Objectives:

i. List the possible etiologies of sinus infections

ii. Compare and contrast the symptoms found in bacterial vs viral
sinusitis
iii. Describe the treatment of viral sinusitis
iv. Describe the treatment of bacterial sinusitis
v. Describe the complications of sinus infections and indications for
referral
vi. Describe the complications of sinus infections and indications for
referral

USC Case #4: Sinusitis

Chief Complaint (CC): cold symptoms, nasal congestion, some sinus pain

History of Present Illness (HPI)

A 24 year old medical student, presents to the office in August complaining of ongoing
upper respiratory cold symptoms for almost 2 weeks now. She has used over-the-counter
medication without significant benefit. She has also taken a few antibiotic pills her
roommate had laying around last week. This also provided little benefit. She lists her
specific symptoms as runny nose, worsening nasal congestion, mildly productive cough,
sore throat, headache, subjective fever and chills, decreased appetite, and overall malaise.

You begin, as any good medical student would do, to form a differential diagnosis. What
are a few of the diagnosis on your list so far?

1. Rhinitis, viral
 2. Sinusitis, viral
3. Sinusitis, bacterial
4. Pneumonia
5. Influenza
6. Meningitis

What other important historical points would you want to elicit?

Questions regarding dental pain, purulent nasal discharge, hemoptysis, epistaxis, chest
pain, and unilateral facial pain or pressure worse with bending over should not be
forgotten. Specific presence of neck pain, visual disturbance, periorbital edema, and
mental status changes should be addressed. One should consider immediate referral if
these findings are present. This information can help eliminate more serious conditions
from your differential. Specific antibiotic use should also be identified.

Periorbital Cellulitis

Review of Systems (ROS)

HEENT: Denies severe headache, diplopia or visual loss, mental status change,
dental pain, neck pain, epistaxis
Reports purulent nasal discharge and right-sided facial pain
Respiratory: Denies hemoptysis, purulent sputum production, dyspnea
CV: Denies chest pain
GI: Denies abdominal pain, nausea, vomiting, and diarrhea
GU: Denies change in urinary pattern or hematuria
Skin: Denies rash
General: Denies weight loss or night sweats
Reports mild loss of appetite since illness began

What is the significance of questioning for chest pain?

Viral myocarditis often begins with flu like illness. This can be a life threatening
condition and should be treated with caution. Signs and symptoms include chest pain or
discomfort, flu like symptoms, fever, dyspnea, fatigue, tachycardia, peripheral edema,
friction rub, S3/S4 gallop, pulmonary crackles, and orthopnea. The complication from
myocarditis is heart failure. If signs and symptoms are noted then appropriate supportive
measures and diagnostic work up are warranted.
What specific questions are important in regards to past medical history in this patient?

Important historical data would include history of allergic rhinitis, swimming, drug and
alcohol use, intranasal cocaine use, sick contacts, smoking history, recent hospitalization,
and chronic medical diseases such as asthma, diabetes, HIV, liver or renal disease,
recurrent dental infections, and cystic fibrosis. History of nasal polyps, facial trauma
(e.g. septal deviation), and head injury should also be obtained. These conditions
predispose a person to acquire infections more readily. Also note season of year for
likelihood of influenza infection.

Past Medical History (PMH)

Denies diabetes mellitus, asthma, allergic rhinitis, HIV, liver or renal disease, or recurrent
infections

Surgical History (SxH)

Denies any previous surgery

Family History (FH)

No diabetes, heart disease, asthma, immune deficiencies, or similar symptoms.

Social History (SH)

Denies cocaine use. Denies IV drug use. Occasional alcohol and marijuana. Smokes 1
PPD x 6 years. Lives with family. Medical student. Heterosexual.

Physical Exam (PE)

Temp: 99.5 Pulse: 88 BP: 125/78 Resp: 18 Weight: 175 Height: 6 0

GENERAL: mild distress. Alert and oriented. Cooperative with fluent speech.

HEENT: normocephalic, atraumatic. External ocular muscles intact. Pupils equal round
and reactive to light. TMs intact c clear fluid. No erythema or exudates noted. Nasal
mucosa swollen and erythematous with thick yellow discharge. No polyps noted. There
is right maxillary and frontal sinus tenderness to palpation. Posterior oropharynx without
exudates. Mild erythema noted.

NECK: supple without lymphadenopathy, thyromegaly, bruits, or mass noted. Full range
of motion.

CHEST: clear to auscultation bilaterally without crackles, rhonchi, or wheeze.

HEART: S1, S2 without murmur, gallop, rub, or click. Regular rate of 88.

ABDOMEN: soft, nontender, nondistended. No organomegaly.

EXTREMITIES: pulses full and equal. Full range of motion.

