Acute sinusitis: diagnosis and treatment update.

Acute sinusitis in adults is manifested by fever, facial pain and purulent rhinorrhea, but children--who rarely have headache or facial tenderness--have persistent cough in addition to fever and purulent rhinorrhea. Sinus transillumination is diagnostically useful only in adults. In children, maxillary sinus radiographs are indicated. New studies show ultrasound examination to be less sensitive than plain radiographs. Cultures obtained by aspiration of the maxillary sinuses are useful in complicated cases. Amoxicillin is still effective as first-line treatment, but treatment failure requires a prompt change to trimethoprim-sulfamethoxazole or ciprofloxacin. Nosocomial sinusitis requires coverage for gram-negative bacteria, including Pseudomonas aeruginosa. Immunocompromised patients, including those with acquired immunodeficiency syndrome, require treatment for fungal organisms. Decongestants are of unproven value. Referral for irrigation and surgical drainage is indicated for recurrent or recalcitrant sinusitis. Flexible endoscopy allows visualization and debridement of diseased tissue in cases of chronic sinusitis.     

Acute sinusitis. When--and when not--to prescribe antibiotics

Clinical diagnosis of acute sinusitis is troublesome because it involves use of a cluster of diagnostic criteria that have only moderate sensitivity. Ancillary testing with radiography or antral puncture is impractical, expensive, and usually unnecessary in the primary care setting. Antibiotic therapy is not beneficial for most patients in whom acute sinusitis is suspected, even when radiographic abnormalities are found. Simple management algorithms and patient information are now available to aid primary care physicians in offering appropriate therapeutic measures and reassuring patients who are expecting "'a pill for every ill' when that pill is an antibacterial."     

Acute sphenoid sinusitis induced blindness: a case report

Background

Acute, isolated sphenoid sinusitis is a rare but potentially devastating clinical entity. Missing this diagnosis can lead to permanent vision loss due to injury of the optic nerve. Patients may present with preseptal inflammation, lid edema, chemosis, or ophthalmoplegia.

Objective

We report a case of acute sphenoid sinusitis in a 10-year-old child who presented to the Emergency Department with essentially painless vision loss.

Case Report

Previously healthy, the patient reported progressive decrease in vision in her right eye for the 5 days prior. Other than blurred vision in the right eye, she complained of a mild frontal headache and right eye irritation the past week, which had abated. On examination, she was reading a book with her head tilted to one side. She had no photophobia, or facial or eyelid swelling. Her pupils were 5 mm bilaterally, but the right was non-reactive to light. She was unable to see two fingers 6 inches in front of her face (right eye), whereas her visual acuity on the left was 20/25. She had bilateral elevated intraocular pressures and a Marcus Gunn pupil on the right. Ophthalmology was consulted and the diagnosis of acute sphenoid sinusitis causing compression and vascular compromise to the optic nerve was diagnosed ultimately by magnetic resonance imaging. The patient was transferred to the nearest pediatric specialty hospital, where an emergent endoscopic sphenoidotomy was performed. The patient’s vision subsequently returned.

Conclusion

Sphenoid sinusitis should be considered in patients presenting with acute vision loss. Awareness, early diagnosis, and intervention help prevent permanent complications.     

Acute paranasal sinusitis related to nasotracheal intubation of head-injured patients

One hundred eleven head-injured patients were examined for paranasal sinusitis during early convalescence. Glascow coma scale (GCS) was less than 8 in 79 patients. Ninety-three patients had sustained blunt injuries, and 18 had penetrating ones. Sixty-five orotracheal intubations (OTI) and 31 nasotracheal intubations (NTI) were performed at the scene or on hospital arrival. Fifteen patients were not tracheally intubated. Paranasal sinus air fluid levels (AFL) were present in 30 patients on their admitting computerized tomography scans. Paranasal sinusitis developed in 19 patients with a mean GCS of 5.4 +/- 3.3 (SD). Sixteen of the 19 had NTI, and three had OTI (p less than .05). Of 30 patients with AFL, sinusitis occurred in 13. Ten of these 13 had NTI, and three had OTI (p less than .05). Penetrating injury did not increase the risk of sinusitis (p greater than .1). Seventeen of the 19 infections were polymicrobial. Sinusitis after head trauma is related to NTI, AFL, and severity of head injury.     

