What are the features and treatment options for sinus infection?

Features and Treatment Options for Sinus Infection

Sinus infections (sinusitis) present with nasal congestion, purulent rhinorrhea, facial pain, post-nasal drainage, headache, and cough as the most prominent symptoms, with treatment primarily consisting of antibiotics for bacterial cases, along with adjunctive therapies to reduce inflammation and promote drainage.

Clinical Presentation

Acute Sinusitis

• Nasal congestion, purulent rhinorrhea, facial/dental pain, post-nasal drainage, headache, and cough are the prominent symptoms of acute sinusitis 1
• In adults, post-nasal purulent discharge and facial pain over the affected sinus that worsens with movement or percussion are cardinal symptoms, with fever occurring in less than 50% of cases 1
• Additional symptoms include hyposmia (reduced sense of smell), jaw pain with chewing, and nasal congestion 1
• Children most commonly present with cough (80%) and nasal discharge (75%), with malodorous breath noted in approximately 50% of preschoolers 1

Chronic Sinusitis

• Symptoms of chronic sinusitis are similar to acute but more subtle and persistent (lasting >3 months) 1
• Pain is less prominent in chronic sinusitis compared to acute cases 1
• Fatigue, general malaise, and an ill-defined feeling of unwellness are often more prominent than local symptoms in chronic cases 1
• Fever is uncommon in chronic sinusitis 1

Physical Examination Findings

• Clinical signs include sinus tenderness on palpation, mucosal erythema, purulent nasal secretions, increased pharyngeal secretions, and periorbital edema 1
• Anterior rhinoscopy may reveal hyperemic and edematous nasal turbinates with purulent discharge from the middle meatus 1

Diagnostic Evaluation

• Computed tomography (CT) is the imaging technique of choice as it can demonstrate abnormalities in both the ostiomeatal complex and sinus cavities 1
• Laboratory evaluation may include nasal cytology, nasal-sinus biopsy, or tests for immunodeficiency, cystic fibrosis, or ciliary dysfunction 1
• Sinus secretions can be obtained for culture in adults via aspiration of the maxillary sinus or endoscopically directed catheter placement at the middle meatus 1
• In children, sinus secretions should be obtained by aspiration only 1

Microbiology

Acute Sinusitis

• Streptococcus pneumoniae and Haemophilus influenzae are responsible for >50% of acute sinusitis cases in adults 1
• In children, Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis account for two-thirds of cases 1, 2
• There has been an increasing prevalence of penicillin-resistant S. pneumoniae and beta-lactamase-producing H. influenzae and M. catarrhalis 2

Chronic Sinusitis

• Chronic sinusitis typically involves polymicrobial infections with anaerobes (Bacteroides, Peptostreptococcus, Fusobacterium, and Veillonella) as predominant isolates 1
• Staphylococcus aureus, Pseudomonas aeruginosa, and certain anaerobes are commonly found in chronic sinusitis 1, 3
• Fungi are increasingly recognized as factors in chronic sinusitis, particularly in the southeast and southwest United States 1

Predisposing Factors

• Viral upper respiratory tract infections are the most common predisposing factor 1
• Allergic rhinitis can lead to inflammation of sinus mucosa and obstruction of sinus openings 4
• Non-allergic rhinitis was found in 26% of patients with chronic sinusitis 1
• Gastroesophageal reflux disease (GERD) has been suggested as a cause of sinusitis 1
• Conditions affecting sinus ostia patency, normal mucociliary function, or immune defenses predispose to sinus infection 1
• Dental extraction or periapical infections of maxillary molar teeth are important causes of maxillary and chronic sinusitis 1

Treatment Options

Antibiotic Therapy

• Antibiotics are the primary therapy for acute bacterial sinusitis, with a 10-14 day course generally adequate for acute disease 1
• Amoxicillin or amoxicillin-clavulanate is recommended as initial therapy 5, 2
• If no improvement occurs in 3-5 days, an alternative antibiotic should be considered 1, 5
• For penicillin-allergic patients, alternatives include cefuroxime, cefpodoxime, or cefdinir 5, 2
• In cases of serious drug allergy, clarithromycin or azithromycin may be prescribed 2
• Levofloxacin is FDA-approved for acute bacterial sinusitis using either 750 mg for 5 days or 500 mg for 10-14 days 6
• The role of antibiotics in chronic sinusitis is more controversial, though longer duration therapy may be required with possible attention to anaerobic pathogens 1

Adjunctive Therapy

• Intranasal corticosteroids as an adjunct to antibiotic therapy may be helpful in treating recurrent acute and chronic sinusitis 1, 5
• Other adjunctive therapies providing symptomatic benefit include antihistamines, decongestants, saline irrigation, mucolytics, and expectorants 1, 5
• Fluids, expectorants, and both oral and topical decongestants should be used to encourage drainage 4
• Comfort measures such as hydration, analgesics, warm facial compresses, steam inhalation, and sleeping with the head elevated are recommended 5

Surgical Management

• Medically resistant sinusitis may respond to appropriate nasal-sinus surgery 1
• Functional endoscopic sinus surgery may result in significant improvement in cases of localized persistent disease within the ostiomeatal complex 1
• The aim of surgery is to improve ventilation and facilitate drainage of the sinuses 7

Special Considerations

When to Refer to a Specialist

• When there is a need to clarify the allergic or immunologic basis for sinusitis 1
• When sinusitis is refractory to usual antibiotic treatment or is recurrent 1, 5
• When sinusitis is associated with unusual opportunistic infections 1
• When sinusitis significantly affects performance and quality of life 1
• When concomitant conditions are present that complicate assessment or treatment 1

Complications

• Potential complications include intraorbital and intracranial sepsis, which may be life-threatening 1
• Intracranial suppurative complications may include epidural or subdural empyema, brain abscess, or cavernous sinus thrombosis 1
• Diseases associated with sinusitis include otitis media and bronchial asthma 1

Caution Against Overtreatment

• Concern has been raised about the overdiagnosis of sinusitis and unnecessary treatment with antibiotics 1
• Appropriate criteria for antibiotic use include symptoms of sinusitis for 10-14 days or severe symptoms of acute sinus infection (fever with purulent nasal discharge, facial pain/tenderness, periorbital swelling) 1