1. Sinusitis
By Emilie Watson

2. Sinuses
What are they for?

3. ….several theories Lightening the weight of the head
Humidifying and heating inhaled air
Increasing the resonance of speech
Serving as a crumple zone to protect vital structures in the event of facial trauma

4. Air filled spaces within the bone

5. What is sinusitis? Inflammation of the lining of the sinuses
Mucosal oedema, mucus retention (which may become infected. Polyps and septal deviation can lead to poor drainage.
Acute (Usually follows URTI but 10% due to tooth infection)
Chronic (often due to structural or drainage problems)
Can be – viral, bactierial, fungal, and have contributing factors such as trauma
Chronic - there are two or more of the following signs and symptoms lasting 12 weeks or more
 recurrent acute - there are four or more episodes of acute bacterial rhinosinusitis per year without signs or symptoms of sinusitis between episodes
Chemical agents
Medications
Surgical procedures
Allergic rhinitis (nasal allergy). The allergy may cause swelling of the tissues on the inside lining of the nose and block the sinus drainage channels. This makes the sinuses more susceptible to infection. See separate leaflets that discuss allergic rhinitis, called 'Hay Fever' and 'Rhinitis (Persistent)', for more details.
Other causes of a blockage to the sinus drainage channels, such as nasal polyps, objects pushed into the nose (especially in children, such as peas or plastic beads), facial injury or surgery and certain congenital abnormalities in children.
Asthma.
Cystic fibrosis.
A poor immune system - for example, people with HIV, people on chemotherapy, etc.
Inflammatory disorders such as Wegener's granulomatosis or sarcoidosis.
Pregnancy, which makes you more prone to rhinitis (nasal inflammation).
Rare tumours of the nose.
Previous injuries to the nose or cheeks.
Medical procedures such as ventilation or the insertion of a tube through the nose into the stomach (nasogastric tube).
Smoking
Diving / swimming infected water

6. Signs and Symptoms Major Factors
Thick colored post nasal drainage or discharge becoming yellowish to yellow-green
Congested nasal passages
Sneezing
Reduction or loss of sense of smell
Facial pain
Facial pressure or fullness
Fever - only with additional symptoms
Pus in the nose upon physical exam
Minor Factors
Fever
Fatigue
Halitosis
Hoarseness
Headache
Ear pain
Irritability
Dental pain
Persistent cough
Blocked feeling/clicking in ears

7. Investigations
Thorough examination – important to rule out any factors that may be causing the sinusitis
CT (usefull pre-surgergy)
MRI (useful differentiating fungal vs tumour)
XRAY – not much use
Allergy and immune testing
Nasal endoscopy
Sinus culture
Biopsy and wash out
Xray – 30% of normal sinsuses show mucosal thickening

8. DD Migraine, TMJ dysfunction Neuralgias Cervical spine disease
Temporal arteritis
Herpes Zoster
Dental pain

9. Treatments

10. ??? Antibiotics???

11. When should I prescribe an antibiotic for acute sinusitis?
Antibiotics are not required for most people presenting with acute sinusitis; instead the mainstay of treatment is symptomatic relief.
Admit if the person is suspected of having a serious localized or systemic illness that requires further assessment or administration of intravenous antibiotics (for example, if there is evidence of peri-orbital or intracranial complications).
Consider an immediate antibiotic prescription only if it is not appropriate to admit the person and they are:
Systemically unwell, or
At high risk of complications because of a pre-existing comorbidity.
Consider a delayed prescribing strategy for all other people, especially if symptoms are causing significant discomfort (such as marked pain or profuse, purulent discharge).
If an antibiotic is required, prescribe according to local protocols where available:
Amoxicillin is a good first-line choice. Prescribe the maximum oral dose (1 g three times a day) for 1 week.
Doxycycline (not in children less than 12 years of age) or a macrolide (erythromycin or clarithromycin for 1 week) are options if the person has a known allergy to penicillin (consider erythromycin for pregnant women).
Usually the person should be advised to use the antibiotic prescription only if their condition has deteriorated within 3 days or not improved after3 days. 

12. When to refer
immediate referral to an ENT for suspected complications (e.g. periorbital infection)
urgent referral to an ENT for suspected sinonasal tumour (persistent unilateral symptoms, such as bloodstained discharge, crusting, or facial swelling)
consider ENT referral for:
if there is recurrent or chronic sinusitis
progressive or unremitting facial pain
children with persistent sinusitis after two antibiotic courses
dental review
if the infection is suspected to be of dental origin, then refer patient for dental review. Initiate antibiotic treatment, with the addition of antibiotics to cover anaerobic bacteria (e.g. metronidazole)

13. Surgery – functional endoscopic sinus surgery, removing polyps
Side effects – muco or pyocoeles, orbital cellulitis/abscess, osteomyelitis

14. …. Can be serious Can cause Meningitis Encephalitis Cerebral abscess
Cavernous sinus thrombosis

15. Frontal sinusitis with pus draining from frontal sinus

16. Polyp causing chronic sinusitis

17. Chronic – atrophic changes