Sinusitis

Introduction

Sinusitis is an inflammation of the mucosal lining of the paranasal sinuses.
It  may be acute or chronic and affect one or more of the sinuses, most commonly the maxillary sinus or antrum (in very young children the ethmoidal sinuses).
Acute sinusitis is often sequel to acute rhinitis.
Common causative organisms are streptococcus, pneumococcus, and haemophilus.
Chronic sinusitis is more insidious. It may be associated with chronic rhinitis and allergy but other factors such as air pollution, smoking, dental sepsis and poor general health may be contributory.
Bacteriology is mixed: sometimes Gram negative and fungal organisms.

Symptoms and clinical features Sinusitis

  1. Rhinorrhoea
  2. Nasal obstruction
  3. Fever with pain over affected sinus in acute cases
  4. Less dramatic symptoms in chronic sinusitis
    • Intermittent nasal obstruction and discharge over a long period
    • Little pain
    • Mucopurulent postnasal (“drip”) discharge.

Differential diagnoses

  • Acute rhinitis (coryza)
  • Allergic rhinitis
  • Vasomotor rhinitis

Complications of Sinusitis

  1. Orbital cellulitis (complicating ethmoidal sinusitis)
  2. Cavernous sinus thrombosis (sphenoidal sinusitis)
  3. Intracranial infection
    • Subdural abscess
    • Meningitis
    • Cerebral abscess
    • Dural vein thrombophlebitis
  4. Osteomyelitis of frontal or maxillary bones.
  5. Chronic pharyngotonsillitis
  6. Chronic laryngitis and bronchitis

Investigations

  • Nasal swab for microscopy, culture and sensitivity
  • X-ray of sinuses: four-view
  • Antrum roof puncture/lavage: specimen for culture
  • CT scan in complicated cases

Treatment for Sinusitis

Treatment objectives

  • Control and eradicate infection
  • Restore adequate drainage of sinuses

Non-drug treatment

  1. Antrum wash-out/lavage
  2. Trephining of frontal sinus
  3. Radical surgery for non-responsive cases
    • Intranasal antrostomy
    • Caldwell-Luc operation
    • Fronto-ethmoidectomy
  4. Functional Endoscopic Sinus Surgery (FESS)

Drug treatment

A. Antibiotics

Amoxicillin

  • Adult: 500mg-1g orally every 8 hours for 5-7 days
  • Child: 40mg/kg orally every 8 hours for 5-7 days.

Or:
Amoxicillin/clavulanic acid
Adult: 500/125 mg orally every 12 hours
Child:

  • General: 0.25 mL/kg of 125/31 mg suspension orally every 8 hours; dose doubled in severe infections
  • 1-6years: 5mL of 250/62 mg suspension every 8 hours; dose doubled in severe infections
  • 6 – 12 years: 5 mL of 250/62 mg suspension every 8 hours; dose doubled in severe infections
  • 12 – 18 years: one 250/125 mg strength tablet every 8 hours, daily increased in severe infection to one 500/125 strength tablet every 8 hours daily

Or:

Cotrimoxazole
Adult: 960mg orally every 12 hours
Child

  • 6 weeks to 5 months: 120 mg orally every 12 hours;
  • 6 months – 5 years: 240 mg every 12 hours;
  • 6-12 years: 480 mg every 12 hours

Ceftriaxone

  • Adult: 1 g intravenously or intramuscularly every 12 hours for 7 days for patients with severe or nosocomial disease

Child: by intravenous infusion over 60 minutes

  • Neonates: 20 – 50 mg/kg once daily, by deep intramuscular injection, intravenous injection over 2-4 minutes, or by intravenous infusion
  • 1 month 12 years (body weight
    under 50 kg): 50 mg/kg once daily, up to 80 mg/kg in severe infections

B. Decongestant

Psuedoephedrine tablets.
Adult: 60 mg orally twice daily until
congestion
Child

  • 2-6 years: 15 mg orally 3-4 times daily;
  • 6 -12 years: 30 mg 3-4 times daily;
  • 12-18 years: 60 mg 3-4 times daily

C. Analgesic

Paracetamol
Adult: 500 mg – 1 g orally every 4-6 hours (to a maximum of 4 g) for 5-7 days
Child:

  • over 50 kg: same as adult dosing
  • 6-12 years: 250-500 mg;
  • 3 months – 5 years: 125-mg taken orally every 4-6 hours for 5-7 days

Supportive measures

  • Steam inhalations with menthol
  • Treat contributory nasal pathology as appropriate
  • Allergy, nasal polyps, septal
    deviations, dental pathology, etc

Notable adverse drug reactions

Amoxicillin

  • Minor gastrointestinal disturbance

Cotrimoxazole

  • Fixed drug eruption
  • Nausea and vomiting
  • Erythema multiforme
  • Steven-Johnson syndrome

Prevention of Sinusitis

  • Avoid airway irritants, smoking, and alcohol
  • Avoid air pollution
  • Maintain good general health and nutrition