnose bacterial sinusitis about half of the time. When diagnostic accuracy is essential, several tests have been studied (see Table 2 for a detailed list of diagnostic test likelihood).
| Test | +Likelihood Ratio | -Likelihood Ratio |
|---|---|---|
| Sedimentation Rate | (>30) LR+ 4.08 (>40) LR+ 7.40 | (<10) LR˗ 0.57 |
| C-reactive Protein | (>20) LR+ 2.92 | (<10) LR˗ 0.45 |
| Direct Nasal Endoscopy | LR+ 3.1 | LR˗ 0.36 |
| Anterior Rhinoscopy | LR+ 3.2, LR+ 5.3, or LR+ 11.0 (depending on location of discharge) | LR˗ 0.2 |
| CT | LR+ 2.9 | LR˗ 0.04 |
| Radiograph | LR+ 3.6 | LR˗ 0.34 |
| Ultrasound | LR+ 3.6 | LR˗ 0.15 |
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