Clinical Presentation

Acute Sinusitis

The most consistent feature distinguishing acute bacterial from a viral upper respiratory infection is persistence of symptoms beyond 7-10 d (Table 2). Cough and nasal discharge are the two most common complaints in children, whereas headache and facial pain are unusual in children younger than age 10. Adult patients with acute sinusitis most often complain of discolored nasal discharge, unilateral facial pain, headache, and cough. Although reported in only a minority of patients, upper tooth pain is a complaint very specific for acute sinusitis.

On examination, high temperature and signs of toxicity are unusual and should prompt a search for complications such as meningitis or periorbital abscess. Anterior rhinoscopy frequently reveals erythematous, swollen turbinates and purulent secretions on the floor of the nose. However, the absence of pus does not rule out active infection, because sinus drainage may be intermittent. Facial tenderness elicited by palpation is an unreliable sign in differentiating sinusitis from acute rhinitis. Although transillumination may be useful in evaluating acute maxillary and frontal sinusitis in adults (if interpretation is confined to extremes of light transmission), it is difficult to employ reliably in practice and is rarely used by most clinicians.

Table 1

Conditions Associated With Sinusitis

• Obstruction of the sinus ostia

Acute viral rhinitis Chronic rhinitis Nasal polyps Adenoidal enlargement Septal deviation

Aerated middle turbinate (concha bullosa) Foreign body (e.g., nasogastric tube)

  • Dental infection
  • Barotrauma (flying, diving)
  • Systemic diseases

Antibody deficiency syndrome Down syndrome Cystic fibrosis Wegener's granulomatosis Ciliary dyskinesia syndrome

Chronic Sinusitis

Patients with chronic sinusitis usually have indolent symptoms of nasal congestion, thick mucoid or purulent postnasal drip, and cough (Table 2). Adult patients may also complain of facial fullness and headache. Secondary eustachian tube obstruction or middle ear fluid may result in popping of the ears and muffled hearing. In addition to these chronic complaints, patients may also experience recurrent exacerbations of symptoms resembling acute sinusitis. Importantly, patients with chronic sinusitis, particularly those with nasal polyps, often have concomitant bronchial asthma. A large percentage of patients with chronic sinusitis and asthma are intolerant of nonsteroidal anti-inflammatory drugs and develop flushing, rhinorrhea, nasal congestion, and/or acute bronchospasm after ingesting these medications.

Physical examination often demonstrates swelling and erythema of the inferior and middle turbinates and occasionally mucopurulent secretions on the floor of the nose and middle meatus. Nasal polyps may be present and usually originate from the middle meatus. In children, middle ear effusions are present in half of all cases and serve as a possible clue to the presence of sinusitis. Transillumination is not useful in evaluating chronic sinus disease because mucosal thickening usually yields equivocal results.

Flexible fiberoptic rhinoscopy is a useful and easily learned procedure that can help identify important anatomical lesions not visible by anterior rhinoscopy, including posterior deviation of the nasal septum, nasal polyps, enlargement or inflammation of the adenoid, and tumor.

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