Following a viral infection, the patient will usually complain of a dull pain
in the face, gradually increasing over a couple of days, exacerbated by sudden
motion of the head, or holding the head dependent, between the knees, and
perhaps radiating to the upper molar teeth (via the maxillary antrum), or with
eye movement (via the ethmoid sinuses). Often there is a sensation of facial
congestion and stuffiness. Children with sinusitis often present with cough
and fetid breath. Fever is only present in half of patients with acute
infection and is usually low grade. A high fever usually indicates a serious
complication such as meningitis or another diagnosis altogether.
Transillumination of sinuses in the ED is usually unrewarding, but you may
elicit tenderness on gentle percussion or firm palpation over the maxillary or
frontal sinuses or between the eyes (ethmoid sinuses). Swelling and erythema
may exist and you may even see pus draining below the nasal turbinates, with a
purulent, yellow-green and sometimes foul-smelling or bloody discharge from
the nose or running down the posterior pharynx. The patient's voice may have a
resonance similar to that of a "stopped up" nose, and he may complain of a
foul taste in his mouth. Stuffy ears and impaired hearing are common because
of associated serous otitis media and eustachian tube dysfunction.
What to do:
* Rule out other causes of facial pain or headache via history (did the
patient wake up with a typical migraine?) and physical examination (palpate
scalp muscles, temporal arteries, temperomandibular joints, eyes, and
* Shrink swollen nasal mucosa (and thereby open the ostia draining the
sinuses) with 1% phenylephrine (Neo-Synephrine) or 0.05% oxymetazoline
(Afrin) nose drops. Drip 2 drops in each nostril, have the patient lie
supine 2 minutes, and then repeat the process (this allows the first
application to open the anterior nose so the second gets farther back).
Have the patient repeat this process every 4 hours, but for no more than
three days (to avoid rhinitis medicamentosa).
* Examine the nose for purulent drainage before and after shrinking the
nasal mucosa with topical vasoconstrictor.
* Add systemic sympathomimetic decongestants (e.g., pseudephedrine (Sudafed)
60mg q6h or phenylpropanolamine (Entex LA) 75mg q12h).
* If there is fever, pus, heat, or any other sign of a bacterial
superinfection, add antibiotics (e.g., amoxicillin, trimethoprim plus
sulfamethoxazole, amoxicillin plus clavulinate, erythromycin plus
sulfasoxazole, cefuroxime). First-line antibiotic therapy is amoxicillin,
or, for patients with penicillin allergy, Bactrim or Sulfa. If the patient
has been recently treated with these medications or if the infection
appears to be serious, then treat with a second-line drug like Ceftin or
* Provide pain relief, when necessary (e.g., ibuprofen, naproxyn,
acetaminophen, oxycodone, hydrocodone)
* Recommend symptomatic relief with hot water vapor inhalation using a
simple teakettle or hot shower or, if available, a steam vaporizer or home
facial sauna device.
* Sinusitis can sometimes be demonstrated on x rays, and you can usually get
adequate visualization of maxillary, frontal, and ethmoid sinuses with one
upright Water's view. Chronic sinusitis appears as thickened mucosa; acute
as an air-fluid level or complete opacification. Films are usually not
necessary, however, on an emergency basis. If symptoms and physical
findings of sinusitis are classic, plain sinus radiographs need not be
obtained before treatment. If an acute attack does not resolve with medical
treatment, or the diagnosis of sinusitis is in doubt, plain films are
helpful as the primary imaging study.
* Arrange for followup within 1-7 days.
What not to do
* Do not ignore signs of an orbital cellulitis with swelling erythema,
decreased extraocular movements and possible proptosis. These patients
require consultation and admission for intravenous antibiotics.
* Do not ignore the toxic patient with marked swelling, high fever, severe
pain, profuse drainage, or other signs and symptoms of a serious infection.
See potential complications below. These patients require immediate
consultation and intervention.
* Do not prescribe antihistamines, which can make mucous secretions dry and
thick, and interfere with necessary drainage. Antihistamines only cure
sinusitis on television, or when it is due to allergic rhinitis.
* Do not allow patients to use decongestant nose drops more than 3 days,
thereby allowing their nasal mucosa to become habituated to sympathomimetic
medication. When they stop the drops they will suffer a rebound nasal
congestion (rhinitis medicamentosa) which requires time, topical steroids,
and reeducation to resolve.
* Do not prescribe topical or systemic sympathomimetic decongestants to a
patient who suffers from hypertension, tachycardia or difficulty initiating
urination, all of which may be exacerbated.
The paranasal sinuses drain through tiny ostia under the nasal turbinates
which, if occluded, allow secretions and pressure differences to build up,
resulting in pressure and pain of acute sinusitis, and the air-fluid levels
sometimes visible on upright x rays. Sinus infections are relatively common
and complications relatively rare, but the bony walls of the paranasal sinuses
are so thin that bacterial infections can spread through them. Most sinusitis
begins with mucosal swelling from a viral upper respiratory infection. Other
causes include dental infection, allergic rhinitis, barotrauma from flying,
swimming or diving, nasal polyps and tumors and foreign bodies, including
nasogastric and endotracheal tubes in hospitalized patients. Abscessed teeth
can be the source of a maxillary sinusitis. If there is tenderness to
percussion of the bicuspids or molars, arrange for dental referral.
Complications such as orbital cellulitis, osteomyelitis, epidural abscell,
meningitis, cavernous sinus thrombosis and subdural empyema can be devastating
and therefore patients must be instructed to get early follow up when signs
and symptoms worsen or do not improve in 48-72 hours, or if there is any
change in mentation. Frontal sinusitis has the greatest potential for serious
complications, particularly in adolescent males, the group at greatest risk
for intracranial complications.br Computerized tomographic scanning of the
sinuses is more accurate than plain x rays, particularly when evaluating the
ethmoid or sphenoid sinuses, but CT scans are needed from the ED only in
unusual circumstances. Most patients can have initial treatment begun on the
basis of history and physical findings alone. Anyone who has facial pain,
headache, purulent nasal discharge and nasal congestion persisting for more
than ten days, with or without a fever, should probably be treated empirically
Many patients have been conditioned by the advertising of over-the-counter
antihistamines for "sinus" problems (usually meaning "allergic rhinitis"), and
may relate a history of "sinuses" which, on closer questioning, turns out to
have been rhinitis.
* Williams JW, Simel DL: Does this patient have sinusitis? Diagnosing acute
sinusitis by history and physical examination. J Am Med Assoc 1993;
from Buttaravoli & Stair: COMMON SIMPLE EMERGENCIES ©
Longwood Information LLC 4822 Quebec St NW Washington DC 20016-3229
1.202.237.0971 fax 184.108.40.20693 firstname.lastname@example.org