• Prerequisites and learning objectives
• Lesson
  • Content
    • 1 - Pathology of acuite nose and sinus infections
      • 1.1 - Acute rhinitis
        • 1 . 1 . 1 - Acute rhinitis in adults: the "common cold"
        • 1 . 1 . 2 - Clinical types
        • 1 . 1 . 3 - Treatment
    • 2 - Acute sinusitis
      • 2.1 - Anatomy review
      • 2.2 - Pathophysiology
      • 2.3 - Acute maxillary sinusitis
      • 2.4 - Diagnosis
      • 2.5 - Clinical types
        • 2 . 5 . 1 - By topography
        • 2 . 5 . 2 - Recurring infections
        • 2 . 5 . 3 - Hyperalgesia: severe acute maxillary or frontal sinusitis
        • 2 . 5 . 4 - Complicated infections
        • 2 . 5 . 5 - Immunocompromised hosts
      • 2.6 - Treatment
        • 2 . 6 . 1 - Guidelines for antibiotic therapy
        • 2 . 6 . 2 - Indications for antibiotic therapy
  • Teachers version
  • PDF Version
• Appendix
• Your opinion
• Teachers resources

• Help
• Authors
• Contacts

2  -  Acute sinusitis

Acute viral or bacterial infection of the mucosa of one or more sinus cavities.

2 . 1  -  Anatomy review

The paranasal sinuses are air-filled cavities in the facial skeleton lined with a layer of respiratory mucosa. The maxillary, anterior ethmoid, and frontal sinuses open into the nasal cavity via the middle meatus; the posterior ethmoid sinus via the superior meatus; and the sphenoidal sinuses via their own ostia (Fig.1).

Fig. 1 : CT scan of normal adult sinuses

A. Coronal slice through the ethmoid and maxillary sinuses:  right inferior turbinate (1); right middle turbinate (2); left middle meatus, providing drainage and aeration of the left maxillary sinus (3).

B. Axial slice through the frontal sinus: anterior wall (1); posterior wall (2).

C. Axial slice through the maxillary sinuses: right maxillary sinus (1)  right medial wall (2); nasal septum (3).

D. Axial slice through the ethmoid sinuses: left ethmoid sinus (1); right sphenoidal sinus (2).

The sinuses develop progressively with age :

–        ethmoid present at birth;

–        maxillary sinuses appear after 3 years;

–        frontal sinuses after 7 years.

2 . 2  -  Pathophysiology

Sinus infections may be :

–        of nasal origin following acute rhinitis or, more rarely, barotrauma; symptom severity depends on the pathogen's virulence and the ostium's permeability; symptoms may come on abruptly or after a common cold; as the cold subsides, potential infectious agents include:

• pneumococcus;
• streptococcus;
• haemophilus influenzae;
• moraxella catarrhalis;
• staphylococcus.

2 . 3  -  Acute maxillary sinusitis

This is the most common type of acute sinusitis. Typically, symptoms are worse in the evening and include throbbing pain under one eye aggravated by effort or lying down, nasal obstruction, and thick or even mucopurulent discharge sometimes streaked with blood, all on the same side of the face, as well as mild fever. Hyperalgesia and sleep-disturbing pain are signs of severe acute sinusitis ("blocked sinusitis").

Anterior rhinoscopy will show pus in the middle meatus on the painful side. Pus may also be found on posterior rhinoscopy or examination of the pharynx.

Pain provoked by palpating the sinuses has no diagnostic value.

Examining physicians should search carefully for signs of rare complications involving the brain, meninges, or eyes, such as meningism, altered consciousness, exophthalmia, palpebral edema, intrinsic or extrinsic ocular motility disorders, as well as visual loss.

2 . 4  -  Diagnosis

Quite often some signs are present, while others are not, meaning that the pattern of symptoms may vary. Diagnostic criteria have been established in order to help clinicians determine whether a secondary bacterial infection has occurred, and whether antibiotics should be prescribed. The presence of a secondary bacterial infection causing purulent acute maxillary sinusitis can be argued if two of the following three major criteria are fulfilled:

–        persistence or aggravation of sinus pain under the eye, with no relief despite symptomatic treatment (analgesics, antipyretics, and decongestants) taken for at least 48 hours;

–        type of pain: unilateral, throbbing, worse with head forward, worst at end of day or at night;

–        increase in rhinorrhea and in purulence of the discharge, which is even more significant when unilateral.

There are also some minor criteria that, in combination with the above, may corroborate a diagnosis:

–        persistence of fever beyond 3 days;

–        nasal obstruction, sneezing, sore throat, or cough lasting longer than a few days (during which time nasopharyngitis usually runs its course).

Standard radiology is not indicated in the face of strong clinical evidence. Computed tomography is more effective, but not indicated unless the diagnosis is in doubt, complications are suspected, or, more rarely, first-line antibiotic therapy fails (Fig.2).

Fig.2 : Coronal CT slice of a patient with right maxillary sinusitis presenting as inhomogenous opacity of the right maxillary sinus

Fig. 2.1

In unilateral acute maxillary sinusitis without rhinitis, the dental origin hypothesis should be explored. Dental examinations are often revealing and should include appropriate radiology (panoramic and periapical X-rays).