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For further information, see CMDT Part 8-10: Infections of the Nose & Paranasal Sinuses

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


  • 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


Laboratory Tests

  • Diagnosis usually made on ...

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