Rhinosinusitis, Acute Bacterial

Key Features

Essentials of Diagnosis

• Purulent yellow-green nasal discharge or expectoration

• Facial pain or pressure over the affected sinus or sinuses

• Nasal obstruction

• Acute onset of symptoms (between 1- and 4-weeks' duration)

• Associated cough, malaise, fever, and headache

General Considerations

• Believed to be the result of impaired mucociliary clearance, inflammation of the nasal cavity mucosa, and obstruction of the ostiomeatal complex, or sinus "pore"

• Edematous mucosa causes obstruction of the complex, resulting in the accumulation of mucus in the sinus cavity that becomes secondarily infected by bacteria

• Typical pathogens are

  • Streptococcus pneumoniae

  • Other streptococci

  • Haemophilus influenzae

  • Less commonly, Staphylococcus aureus and Moraxella catarrhalis

• About 25% of healthy asymptomatic individuals may, if sinus aspirates are cultured, harbor these bacteria

• Discolored nasal discharge and poor response to decongestants suggest sinusitis

Demographics

• Uncommon compared with viral rhinitis, but still affects nearly 20 million Americans annually

Clinical Findings

Symptoms and Signs

• Major symptoms

  • Purulent nasal drainage

  • Nasal obstruction/congestion

  • Facial pain/pressure

  • Altered smell

  • Cough

  • Fever

• Minor symptoms

  • Headache

  • Otalgia

  • Halitosis

  • Dental pain

  • Fatigue

• More specific signs and symptoms may be related to the affected sinuses

• Bacterial rhinosinusitis can be distinguished from viral rhinitis when symptoms last > 10 days after onset or worsen within 10 days after initial improvement

• Maxillary sinusitis

  • Unilateral facial fullness, pressure, and tenderness over the cheek

  • Pain may refer to the upper incisor and canine teeth

  • May result from dental infection, and tender teeth should be carefully examined for abscess

  • Nonspecific symptoms include fever, malaise, halitosis, headache, hyposmia, cough

• Ethmoid sinusitis

  • Usually accompanied by maxillary sinusitis; the symptoms of maxillary sinusitis generally predominate

  • Pain and pressure over the high lateral wall of the nose between the eyes that may radiate to the orbit

• Sphenoid sinusitis

  • Usually seen in the setting of pansinusitis, or infection of all the paranasal sinuses on at least one side

  • The patient may complain of a headache "in the middle of the head" and often points to the vertex

• Frontal sinusitis

  • May cause pain and tenderness of the forehead

  • This is most easily elicited by palpation of the orbital roof just below the medial end of the eyebrow

• Hospital-acquired sinusitis

  • May present without any symptoms in head and neck

  • Common source of fever in critically ill patients

  • Often associated with prolonged presence of nasogastric or, rarely, nasotracheal tube

  • Pansinusitis on side of tube commonly seen on imaging studies

Differential Diagnosis

• Upper respiratory tract infection

• Viral rhinitis

• Allergic rhinitis

• Nasal polyposis

• Dental abscess

• Rhinocerebral mucormycosis

• Otitis media

• Pharyngitis

• Dacryocystitis

• Paranasal sinus cancer

Diagnosis

Laboratory Tests

• Diagnosis usually made on ...