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Emergency and Acute Medicine - Sinusitis (Rhinosinusitis)
Rhinosinusitis refers to inflammation of the mucous membranes lining the nasal passages and paranasal sinuses, with or without fluid accumulation. It is classified based on duration: acute (<4 weeks), subacute (4–8 weeks), chronic (>8 weeks despite treatment), and recurrent (three or more episodes per year). The term “rhinosinusitis” is preferred because sinus inflammation rarely occurs without concurrent nasal mucosal involvement.
Most cases begin with a viral upper respiratory infection or allergic inflammation, which leads to mucosal swelling, obstruction of sinus drainage pathways, impaired mucociliary clearance, and thickened secretions. Although viral causes predominate, a small percentage (0.5–2.2%) progress to bacterial infection when trapped secretions allow bacterial proliferation. Chronic and subacute forms are multifactorial, involving allergies, immune dysfunction, impaired ciliary function, anatomical obstruction, or dental infections. Common bacterial pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, while chronic disease may involve polymicrobial and anaerobic organisms. Immunocompromised patients are at risk for fungal infections such as Aspergillus.
Patients typically present with facial pain or pressure, headache, purulent nasal discharge, postnasal drip, cough, fever, and decreased sense of smell. Pain location may help identify the affected sinus: frontal sinusitis causes forehead pain, maxillary sinusitis causes cheek or dental pain, ethmoid sinusitis causes retro-orbital pain with possible periorbital swelling, and sphenoid sinusitis (rare) causes occipital or deep head pain. On examination, findings may include nasal mucosal edema, purulent discharge, sinus tenderness, and sometimes periorbital edema.
Diagnosis is primarily clinical. Acute viral rhinosinusitis usually resolves within 7–10 days. Acute bacterial rhinosinusitis should be suspected in three scenarios: persistent symptoms beyond 10 days without improvement, severe symptoms (fever ≥39°C with purulent discharge for at least 3–4 days), or worsening symptoms after initial improvement (“double worsening”). Imaging is not required for uncomplicated cases but CT scanning is indicated if complications are suspected, such as orbital involvement, neurologic deficits, or severe disease.
Management depends on severity and duration. Most cases require only supportive care, including analgesics, saline nasal irrigation, and possibly intranasal corticosteroids—especially in patients with allergic components. Antibiotics are reserved for suspected bacterial cases and typically include amoxicillin–clavulanate as first-line therapy, with alternatives such as doxycycline in adults. Decongestants and certain antibiotics (e.g., macrolides, TMP-SMX) are generally not recommended due to limited benefit or resistance.
Hospital admission is required for patients with complications, such as orbital cellulitis, intracranial spread, severe systemic illness, or in immunocompromised individuals. Most uncomplicated cases can be managed on an outpatient basis with close follow-up.
Important clinical points include avoiding unnecessary antibiotics in mild cases of less than 10 days’ duration, recognizing red flags such as periorbital swelling or neurologic symptoms, and understanding that worsening symptoms after initial improvement strongly suggest bacterial infection.
Rhinosinusitis refers to inflammation of the mucous membranes lining the nasal passages and paranasal sinuses, with or without fluid accumulation. It is classified based on duration: acute (<4 weeks), subacute (4–8 weeks), chronic (>8 weeks despite treatment), and recurrent (three or more episodes per year). The term “rhinosinusitis” is preferred because sinus inflammation rarely occurs without concurrent nasal mucosal involvement.
Most cases begin with a viral upper respiratory infection or allergic inflammation, which leads to mucosal swelling, obstruction of sinus drainage pathways, impaired mucociliary clearance, and thickened secretions. Although viral causes predominate, a small percentage (0.5–2.2%) progress to bacterial infection when trapped secretions allow bacterial proliferation. Chronic and subacute forms are multifactorial, involving allergies, immune dysfunction, impaired ciliary function, anatomical obstruction, or dental infections. Common bacterial pathogens include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis, while chronic disease may involve polymicrobial and anaerobic organisms. Immunocompromised patients are at risk for fungal infections such as Aspergillus.
Patients typically present with facial pain or pressure, headache, purulent nasal discharge, postnasal drip, cough, fever, and decreased sense of smell. Pain location may help identify the affected sinus: frontal sinusitis causes forehead pain, maxillary sinusitis causes cheek or dental pain, ethmoid sinusitis causes retro-orbital pain with possible periorbital swelling, and sphenoid sinusitis (rare) causes occipital or deep head pain. On examination, findings may include nasal mucosal edema, purulent discharge, sinus tenderness, and sometimes periorbital edema.
Diagnosis is primarily clinical. Acute viral rhinosinusitis usually resolves within 7–10 days. Acute bacterial rhinosinusitis should be suspected in three scenarios: persistent symptoms beyond 10 days without improvement, severe symptoms (fever ≥39°C with purulent discharge for at least 3–4 days), or worsening symptoms after initial improvement (“double worsening”). Imaging is not required for uncomplicated cases but CT scanning is indicated if complications are suspected, such as orbital involvement, neurologic deficits, or severe disease.
Management depends on severity and duration. Most cases require only supportive care, including analgesics, saline nasal irrigation, and possibly intranasal corticosteroids—especially in patients with allergic components. Antibiotics are reserved for suspected bacterial cases and typically include amoxicillin–clavulanate as first-line therapy, with alternatives such as doxycycline in adults. Decongestants and certain antibiotics (e.g., macrolides, TMP-SMX) are generally not recommended due to limited benefit or resistance.
Hospital admission is required for patients with complications, such as orbital cellulitis, intracranial spread, severe systemic illness, or in immunocompromised individuals. Most uncomplicated cases can be managed on an outpatient basis with close follow-up.
Important clinical points include avoiding unnecessary antibiotics in mild cases of less than 10 days’ duration, recognizing red flags such as periorbital swelling or neurologic symptoms, and understanding that worsening symptoms after initial improvement strongly suggest bacterial infection.
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