3.11 Sinusitis
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agk's Library of Common Simple Emergencies

Presentation
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Following a viral infection, the patient will 
usually complain of a dull pain in the face, 
gradually increasing over a couple of days, 
exacerbated by sudden motion of the head, or 
holding the head dependent, between the knees, 
and perhaps radiating to the upper molar teeth 
(via the maxillary antrum), or with eye 
movement (via the ethmoid sinuses). Often there 
is a sensation of facial congestion and 
stuffiness. Children with sinusitis often 
present with cough and fetid breath. Fever is 
only present in half of patients with acute 
infection and is usually low grade. A high 
fever usually indicates a serious complication 
such as meningitis or another diagnosis 
altogether. Transillumination of sinuses in the 
ED is usually unrewarding, but you may elicit 
tenderness on gentle percussion or firm 
palpation over the maxillary or frontal sinuses 
or between the eyes (ethmoid sinuses). Swelling 
and erythema may exist and you may even see pus 
draining below the nasal turbinates, with a 
purulent, yellow-green and sometimes 
foul-smelling or bloody discharge from the nose 
or running down the posterior pharynx. The 
patient's voice may have a resonance similar to 
that of a "stopped up" nose, and he may 
complain of a foul taste in his mouth. Stuffy 
ears and impaired hearing are common because of 
associated serous otitis media and eustachian 
tube dysfunction.

What to do:
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- Rule out other causes of facial pain or 
   headache via history (did the patient wake 
   up with a typical migraine?) and physical 
   examination (palpate scalp muscles, temporal 
   arteries, temperomandibular joints, eyes, 
   and teeth).
- Shrink swollen nasal mucosa (and thereby open 
   the ostia draining the sinuses) with 1% 
   phenylephrine (Neo-Synephrine) or 0.05% 
   oxymetazoline (Afrin) nose drops. Drip 2 
   drops in each nostril, have the patient lie 
   supine 2 minutes, and then repeat the 
   process (this allows the first application 
   to open the anterior nose so the second gets 
   farther back). Have the patient repeat this 
   process every 4 hours, but for no more than 
   three days (to avoid rhinitis 
   medicamentosa).
- Examine the nose for purulent drainage before 
   and after shrinking the nasal mucosa with 
   topical vasoconstrictor.
- Add systemic sympathomimetic decongestants 
   (e.g., pseudephedrine (Sudafed) 60mg q6h or 
   phenylpropanolamine (Entex LA) 75mg q12h).
- If there is fever, pus, heat, or any other 
   sign of a bacterial superinfection, add 
   antibiotics (e.g., amoxicillin, trimethoprim 
   plus sulfamethoxazole, amoxicillin plus 
   clavulinate, erythromycin plus 
   sulfasoxazole, cefuroxime). First-line 
   antibiotic therapy is amoxicillin, or, for 
   patients with penicillin allergy, Bactrim or 
   Sulfa. If the patient has been recently 
   treated with these medications or if the 
   infection appears to be serious, then treat 
   with a second-line drug like Ceftin or 
   Augmentin.
- Provide pain relief, when necessary (e.g., 
   ibuprofen, naproxyn, acetaminophen, 
   oxycodone, hydrocodone)
- Recommend symptomatic relief with hot water 
   vapor inhalation using a simple teakettle or 
   hot shower or, if available, a steam 
   vaporizer or home facial sauna device.
- Sinusitis can sometimes be demonstrated on x- 
   rays, and you can usually get adequate 
   visualization of maxillary, frontal, and 
   ethmoid sinuses with one upright Water's 
   view. Chronic sinusitis appears as thickened 
   mucosa; acute as an air-fluid level or 
   complete opacification. Films are usually 
   not necessary, however, on an emergency 
   basis. If symptoms and physical findings of 
   sinusitis are classic, plain sinus radio- 
   graphs need not be obtained before treat- 
   ment. If an acute attack does not resolve 
   with medical treatment, or the diagnosis of 
   sinusitis is in doubt, plain films are 
   helpful as the primary imaging study.
- Arrange for followup within 1-7 days.

What not to do
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- Do not ignore signs of an orbital cellulitis 
   with swelling erythema, decreased extra- 
   ocular movements and possible proptosis. 
   These patients require consultation and 
   admission for intravenous antibiotics.
- Do not ignore the toxic patient with marked 
   swelling, high fever, severe pain, profuse 
   drainage, or other signs and symptoms of a 
   serious infection. See potential complicat- 
   ions below. These patients require immediate 
   consultation and intervention.
- Do not prescribe antihistamines, which can 
   make mucous secretions dry and thick, and 
   interfere with necessary drainage. 
   Antihistamines only cure sinusitis on 
   television, or when it is due to allergic 
   rhinitis.
- Do not allow patients to use decongestant 
   nose drops more than 3 days, thereby 
   allowing their nasal mucosa to become 
   habituated to sympathomimetic medication. 
   When they stop the drops they will suffer a 
   rebound nasal congestion (rhinitis 
   medicamentosa) which requires time, topical 
   steroids, and reeducation to resolve.
- Do not prescribe topical or systemic 
   sympathomimetic decongestants to a patient 
   who suffers from hypertension, tachycardia 
   or difficulty initiating urination, all of 
   which may be exacerbated.

Discussion
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The paranasal sinuses drain through tiny ostia 
under the nasal turbinates which, if occluded, 
allow secretions and pressure differences to 
build up, resulting in pressure and pain of 
acute sinusitis, and the air-fluid levels 
sometimes visible on upright x-rays. Sinus 
infections are relatively common and complic- 
ations relatively rare, but the bony walls of 
the paranasal sinuses are so thin that 
bacterial infections can spread through them. 
Most sinusitis begins with mucosal swelling 
from a viral upper respiratory infection. Other 
causes include dental infection, allergic 
rhinitis, barotrauma from flying, swimming or 
diving, nasal polyps and tumors and foreign 
bodies, including nasogastric and endotracheal 
tubes in hospitalized patients. Abscessed teeth 
can be the source of a maxillary sinusitis. If 
there is tenderness to percussion of the bi- 
cuspids or molars, arrange for dental referral.

Complications such as orbital cellulitis, 
osteomyelitis, epidural abscess, meningitis, 
cavernous sinus thrombosis and subdural empyema 
can be devastating and therefore patients must 
be instructed to get early follow up when signs 
and symptoms worsen or do not improve in 48-72 
hours, or if there is any change in mentation. 
Frontal sinusitis has the greatest potential 
for serious complications, particularly in 
adolescent males, the group at greatest risk 
for intracranial complications.br Computerized 
tomographic scanning of the sinuses is more 
accurate than plain x-rays, particularly when 
evaluating the ethmoid or sphenoid sinuses, but 
CT scans are needed from the ED only in unusual 
circumstances. Most patients can have initial 
treatment begun on the basis of history and 
physical findings alone. Anyone who has facial 
pain, headache, purulent nasal discharge and 
nasal congestion persisting for more than ten 
days, with or without a fever, should probably 
be treated empirically for sinusitis.

Many patients have been conditioned by the 
advertising of over-the-counter antihistamines 
for "sinus" problems (usually meaning "allergic 
rhinitis"), and may relate a history of 
"sinuses" which, on closer questioning, turns 
out to have been rhinitis.

References
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- Williams JW, Simel DL: Does this patient have 
   sinusitis? Diagnosing acute sinusitis by 
   history and physical examination. *J Am Med 
   Assoc* 1993; 270:1242-1246.

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