SKIN: No rash or erythema noted.

What is your diagnosis at this point?

Acute rhinosinusitis.
What is the most common cause of acute sinusitis/rhinosinusitis?

Viral infection accounts for nearly 98% of all acute sinus infections. Only 2% of viral
infections are complicated by bacterial superinfection. One of the most important issue
surrounding sinusitis is determining the exact etiology of the infection. See table below
for common viral, bacterial, and fungal agents causing sinusitis.
What is the natural course of rhinosinusitis?

Typical viral infections last 7 to 10 days whereas of all bacterial infections resolve at
one months time. However the accompanying morbidity and possibility of extension of
infection into the skull, orbital, and meninges warrants antibiotic intervention.

What benefit is transillumination of the sinuses?

Transillumination can only be performed for the frontal and maxillary sinuses.
Additionally, it cannot differentiate between viral or bacterial sinusitis and is very
operator dependant. It has little clinical value and poor predictive information.

What role does radiological imaging play in the diagnosis of sinusitis?

Imaging is not recommended for the usual community acquired sinusitis, unless
intracranial or orbital extension is suspected. CT is normally reserved for those who
have failed multiple antibiotic courses and surgery is a consideration. CT also provides
better sensitivity and specificity than plain x-ray. Again, these diagnostic tests cannot
differentiate between viral and bacterial causation. Additionally, CT occasionally will
result in false positives. In one study, 27 of 31 patients with simple common colds had
abnormal sinus CT films. (see image below)
Arrows indicate inflamed mucosal lining of maxillary sinuses
What is the criterion for diagnosing bacterial sinusitis?

Studies have been done using clinical findings to differentiate viral vs. bacterial infection,
however they used imperfect diagnostic controls. The definitive diagnostic test for
sinusitis etiology is sinus aspirate culture, which have not been implemented in
comparison studies. Up to Date has published three organizational guideline
comparisons which comment on duration of symptoms, fever, sinus pain, and purulent
nasal discharge as criteria for diagnosis. (See below)

What is the accepted treatment for acute viral sinusitis?

Treatment of rhinoviral infections should be aimed at controlling the inflammation and

facilitating drainage. 1st generation antihistamines help decrease sneezing, rhinorrhea,
and nasal mucous thickness. Expectorants can also aid in thinning secretions.
Osteopathic manipulation such as facial effleurage and myofascial release of the thoracic
outlet can facilitate improved drainage and produce little side effects. NSAIDs can also
benefit by reducing malaise and headache. Decongestants and cough suppressants can be
added but should not be used for prolonged periods.

What about bacterial sinusitis?

There are no good randomized placebo controlled studies for treatment of bacterial
sinusitis using pre and post treatment sinus aspirate cultures as standards for cure.
However, it is felt that antibiotic therapy reduces the degree of symptoms and duration of
the illness based on clinical and radiographic evidence. Antibiotic resistance to S.
pneumoniae, H. influenza, and M. catarrhalis is a growing concern mainly due to use of
antibiotics for viral infections. Cephalexin, clindamycin, and macrolides generally do not
provide adequate coverage or they are associated with resistance in the community.
Therefore, first line therapy should include narrow spectrum antibiotics such as
amoxicillin, trimethoprim-sulfamethoxazole, and doxycycline. One could also consider
no antibiotic intervention based on the self limited nature and very low frequency of
complications mentioned earlier. If the patient does not improve or worsens, other agents
such as levofloxacin, amoxicillin-clavulanate, or a 3rd generation cephalosporin could be
implemented. Typical course would be 7 to 10 days of treatment. The viral sinusitis
treatment plan would also be prescribed in addition to antibiotics. There is some data
supporting chronic infections responding favorably to intranasal steroids.

When should a primary care physician refer their patient to a specialist (ENT)?

If the patient were to fail multiple antibiotic courses or they presented with significant
symptoms mentioned previously, then referral would be in order. One should begin
thinking about referral if CT scan is being ordered. An otolaryngologist can perform
sinus aspirate cultures for specific antibiotic resistance, nasal endoscopy, sinus washings,
or surgery to correct any anatomical predisposing conditions.

Facial Cellulitis

Algorithm for the antibiotic management of acute bacterial

rhinosinusitis
Algorithm for the management of acute bacterial rhinosinusitis.
CT: computed tomography; MRI: magnetic resonance imaging.

* In patients with uncomplicated ABRS with good follow-up, observation without antibiotics is

an option. Antibiotics should be started if there is no improvement in symptoms. Guidelines

differ as to when to start antibiotics if there is no improvement in symptoms.

REFERENCE
Acute sinusitis and rhinosinusitis. 2015 UpToDate. uptodate.com