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Table of Contents
Rhinosinusitis is a disease characterised by inflammation of the paranasal sinuses and nasal cavity. Since sinusitis is so commonly accompanied by inflammation in the nasal cavity, it is preferable to refer to “rhinosinusitis” as opposed to considering it a separate entity.
Rhinosinusitis is categorised according to its duration. Acute rhinosinusitis (ARS) lasts up to 4 weeks, while chronic rhinosinusitis (CRS) persists for more than 12 weeks.1
Aetiology and Risk Factors
ARS may be further subdivided based on its aetiology into bacterial (ABRS) or viral rhinosinusitis (AVRS). Most cases of ARS have a viral aetiology.2 The most common viralcauses of ARS include:
ABRS most commonly occurs as a secondary infection of inflamed paranasal sinuses, either following a viral illness or another method which impairs the physiological clearance mechanisms and promotes bacterial stasis. Such factors may include physical obstruction (for example, due to individual anatomy), immunodeficiency, illnesses which impair ciliary clearance (cystic fibrosis, Kartagener syndrome), and allergic or non-allergic rhinitis.3
Bacterialpathogens that mostcommonly cause ABRS include:1
Recent clinical guidelines describe three cardinal symptoms of ARS.1 These include purulent nasal discharge, facial pressure and nasal obstruction.4 The combination of these symptoms is highly specific for ARS, though the absence of this triad does not preclude ARS. Other symptoms can include:
Although there are no validated symptoms that reliably differentiate between AVRS and ABRS5, 6, the two have different clinical courses. AVRS typically has a shorter and milder course, with symptoms lasting between 7 and 10 days2, 7-10. In contrast, ABRS is more likely to last beyond 10 days. Additionally, ABRS often presents with a “biphasic” pattern of illness. This pattern is characterised by a period of recovery, followed by a worsening of symptoms.
Diagnosis of ARS relies on the patient history more so than the clinical examination, since physical signs are not always present and may be nonspecific. Of the physical signs that may be present, the most specific for the diagnosis of ARS is purulent discharge in the nasal cavity or posterior pharynx. However, other signs that may be evident on examination include:
Palpable cheek tenderness
Minor upper respiratory conditions may resemble ARS, including the common cold, allergic and non-allergic rhinitis. However, facial pain and purulent nasal discharge are unlikely to present in any of these illnesses. Additionally, the common cold and rhinitis are more likely to feature sneezing as opposed to ARS. The common cold may also present with throat pain, which is unlikely to occur in acute sinusitis. Aside from these differentials, another cause of facial pain that may mimic ARS is cluster headache or migraine. Although neither of these typically present with facial pain, the retro-orbital pain of a cluster headache may be confused for frontal, ethmoidal or maxillary sinus pathology. However, cluster and tension headaches are unlikely to present with acute tenderness over the paranasal sinuses, or purulent nasal discharge. Both of these conditions also have characteristic temporal patterns, neither of which are similar to acute rhinosinusitis. Cluster headaches classically present in short (30-60 minutes) episodes of excruciating unilateral pain, often multiple times in one day. Migraine headaches usually have a protracted course (over multiple hours) and may be accompanied by additional features such as photophobia, phonophobia, nausea, vomiting and visual aura. Overall, the symptomatology of ARS is unique, and the presence of all three cardinal symptoms is sufficient for a clinical diagnosis.
Since the diagnosis of ARS relies on clinicalfeatures, the utility of investigations is limited to situations where the clinician is unsure of the diagnosis or suspects a complicated infection.
For cases of complicated ABRS unresponsive to initial antibiotic therapy, nasalcultures can help to identify the causative agent.
Experts dispute the role of imaging studies in ARS. It is generally not recommended to request imaging in cases of suspected ARS unless the clinician suspects either a complicated infection or an alternate diagnosis.1 In these cases, a CTscanwithcontrast can help to reveal intracranial or orbital involvement.
Since the majority of cases of ARS are viral in origin and will improve within 10 days, symptomatic relief is the mainstay of treatment.1 Symptomatic relief may include oralanalgesics, salinenasalirrigation or intranasalcorticosteroids. If patients do not feel any improvement after 10 days or feel worsening of symptoms at any time, treat them as a presumed case of ABRS.
In immunocompetent patients with ABRS, watchfulwaiting for 7 days may be more prudent than early antibiotic use. However, if these patients do not improve within 7 days or experience worsening of symptoms at any time, prescribe appropriateantibiotics. Current guidelines for empiric management of ABRS recommend amoxicillin first-line.
Clinicians managing patients with ABRS should have a low threshold for referral to an ENT service, as complications may develop rapidly and be particularly devastating. However, clinicians can manage the vast majority of patients with ARS through symptomatic treatment and watchful waiting if secondary infection occurs.
Although the majority of ABRS cases are uncomplicated, complications may cause significant morbidity. The severity of these complications is due to the proximity between the paranasal sinuses and other intracranial structures, including the orbit, cavernoussinus and meninges. The following symptoms may be present in patients with a complicated bacterial infection:
Altered mental status
Acuterhinosinusitis (ARS) describes inflammation of the paranasalsinuses and nasalcavity lasting under4weeks.
Cases of ARS are classified as having a bacterial or viral aetiology.
Acute viral rhinosinusitis (AVRS) is verycommon and should improve within 10days, but a small number of patients develop a secondarybacterialinfection (ABRS).
The cardinalsymptoms of ARS are purulentnasaldischarge, nasalcongestion and facialpain or fullness.
Investigations are notwarranted in most cases of ARS unless the clinician suspects a complicated infection or an alternative diagnosis.
Symptomatictreatment with analgesics and salineirrigation is sufficient for the majority of patients with AVRS.
In otherwise healthy patients with ABRS, watchfulwaiting over 7 days may avoid unnecessary antibiotic prescription.
Complications of ARS are rare but may cause highmorbidity.
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