Sinusitis (Rhinosinusitis)
Sinusitis, also known as rhinosinusitis, is a symptomatic inflammation of the mucosal lining of the paranasal sinuses and nasal cavity. Acute sinusitis is usually infectious and most often viral, while chronic sinusitis is usually inflammatory and lasts for 12 weeks or longer.
This updated UKMLA guide to acute and chronic sinusitis is based on NICE NG79 and NICE CKS, which covers causes, symptoms, complications, diagnosis, and management.
Classification
- Acute sinusitis: symptoms that completely resolve within 12 weeks
- Chronic sinusitis: symptoms lasting 12 weeks or longer
Causes and Risk Factors
Acute sinusitis is usually infectious, while chronic sinusitis is mainly inflammatory.
Acute Sinusitis
Acute sinusitis is mainly caused by an infection:
- Most commonly caused by a viral upper respiratory tract infection
- In some cases, acute viral sinusitis may progress to a secondary bacterial infection
Common organisms:
- Viral: rhinovirus, RSV, influenza, parainfluenza
- Bacterial: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis
Risk factors include:
- Impaired mucociliary clearance (e.g. smoking, cystic fibrosis, Kartagener syndrome)
- Allergic rhinitis
- Dental infection (can spread to the maxillary sinus)
- Anatomical obstruction (e.g. septal deviation, nasal polyps)
- Immunosuppression
Chronic Sinusitis
Chronic sinusitis is primarily an inflammatory condition, rather than an acute infection.
Risk factors include:
- Impaired mucociliary clearance (e.g. smoking, cystic fibrosis, Kartagener syndrome)
- Allergic rhinitis
- Asthma and COPD
- Immunocompromise
- Occupational exposure (e.g. firefighters, farmers, fishermen)
- Anatomical obstruction (e.g. septal deviation, nasal polyps)
Clinical Features
Acute Sinusitis
A preceding upper respiratory tract infection is common
| Symptoms | Signs |
|---|---|
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The following features are suggestive of acute bacterial sinusitis:
- Symptoms persist for ≥10 days
- Discoloured or purulent nasal discharge
- Severe localised pain (often unilateral, esp. pain over teeth and jaw)
- Fever > 38°C
- Marked deterioration after an initial milder phase (double sickening)
Chronic Sinusitis
Clinical features are similar to acute sinusitis, but are persistent (>12 weeks) and often less severe.
Core features include:
- Persistent nasal obstruction / congestion / discharge
- Nasal polyps
- Hyposmia / anosmia
Complications
Possible complications of acute sinusitis (rare):
- Orbital infections – preseptal (periorbital) cellulitis, orbital cellulitis, orbital abscess
- Intracranial infections – brain abscess, epidural abscess
- Osteomyelitis and Pott’s puffy tumour
Chronic sinusitis mainly causes a negative impact on the quality of life (e.g. sleep problems, fatigue, impact on employment, reduction in social functioning, high healthcare costs)
Diagnosis
Acute Sinusitis
Acute sinusitis is primarily a clinical diagnosis.
Do NOT routinely perform laboratory tests and imaging for those who meet the diagnostic criteria for acute uncomplicated sinusitis.
Acute sinusitis can be diagnosed if there is sinonasal inflammation lasting less than 12 weeks and associated with the sudden onset of at least 2 diagnostic symptoms:
| Adults |
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| Children |
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Chronic Sinusitis
Chronic sinusitis is a clinical diagnosis in primary care. However, imaging can be used in secondary care (see the objective evidence section of the diagnostic criteria).
Chronic sinusitis can be diagnosed if there is sinonasal inflammation lasting 12 weeks or longer with at least 2 diagnostic symptoms and at least 1 objective evidence of sinonasal inflammation:
| Diagnostic symptoms (in adults) |
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| Diagnostic symptoms (in children) |
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| Objective evidence of sinonasal inflammation |
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Management
Acute Sinusitis
Approach:
- Step 1: conservative management
- Only step up if there is no improvement after ≥10 days or symptoms worsen after 5 days
Step 1: Conservative Management
Do not offer antibiotics to manage patients presenting with <10 days of acute sinusitis.
| Patient education | Advise patient that:
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| Symptomatic relief |
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Step 2: Further Management
In addition to patient education and symptomatic relief strategies, consider:
- Intranasal corticosteroids (e.g. mometasone) for 14 days
- Antibiotic therapy for 5 days
Information on antibiotic therapy
Take the following into account when deciding whether to give antibiotics or not:
- If acute bacterial sinusitis is more likely → backup antibiotic prescription may be preferred
- For back-up prescription: advise the patient to take the antibiotics if symptoms do NOT improve within 7 days or worsen rapidly at any time
- Factors not supporting an antibiotic prescription
- Antibiotics make little difference to how long symptoms last or the proportion of people with improved symptoms
- Withholding antibiotics is unlikely to lead to complications
- Antibiotics can lead to adverse effects, including diarrhoea and nausea
Choice of antibiotics:
- 1st line: phenoxymethylpenicillin (penicillin V)
- 2nd line (penicillin alternative): doxycycline / clarithromycin / erythromycin (if pregnant)
- If systemically unwell / features of more serious illness / high risk of complications: co-amoxiclav
There is no evidence for using oral decongestants, antihistamines, mucolytics, steam inhalation, or warm face packs
Chronic Sinusitis
Advice on lifestyle changes:
- Stop smoking and avoid passive smoking
- Avoid allergic triggers
- Practise good dental hygiene to reduce risk of dental infection (which can be associated with bacterial sinusitis)
- Avoid underwater diving if there are prominent symptoms
If the patient has concurrent allergic rhinitis or asthma, good control of these conditions are likely to be beneficial
Consider symptomatic treatment (primary care):
- Nasal irrigation with saline solution
- In adults, a course of intranasal corticosteroid (e.g. mometasone, fluticasone) – especially if there is a suspected allergic cause (e.g. concurrent allergic rhinitis)
- Consider adding an intranasal decongestant to a corticosteroid temporarily if there is severe nasal congestion
Secondary care treatment options include:
- Oral corticosteroids
- Long-term antibiotics
- Intranasal corticosteroid in children