Development of the paranasal sinuses
- Ethmoid are present at birth and developed at 3 years of age
- Maxillary are present at birth and developed by 3 years of age
- Sphenoid are present at 3 years of age and developed by 12 year of age
- Frontal are present at 8 years of age and developed by 12 years of age
Normal physiology of the paranasal sinuses dependent on
- Patency of the ostia
- Normal functioning of the cilia
- Normal viscosity of the secretions
Pathogenesis of sinus infection
- Ostial obstruction leads to negative pressure in the sinus and when obstruction is released, bacteria enter the sinus cavity. Sneezing and blowing of the nose may also allow bacteria to enter the sinuses. Obstruction most often associated with URI and allergies.
- Decreased number of cilia, dysfunction, and changes in morphology may allow for entry of bacteria into the sinuses
- Thickened secretions may affect cilia function and also lead to obstruction. This occurs in asthma and CF
Presentation of Acute Sinusitis
- Prolonged URI symptoms without clinical improvement. Sinusitis may complicate 0.5% to 10% of URIs
- The nasal discharge may be clear, mucousy, or purulent.
- Cough is present in the daytime although worse at night.
- Headache and facial pain are uncommon.
- Periorbital swelling (greatest earlier in the day) and low grade fever
Physical findings (may differ from URI)
- Erythema of nasal mucosa
- Red pharynx
- Otitis media
- Swelling of the eyelids that aren't tender
- Tenderness over the paranasal sinuses
- Bad breath
- Differential Diagnosis- mucopurulent rhinitis, allergic rhinitis, foreign body, pharyngitis, adenoiditis
- Transillumination-difficult to perform
- Presence of opacification, air fluid levels, and mucosal thickening on a plain radiograph are non-specific findings but may help in making the diagnosis
- CT- During a common URI, CT will demonstrate fluid in the sinus cavities. Most useful in complicated or chronic cases and able to find intracranial and intraorbitial abnormalities. Also useful when the patient isn't improving or the host is immunocompromised.
- "10 day rule". Most URIs are better in 10 days. Therefore entertaining the diagnosis of sinusitis before 10 days may be premature.
Common Bacterial Etiologies
- Streptococcus pneumoniae-30%
- Non-typable H. Flu-20%
- Moraxella catarrhalis-20%
- Streptococcus pyogenes-4%
- Antibiotics- treatf or 7 days after the patient is symptom-free. Antibioic choice dependent on severity of symptoms and whether the patient was recently on antibiotics.
- Amoxicillin- should be the initial drug of choice
- Cefaclor ,Cefuroxime and other second and third generation Cephalosporins
- Clindamycin- good for anaerobes and penicillin resistant pneumocoocal infections
- Antihistamines and decongestants not proven to be effective
- Topical anti-inflammatory drugs may also help
- Periorbital and orbital cellulitis
- Orbital abscess
- Optic neuritis
- Intracranial complications- meningitis and abscess
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