What are the signs and symptoms of sinusitis and what history and physical examinations should be performed?

Clinical Approach to Sinusitis: Signs, Symptoms, and Examination

Key Diagnostic Criterion

Suspect acute bacterial sinusitis when upper respiratory symptoms persist beyond 10-14 days without improvement, or when symptoms worsen within 10 days after initial improvement (double worsening). 1

Cardinal Signs and Symptoms

Primary Symptoms in Adults

The most prominent features include:

• Nasal congestion 1
• Purulent rhinorrhea (thick, colored nasal discharge) 1
• Postnasal drainage 1
• Facial or dental pain 1
• Headache 1
• Cough (frequently worse at night) 1

The combination of persistent purulent rhinorrhea and facial pain has the strongest correlation with bacterial sinusitis. 1

Primary Symptoms in Children

Children present similarly but with additional features:

• Increased irritability 1
• Vomiting associated with gagging on mucus 1
• Prolonged cough 1
• Purulent rhinorrhea and nasal congestion 2

Secondary Symptoms (All Ages)

Less frequent but important symptoms include:

• Fever 1
• Nausea and malaise 1
• Fatigue 1
• Halitosis (bad breath) 1
• Hyposmia (decreased sense of smell) 1
• Sore throat 1

Essential History Taking

Duration and Pattern Assessment

• Document symptom duration precisely: Acute sinusitis is defined as symptoms lasting less than 4 weeks 1
• Identify the pattern: Determine if this represents persistent URI symptoms beyond 10-14 days or a "double worsening" pattern 1
• Assess for recurrence: Three or more episodes per year defines recurrent sinusitis 1

Predisposing Risk Factors to Identify

Query specifically about:

• Allergic rhinitis (most common predisposing factor) 1
• Environmental exposures and allergen triggers 1
• Asthma (sinusitis can trigger or worsen bronchial hyperresponsiveness) 1
• Nasal polyps 1
• Previous sinus surgery 1
• Aspirin sensitivity (especially with nasal polyps) 1
• Immunodeficiency conditions 1
• Cystic fibrosis (particularly in children with nasal polyps) 1
• Ciliary dyskinesia 1
• Cocaine abuse 1
• Diabetes or immunosuppression (risk for invasive fungal sinusitis) 1

Symptom Severity and Red Flags

Immediately identify any complications requiring urgent evaluation:

• Orbital swelling or pain 1
• Visual changes or diplopia 1
• Abnormal extraocular movements 1
• Proptosis 1
• Swelling of the forehead 1
• Periorbital inflammation, edema, or erythema 1
• Mental status changes or neurologic signs 1

Physical Examination Components

General Inspection

• Assess for sinus tenderness: Palpate over the maxillary and frontal sinuses 1
• Look for periorbital signs: Dark circles beneath the eyes (allergic shiners) and periorbital edema suggest sinusitis 1
• Distinguish from allergic facies: Allergic rhinitis shows dark infraorbital swollen semicircles, transverse nasal crease, or Morgan-Dennie lines 1

Nasal Examination

Examine the nasal mucosa and secretions carefully:

• Red, swollen nasal tissue indicates infectious rhinitis/sinusitis 1
• Pale, boggy turbinates suggest allergic rhinitis rather than infection 1
• Purulent secretions (yellow-green, green, or gray) in the middle meatus are highly predictive of bacterial sinusitis 1
• Mucosal erythema is a key finding 1

Consider nasal endoscopy (rigid or fiberoptic) for superior visualization:

• Provides significantly better view than nasal speculum 1
• Allows direct visualization of purulent ostial secretions 1
• Identifies nasal polyps and their extent (use topical decongestants first for better visualization) 1
• Evaluates septal deviation, turbinate abnormalities, and anatomic variants 1

Important caveat: Absence of visible purulent secretions does not exclude sinusitis, as secretions may not be visible without decongestion 1

Posterior Pharynx Examination

Look for:

• Pharyngeal erythema 1
• Lymphoid hyperplasia 1
• Purulent material in the posterior pharynx 1
• Increased pharyngeal secretions 1

Ear Examination

• Check for middle ear effusions: Frequently present with acute sinusitis due to eustachian tube dysfunction 1

Chest Examination

Perform chest auscultation in patients with cough:

• Sinusitis can initiate or worsen asthma 1
• Consider office spirometry for objective assessment of airflow obstruction 1

Complication Assessment

Systematically evaluate for complications:

• Facial swelling or erythema over involved sinus 1
• Visual changes 1
• Abnormal extraocular movements 1
• Proptosis 1
• Periorbital inflammation, edema, or erythema 1
• Neurologic signs suggesting intracranial involvement 1

Imaging Considerations

Plain radiographs are NOT recommended for routine diagnosis:

• Significant false-positive and false-negative results 1
• Not necessary when clinical diagnosis is clear 1

Reserve imaging for specific situations:

• Diagnosis is uncertain 1
• Need to assess degree of mucosal involvement to guide aggressive therapy 1
• Suspected complications 1
• Chronic or recurrent sinusitis requiring further evaluation 3

Common Pitfalls to Avoid

• Don't diagnose sinusitis before 10 days: Most viral URIs resolve within 5-7 days; bacterial sinusitis is suspected when symptoms persist beyond 10-14 days 1
• Don't rely solely on colored nasal discharge: While purulent rhinorrhea is common, it can occur with viral infections; the key is persistence beyond 10 days 1
• Don't miss nasal polyps in children: Their presence should prompt evaluation for cystic fibrosis 1
• Don't overlook underlying allergic rhinitis: It's the most common predisposing factor and requires concurrent management 1, 4
• Don't forget to assess for complications: Always examine for orbital and intracranial involvement, especially with severe symptoms 1