Pocket Emergency Medicine (Pocket Notebook Series) 3rd Ed.

SINUSITIS

Acute Sinusitis

Definition

• Inflammation of the paranasal sinuses

• Usually viral or allergic

• Common bacterial etiologies: S. pneumoniae, nontypable H. influenzae, M. catarrhalis

• Pseudomonas is seen in HIV, cystic fibrosis, or after instrumentation

• Mucormycosis is invasive fungal sinusitis (Rhizopus) in diabetics or immunocompromised

Presentation

• Mucopurulent d/c, postnasal drip, cough, sinus pressure, HA, ±fever

• Typically progresses over 7–10 d & resolves spontaneously

• Sxs >7 d, worsening course, or worsening after improving, all suggest bacterial dz

• Consider sinusitis w/ positional HA that is worse when bending forward

• Sphenoid sinusitis is a difficult Dx, often presents late; classically worse w/ head tilt

Evaluation

• Clinical, no routine imaging. CT sens but not spec, can r/o cx.

• Cx to look out for orbital cellulitis, osteomyelitis, cavernous sinus thrombosis, cerebral abscess, meningitis, frontal bone abscess (Pott’s puffy tumor)

Treatment

• Supportive (analgesics, antipyretics, decongestants, antihistamines if allergic)

• Decongestants: Neo-Synephrine nasal spray TID × 3 d, Afrin nasal spray BID × 3 d

• Abx not routinely indicated. Reserve for pts w/ sxs >7 d, worsening sxs, fever, purulent d/c, or high risk for severe infection or cx.

• Amoxicillin 500 mg PO TID × 10 d, or TMP–SMX or azithromycin

• If no improvement: Amoxicillin–clavulanate, fluoroquinolone, clindamycin

Disposition

• Vast majority are managed outpt

• Admit if toxic, severe HA, high fever, immunocompromised, poor f/u

Pearl

• Sphenoid/ethmoid sinusitis is less common than maxillary sinusitis but has significant potential cx (eg, orbital cellulites, cavernous sinus thrombosis)