Sinusitis

Diagnosis/Definition

• Sinusitis is defined as an infection of the paranasal sinuses, typically secondary to obstruction of normal sinus outflow.
• The obstruction can be either mucosal (i.e. edema due to allergy, URI, irritants etc) or bony (i.e. anatomical narrowing due to trauma, polyps etc) or a combination of both.
• Treatment is designed to relieve the obstruction and eradicate the infection.
• Chronic sinusitis refers to the persistence of symptoms despite adequate medical therapy for over 12 weeks.

Initial Diagnosis and Management

• History: Pertinent historical data include the duration of symptoms and previous treatment, history of prior episodes, and complaints of nasal obstruction, anosmia, facial or dental pain, rhinorrhea (clear, mucoid or purulent), post nasal drip, and visual changes. Documentation of any facial trauma and allergy history should also be done.
• Physical: Physical findings should note any rhinorrhea, septal deviation, nasal polyps, facial tenderness or asymmetry, post nasal drainage, and turbinate hypertrophy pre and post decongestant treatment.
• Additional studies: Plain film X-rays are discouraged in the acute sinusitis setting because they rarely add useful information. A CT scan of the sinuses is indicated after a second 3-week trial of antibiotics with recurrent or unresolved symptoms.
• Initial management: For acute sinusitis, a 2-week course of first line antibiotic therapy (refer to the MAMC Intranet Pharmacy Guidelines or the Sanford Antimicrobial Handbook) is indicated. This is supplemented with nasal saline rinses and topical nasal decongestant therapy for 3-5 days. The use of mucolytics (guaifenesin), oral decongestants, antihistamines, and nasal steroids are dictated by the patient’s history. For recurrent or unresolved symptoms, a second line antibiotic is used for no less than 3 weeks, and nasal steroid therapy is instituted. A CT scan is obtained after this therapy for recurrent or persistent symptoms. For those patients with a strong allergy history, a nasal smear for eosinophils and/or allergy evaluation are indicated. For recurrent sinusitis (3 or more episodes in 6 months) despite maximal medical therapy, a sinus CT scan is indicated.

Ongoing Management and Objectives

Prevention and control of further infections.

Indications for Specialty Care Referral

Sinusitis unresponsive to medical therapy after a 3 week trial of a second line agent and a full course of nasal steroid therapy with evidence of disease on the sinus CT scan.

Recurrent sinusitis – 3 or more episodes in a 6 month period despite adequate medical treatment as outlined above and evidence of disease on the sinus CT scan.

Patient with known immune compromise or ciliary motility problem.

Orbital or cranial complications of sinus infections.

Recurrent nasal polyps unresponsive to medical therapy and evidence of disease on the sinus CT scan.

Any evidence of tumor noted on exam or CT.

Criteria for Return to Primary Care

Resolution or control of the problem by appropriate medical or surgical therapy.