What is the appropriate emergency department management for a 40-year-old female presenting with sinus pressure, tooth pain, right-sided facial swelling, and a hard spot in the maxillary sinus region, with no symptoms of dysphagia (difficulty swallowing), dyspnea (difficulty breathing), or xerostomia (impaired saliva tolerance)?

From the Guidelines

For this patient with right-sided facial swelling, maxillary sinus pressure, and tooth pain, the emergency department should perform a focused evaluation for possible odontogenic infection or sinusitis, and initial management should include a thorough oral and facial examination, vital signs assessment, and pain control with acetaminophen 650-1000mg or ibuprofen 400-600mg. The patient's symptoms of sinus pressure, tooth pain, and facial swelling are consistent with acute sinusitis, which is defined as up to 4 weeks of cloudy or colored drainage from the nose plus one or both of the following: a stuffy, congested, or blocked nose or pain, pressure or fullness in the face, head, or around the eyes 1. Given the patient's symptoms, it is essential to determine whether the sinusitis is caused by viruses or bacteria, as the treatment approach differs between the two 1. The patient's lack of difficulty swallowing, breathing, tolerating saliva, or pain suggests that the condition is not severe, but further evaluation is necessary to rule out complications. Imaging studies are not necessary for diagnosis in patients who already meet clinical diagnostic criteria for acute bacterial rhinosinusitis (ABRS), but may be obtained when a complication of ABRS or an alternative diagnosis is suspected 1. In this case, the patient's symptoms of facial swelling and maxillary sinus pressure may indicate a complication of ABRS, such as orbital, intracranial, or soft tissue involvement, and therefore, imaging studies such as a CT scan of the sinuses may be necessary 1. The patient should be instructed to follow up with a dentist or an ENT specialist within 1-2 days, maintain good oral hygiene, use warm salt water rinses, and return if symptoms worsen or if she develops fever, increased swelling, difficulty breathing or swallowing. Some key points to consider in the management of this patient include:

• The importance of determining the cause of the sinusitis, whether viral or bacterial, to guide treatment 1
• The need for imaging studies to rule out complications of ABRS or alternative diagnoses 1
• The importance of pain control and oral hygiene in the management of sinusitis and odontogenic infections
• The need for follow-up care with a specialist to ensure definitive management of the underlying condition.

From the Research

Patient Evaluation

• The patient presents with sinus pressure, tooth pain, and right-sided facial swelling with a hard spot in the maxillary sinus region.
• She denies any difficulty swallowing, breathing, tolerating saliva, or pain, but is concerned about the swelling of the gum above the right side of the teeth and the swelling in her maxillary sinus.

Diagnostic Approach

• Computed Tomography (CT) scans can be used to evaluate the location and extent of sinus disease, as well as detect anatomic abnormalities prior to surgery 2.
• A preoperative checklist can be developed to focus on the most salient and potentially dangerous areas of the paranasal sinuses, which may include the evaluation of coronal scans with 3 mm sections through the frontal and sphenoid sinuses and 2 mm sections through the ethmoid region 2.
• ENT specialists recommend that a maxillary sinus CT scan should be routinely prescribed before a sinus-lift surgery, especially in patients with symptoms such as nose complications or sinus issues 3.

Imaging Studies

• CT scans can be used to analyze and detect apical periodontitis and other odontogenic causes of maxillary sinusitis 4.
• Radiological imaging is an important tool for establishing the diagnosis of maxillary sinus pathology, and CT scans can be used to complement the diagnosis of odontogenic sinusitis 4.
• Conventional sinus radiography has a high specificity but low sensitivity, except for the maxillary sinus, where plain film examination was reasonably accurate 5.

Treatment Approach

• Odontogenic sinusitis is a unique cause of sinus disease that deserves special consideration, and treatment may involve a combination of antibiotic therapy, dental procedures, and endoscopic sinus surgery 6.
• An astute clinician can elicit historical findings such as recent dental work, and symptoms such as unilateral facial pain and foul drainage, despite a relatively benign oral cavity examination 6.