• 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
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2 . 5  -  Clinical types

2 . 5 . 1  -  By topography

Frontal sinusitis

Pain is in the forehead, over the eyes, sometimes hemicranial, intense, and throbbing, with rhinorrhea and nasal obstruction. Frontal sinusitis presents a greater risk of complications and must thus not be misdiagnosed (Fig. 3).

Fig.3

Sphenoid sinusitis

Pain may be located in one of several places (occipital region, crown, or behind the eyes), making it important to consider all the options. Nasofibroscopy reveals a mucopurulent discharge at the ostium of the sphenoidal sinus. Diagnosis requires a CT scan.

Acute ethmoiditis in children

Acute ethmoiditis (fever with upper inner eyelid swollen and painful) strikes young children. This condition is rare, but prognosis may be serious. It must be recognized in a clinical setting so that hospitalization can occur followed by the urgent and sometimes parenteral administration of antibiotics.

Infections with edema

Inflammatory swelling of the orbital region: palpebral edema predominant at the inner corner of the orbit and upper eyelid; no pus from conjunctivitis; painful with high fever (39-40 °C, 102.2-104 °F).

This palpebral cellulitis can be attributed to sinusitis based on the following criteria:

– no pus from conjunctivitis (rules out conjunctivitis and dacrocystitis);

– pus running inconsistently, sometimes with blood, from one side of nose;

– CT scan shows predominantly unilateral opacification of the ethmoid and maxillary sinuses.

Broad-spectrum ambulatory antibiotic therapy is possible if the patient remains stable overall, provided there is clinical follow-up after 48 hours and a gravity sign update given to the family.

Infections with orbital abscess

Pus collects in the orbit between the periosteum and the lamina papyracea, leading to painful exophthalmia, thus far without visual loss or major disruption of ocular motility, although eye movement may be limited and painful. Rule out:

–        the rare possibility of maxillary osteomyelitis: edema predominant at the lower eyelid, swollen gums and palate;

–        severe staphylococcus infection from a furunculus on the upper lip or ala of the nose;

–        streptococcal erysipelas.

Complicated infections

Two complications should always be checked for:

–        pus formation in the orbit, to be suspected in cases of paralytic mydriasis, corneal anesthesia, or partial or total ophthalmoplegia;

–        intracranial thrombophlebitis: swinging fever with chills and meningism; oculomotor involvement.

Because such complications are late and often irreversible, a contrast-enhanced CT scan should be done in order to locate any orbital abscess as soon as ethmoiditis is diagnosed.

Surgical drainage of the abscess and ethmoiditis is indicated in the presence of pus on imaging, ophthalmoplegia, loss of light reflex, or vision loss (Fig. 4). These signs require immediate hospitalization, bacteriological testing, and the initiation of broad-spectrum double- or triple-agent parenteral antibiotic therapy combining third-generation cephalosporins, fosfomycin or vancomycin, and metronidazole with subsequent adjustment to bacteriological test results.  

Fig. 4

2 . 5 . 2  -  Recurring infections

Recurring unilateral infections suggest that the origin may be dental or locoregional (tumor, fungus ball, or anatomical anomaly), hence the benefit of CT or even MRI. Protracted infections lasting more than 12 weeks are labeled as chronic.

Chronic rhinosinusitis can flare up in the form of acute secondary infections. Chronic bilateral infections may lead to nasal polyps, an inflammatory condition of the respiratory mucosa starting in the ethmoid region and potentially causing anosmia and obstruction. They also often cause asthma or bronchial hyper-reactivity, not to be overlooked. Nasal polyposis may occur as part of Samter's triad (polyps, asthma, and salicylate sensitivity).

2 . 5 . 3  -  Hyperalgesia: severe acute maxillary or frontal sinusitis

The pattern of symptoms differs in that the pain is more intense, and no improvement occurs despite medical treatment. Pain can be relieved immediately by puncturing the sinuses through:

–        the inferior meatus (severe acute maxillary sinusitis);

–        the canine fossa (severe acute frontal sinusitis).

2 . 5 . 4  -  Complicated infections

Eye and orbit: palpebral cellulitis, subperiosteal orbital abscess, and orbital cellulitis (cf. acute ethmoiditis in children).

Brain and meninges: cerebral abscess, meningitis, subdural empyema, and thrombophlebitis of the cavernous or superior sagittal sinus.

Frontal bone osteitis.

These complications are often encountered in young patients. They may be life-threatening or lead to visual loss, which is why they should be diagnosed early on through detailed clinical examinations performed systematically whenever symptoms suggest acute sinusitis.

2 . 5 . 5  -  Immunocompromised hosts

In immunocompromised patients (Type 1 diabetes, HIV, prolonged corticosteroid treatment, chemotherapy-induced aplasia, malignant blood disease and bone marrow transplant, immunosuppressive drug regimen, etc.), acute invasive fungal infections must be spotted early on despite limited symptoms, such as fever of unknown origin. Prognosis is very poor.