Rhinosinusitis
Overview
•Inflammation of nasal mucosa + paranasal sinuses - almost never occurs in isolation
•Vast majority of acute cases are viral (rhinovirus most common); bacterial superinfection complicates ~0.5-2% of viral URTIs
•Common bacterial pathogens: *Streptococcus pneumoniae*, *Haemophilus influenzae*, *Moraxella catarrhalis*
Classification
Type | Duration |
Acute | <12 weeks, resolves completely |
Chronic | ≥12 weeks, symptoms persist |
Presentation
•Diagnosis requires: nasal blockage or discharge PLUS at least one of: facial pain/pressure OR reduced/loss of smell
•Nasal blockage/congestion - mucosal oedema
•Purulent nasal discharge - yellow/green; does NOT reliably indicate bacterial cause
•Facial pain/pressure - worse on bending forward; maxillary = cheek pain; frontal = forehead pain; ethmoid = periorbital/nasal bridge pain
•Hyposmia/anosmia - olfactory cleft oedema
•Upper tooth pain - classic feature of maxillary sinusitis (molar roots abut sinus floor)
•Features suggesting bacterial superinfection:
•Double-sickening - worsening after initial improvement
•Unilateral facial pain or tenderness
•Purulent discharge with fever persisting >10 days
•High fever (>38°C) or fever persisting beyond 3-4 days
Investigations
•Rhinosinusitis is a clinical diagnosis - investigations not required in straightforward acute cases
•First-line (if needed): clinical assessment + anterior rhinoscopy; bloods (FBC, CRP) if bacterial superinfection or sepsis suspected
🏆 Gold standard
•CT sinuses (coronal) - for chronic rhinosinusitis, surgical planning, or suspected complications; plain X-rays not recommended
🥈 Second-line
•MRI if intracranial/orbital complications suspected (superior soft tissue detail); allergy testing (skin prick or specific IgE) in chronic/recurrent disease
Management
•Most acute rhinosinusitis is self-limiting - resolves within 2-3 weeks without antibiotics
•No antibiotic or delayed antibiotic strategy for most patients (antibiotics reduce symptom duration by ~half a day only)
•First-line (all patients):
•Saline nasal irrigation - high-volume, twice daily
•Analgesia - paracetamol or ibuprofen (ibuprofen has additional anti-inflammatory benefit)
•Intranasal corticosteroid - mometasone or fluticasone up to 3 months; especially useful with co-existing allergic rhinitis or chronic rhinosinusitis
•Antibiotics - when to prescribe: severe symptoms, bacterial superinfection features (double-sickening, symptoms >10 days without improvement, high fever), immunocompromised, or significant co-morbidities
•First-line antibiotic: phenoxymethylpenicillin 500 mg four times daily for 5-7 days
•Second-line antibiotic: co-amoxiclav - if no improvement with penicillin V after 2-3 days, or more severely unwell
•Penicillin allergy: doxycycline - first-line alternative
•Topical decongestant (second-line): xylometazoline or oxymetazoline - limit to 5-7 days (risk of rhinitis medicamentosa with prolonged use)
•Chronic rhinosinusitis: intranasal corticosteroids (up to 3 months), treat allergic rhinitis, refer ENT if persistent or polyps present; FESS is definitive surgical option - improves symptoms in ~80% of selected patients
Complications
•Orbital complications (most common) - periorbital/preseptal cellulitis → subperiosteal abscess → orbital abscess → cavernous sinus thrombosis (Chandler's staging)
•Cavernous sinus thrombosis - proptosis, chemosis, ophthalmoplegia, high fever, severe headache; bilateral involvement distinguishes from orbital cellulitis; neurosurgical emergency
•Meningitis - neck stiffness, photophobia, altered consciousness
•Intracranial abscess - frontal sinusitis classically causes frontal lobe abscess; altered behaviour, focal neurology, reduced GCS
•Pott's puffy tumour - subperiosteal abscess of frontal bone; fluctuant forehead swelling with osteomyelitis