Acute bacterial maxillary sinusitis: time to symptom resolution and return to normal activities with moxifloxacin

Objectives: This prospective, single‐arm, open‐label, multicentre phase IV (postmarketing surveillance) study determined time to resolution of key symptoms and return to normal activities in adults with acute bacterial maxillary sinusitis treated with moxifloxacin 400 mg qd for 10 days. The study also assessed whether responses to the Sino‐Nasal Outcome Test‐16 (SNOT‐16) questionnaire [not yet validated for acute bacterial sinusitis (ABS)] accurately reflect clinical findings in these patients. Methods: Adults with a clinical diagnosis of acute bacterial maxillary sinusitis with signs/symptoms present for ≥ 7 but < 28 days took part. Patients were evaluated bacteriologically and clinically on day 1 (pretherapy), days 2–4 and 10–13 (test of cure), for bacterial presence and improvement/resolution of the signs/symptoms of acute bacterial maxillary sinusitis. They completed SNOT‐16 and Activity Impairment Assessment questionnaires daily, before receiving moxifloxacin, until day 10. Results: In both the bacteriologically and clinically evaluable populations, over 85% of patients showed clinical improvement by day 2, rising to over 96% by day 4. Pretherapy, according to the SNOT‐16 questionnaire, almost all of the bacteriologically evaluable patients reported facial pain/pressure but this proportion had fallen to below 50% by day 4. In the bacteriologically evaluable population, 32/42 (76%) patients reported an improvement in facial pain/pressure from the pretherapy visit to day 4. Of patients showing improvement, 50% improved from ‘moderate‐to‐severe facial pain’ at pretherapy to ‘no problem’ at day 4. At day 4, 45–50% of patients reported impairment of normal activities, compared with 79–88% pretherapy. Conclusions: Moxifloxacin rapidly improves the signs and symptoms of acute bacterial maxillary sinusitis and results in clinical cure in most patients. Responses to the SNOT‐16 questionnaire accurately reflected clinical assessments, indicating that when fully validated the SNOT‐16 questionnaire may be a valuable tool for the assessment of patient outcomes in ABS.     

Childhood sinusitis.

Childhood sinusitis is difficult to diagnose. It is classified on the basis of duration of inflammation--acute or chronic--and cause of inflammation--infectious or noninfectious. Infectious sinusitis is often a result of obstruction of the osteomeatal complex. Inflammation in noninfectious sinusitis is similar to the inflammatory changes detected in respiratory mucosa of patients with asthma. Acute sinusitis is primarily an infectious process similar to a prolonged infection of the upper respiratory tract. Plain radiography has limited value for the diagnosis of acute sinusitis in children. The most effective treatment of acute sinusitis is administration of a beta-lactamase-resistant antibiotic. Chronic sinusitis may be infectious, noninfectious, or both. Coronal computed tomography of the sinuses and nasal endoscopy are the preferred methods for determining the presence of chronic sinusitis. When physicians prescribe therapy for chronic sinusitis, they need to consider whether the underlying cause is infectious, noninfectious, or both. Treatment of chronic infectious sinusitis is most effective when a beta-lactamase-resistant antibiotic is administered. Chronic noninfectious sinusitis may respond to topically intranasally applied corticosteroids. If medical treatment fails to resolve the disease within 3 months, surgical intervention may be necessary. Finally, although an association between asthma and sinusitis exists, a cause-and-effect relationship has not been established.     

Managing sinusitis in children

Because of the prevalence of upper respiratory tract infections (URIs), sinusitis is a condition commonly encountered in the pediatric population. Some 5% to 10% of children with URIs also have sinusitis. A thorough clinical evaluation enables the health care provider to accurately diagnose sinusitis in children without overuse of computed tomography scans or antibiotics. This article discusses the diagnosis and treatment of acute sinusitis in children.