SINUSITIS   12A

A 25-year-old man presents to the urgent care clinic with 3 weeks of facial pain and pressure. He describes a right-sided fullness and tenderness over his cheek. He has also had yellow-green drainage from his nose along with subjective fevers, halitosis, and malaise. He felt as though he was getting better 1 week ago, but then his symptoms returned worse than ever. On physical examination, his right maxillary sinus is tender to palpation and percussion.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Unilateral facial pain, pressure, and fullness; purulent drainage; fevers and halitosis; partial resolution with subsequent worsening; maxillary sinus tenderness on examination

How to think through: Sinus pressure and nasal discharge, accompanied by headache, cough, or subjective fever, are a common constellation of findings in sinusitis. The majority of cases are caused by viral rhinosinusitis, are self-limited, and are treatable symptomatically. The two main tasks for the clinician are to determine the likelihood of bacterial sinusitis and to rule out serious complications. What are the elements of the clinical history associated with bacterial sinusitis? (Unilateral facial pain, purulent drainage, fevers, associated dental pain, partial resolution followed by worsening symptoms [“double worsening”] and duration of >7 days.) What organisms are commonly implicated in bacterial sinusitis? (Streptococcus pneumoniae, other streptococci, Haemophilus influenzae; possibly Staphylococcus aureus or Moraxella catarrhalis.) What are the “red flags” for a serious complications? (Eye involvement [proptosis, double vision], altered mental status, and facial erythema suggesting cellulitis. Immune compromise should heighten vigilance for such complications.) When should one consider sinus imaging or referral to an otolaryngologist for nasal endoscopy? (Patients who receive appropriate antibiotic treatment and have no improvement at 4 weeks.) What are first-line antibiotics for treatment or acute bacterial sinusitis? (Amoxicillin, trimethoprim–sulfamethoxazole [TMP-SMZ], doxycycline.) What other treatments can help? (Oral decongestant, intranasal decongestant [for ≤3 days], intranasal steroid spray, and intranasal saline wash.)

SINUSITIS   12B

What are the essentials of diagnosis and general considerations regarding sinusitis?

Essentials of Diagnosis

Purulent yellow-green nasal discharge or expectoration and nasal obstruction

Acute onset (1- to 4-week duration) of facial pain or pressure over the affected sinus or sinuses

Associated symptoms, including cough, malaise, fever, and headache

General Considerations

Common disease affecting nearly 20 million Americans annually

Usually is a result of impaired mucociliary clearance and obstruction of the osteomeatal complex, or sinus “pore”

Edematous mucosa causes obstruction of the complex, resulting in the accumulation of mucous secretion in the sinus cavity that becomes secondarily infected by bacteria

The typical pathogens are S. pneumoniae; other streptococci; H. influenza; and less commonly, S. aureus and M. catarrhalis

Discolored nasal discharge and poor response to decongestants suggest sinusitis

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