Acute Rhinosinusitis

Red flags

  • Periorbital swelling/erythema in a patient with acute rhinosinusitis (ARS) – see Periorbital cellulitis.
  • Altered conscious level, seizures or other neurology may indicate an intracranial complication of ARS.
  • Severe sepsis in a patient with acute rhinosinusitis, particularly if immunosuppressed, may indicate invasive or fungal disease (rare).

 

Why is this important?

  • Acute rhinosinusitis (ARS) is a very common condition in general practice, although it presents only rarely to secondary care.
  • It presents a significant economic and quality-of-life burden, and is commonly over-treated – see EPOS 2012 (reference below).
  • Rare complications of ARS can be life- or sight-threatening.

 

When to involve the ENT registrar

  • In any patient suspected to have a complication of acute rhinosinusitis.
  • Any patient with severe sepsis who is not responding to treatment, particularly if immunosuppressed.

 

Who to admit

Admit patients who have red flags symptoms/signs. People with uncomplicated ARS can be managed as outpatients. 

 

Assessment & recognition

The key features of acute rhinosinusitis are:

  • Nasal blockage
  • Rhinorrhoea (nasal discharge)

In association with: 

  • Hyposmia (reduced sense of smell)
  • Facial or dental pressure/pain 

The above four symptoms are the most predictive of ARS, although patients do not necessarily present with all four. Patients may also have systemic malaise, fever, cough or sore throat.

ARS is an acute inflammatory condition that typically evolves following a viral upper respiratory tract infection; the patient reports an increase in the symptoms following the initial viral illness – this phenomenon is known as “double-sickening”.

On examination there may be purulent material in the nasal cavity (particularly in the middle meatus). Tenderness over the sinuses occurs, but is not a specific or reliable sign, and there is not usually any swelling.

In general, sinusitis does not cause swellings below the zygoma. Therefore beware tender swellings of the cheek or jaw, as this is a common presentation of dental abscess or salivary gland infection.  

 

EXAMINATION & INVESTIGATIONS

Examining the patient with a head-light or endoscope can be helpful to confirm the diagnosis (this is less applicable to primary care).

Microbiological testing is of questionable value in uncomplicated cases, but may be necessary in systemically unwell patients or resistant cases.

Imaging is not required in the vast majority of cases. Plain sinus X-rays are of no value and should not be requested. In complex cases, or where a complication of ARS is suspected, a CT of the sinuses and brain (with contrast) should be performed.

 

Immediate and overnight management

The mainstay of management in otherwise well patients is symptomatic care: simple analgesia such as paracetamol and ibuprofen, with a short five-day course of nasal decongestant if desired (this improves symptoms but does not alter the clinical course).

Antibiotics are greatly over-prescribed in ARS. The tendency of ARS is to remit spontaneously; a large body of high-quality evidence has shown that antibiotics have minimal effect on the course of the condition. The use of antibiotics introduces a significant risk of side-effects which largely outweighs their benefit.

Antibiotics should not be prescribed in the majority of cases of ARS. They should be reserved for patients with persistent infective symptoms beyond 10 days or signs of sepsis. They can also be prescribed for those with co-morbidities such as post-transplant immune suppression. Penicillin V 500mg qds for 5 days has been suggested by the new NICE guidelines 2017 as first choice. For patients who are systemically unwell / more serious illness / high risk of complications/ not responding after 2-3 days on first line antibiotics, co-amoxiclav 500/125mg tds for 5 days is recommended. Macrolides (eg clarithromycin or erythromycin) or doxycycline are suitable alternatives for patients with penicillin allergy. Patients with red flags / complications of sinusitis should be started on intravenous antibiotics based on local microbiological guidelines (most trusts suggest IV co-amoxiclav).

Nasal steroid drops or sprays have a proven, although modest, beneficial effect and are recommended after 10 days of illness.

There is no proven role for steam inhalation, oral corticosteroids, antihistamines, mucolytics and complementary treatment in acute sinusitis.

 

References

European Position Paper on Rhinosinusitis (EPOS) 2012

Lemiengre MB, van Driel ML, Merestein D et al (2012). Antibiotics for clinically diagnosed acute rhinosinusitis in adults (Cochrane Review).

Sinusitis. Nice Clinical Knowledge Summary (CKS) 2017.

 

Page last reviewed: 26 July 2018