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Sinusitis

 

Definitions in sinusitis

  • Acute – Symptoms completely resolve within 12 weeks
  • Chronic – Symptoms last longer than 12 weeks.

 

Aetiology of sinusitis

  • Acute:
    • Often follows URTI
    • Usually viral, 0.5 – 2% are bacterial.
  • Chronic:
    • Can follow acute sinusitis
  • Other risk factor:
    • Atopy, asthma, ciliary dyskinesia, aspirin sensitivity, immunocompromise, smoking
  • Beware unilateral symptoms are not a foreign body or malignancy.

 

Symptoms of sinusitis

  • Adults: 2 symptoms out of those below:
    • One must be nasal blockage (obstruction/congestion) or nasal discharge (anterior/posterior nasal drip)
    • +/- facial pain/headache
    • +/- reduction of smell
  • Children
    • As above but +/- cough rather than smell changes.

 

Simple video explaining sinusitis

 

Examination in sinusitis

  • Assess for complications
    • e.g. periorbital cellulitis or neurological changes
  • Anterior rhinoscopy using otoscope
    • If equipment not available then look for discharge/mucopus, inflamed mucosa/turbinates, deviated septum.
  • Polyps may be present and are pale and insensate.
    • Unilateral polyps should not occur.

 

Treatment of sinusitis

  • Acute (admit urgently if complications)
    • Analgesia
    • Max one week of decongestant e.g. otrivine. (Longer course results in rebound congestion)
    • Nasal douching with saline (e.g. NeilMed Sinurinse)
    • If symptoms persist after 10 days or worsen after 5 days then give topical steroid e.g. fluticasone, mometasone
    • If no improvement after 10-14 days of spray then refer to ENT
    • If suspected bacterial (discoloured discharge, fever, raised inflammatory markers, severe local pain) or severe symptoms then as well as topical steroid add antibiotics.
      • First line antibiotic is amoxicillin (7 days) or doxycycline/clarithromycin (7 days if penicillin allergic)
      • If no effect in 48 hours with antibiotics try co-amoxiclav (7 days) or azithromycin (3 days)
      • If no improvement after 48 hours then refer to ENT.
  • Chronic without polyps
    • Nasal douching
    • Steroid spray if mild symptoms or drops if moderate/severe (e.g. fluticasone, mometasone).
    • If moderate/severe add long term macrolide (clarithromycin)
    • Review after 3 months
      • If improvement can wean down treatment to spray/douching alone.
      • If no improvement refer to ENT.
  • Chronic with polyps
    • Nasal douching
    • Steroid spray if mild symptoms or drops if moderate (e.g. fluticasone, mometasone).
    • Short course oral steroids if severe (40mg 7 days)
    • Review after 3 mmonths unless severe in which case review after 1 month.
    • If improvement can wean down treatment to spray/douching alone.
    • If no improvement refer to ENT.

 

Click here to download free teaching notes on Sinusitis: Sinusitis

Perfect revision for medical students, finals, OSCEs and MRCP PACES

 

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