Rhinitis, Sinusitis, Including Orbital and Cranial Complications, Invasive Fungal Rhinosinusitis

Rhinitis, Sinusitis, Including Orbital and Cranial Complications, Invasive Fungal Rhinosinusitis

Ashton Lehman

Di Coneybeare


Rhinitis, rhinosinusitis, and their suppurative complications present commonly in the emergency department (ED). Rhinitis alone afflicts 10% to 40% of the general population globally and more than 60 million Americans annually, whereas rhinosinusitis afflicts about one in six Americans annually.1,2,3

The sinonasal region—including the nasal cavity and bilateral paranasal sinuses—serves as a conduit for air movement while heating and humidifying inspired air; a filter for airborne particulate matter; a detection system for odorants, irritants, and temperature changes; and a defense system capable of triggering innate and adaptive immune system responses.4 This region is susceptible to a heterogeneous group of infectious and inflammatory conditions, many of which result in overlapping symptomatology in children and adults.5

When rhinosinusitis inflammation or infection extends beyond the paranasal sinuses and nasal cavity to involve neurologic, ophthalmologic, osseous, or soft tissue regions, it is considered complicated. Although rare, such complications (eg, orbital cellulitis, orbital abscesses, meningitis, and brain abscesses) can lead to significant morbidity and mortality.6 Given this potential risk, accurate and expeditious diagnosis and prompt management of sinonasal conditions are critical in ED and urgent care settings.


Because the sinus and nasal structures abut each other sharing continuous mucosa, many consider diseases of the sinonasal region along a pathologic spectrum.1,2 However, treatment options may differ dramatically depending on the underlying pathophysiology, location, and the severity of disease. Allergic and nonallergic rhinitis often share similar symptoms.3 Likewise, viral rhinitis and rhinosinusitis have significant symptomatologic overlap with acute bacterial rhinosinusitis.2 Differentiating between viral and bacterial rhinosinusitis is challenging to emergency providers. Physical exam findings are often subtle, and many serious suppurative complications of bacterial rhinosinusitis may present without the overt neurologic deficits that traditionally signify their presence.6 Imaging from computed tomography (CT) will result in similar findings in patients with a common cold as well as
in patients with bacterial rhinosinusitis.5 Furthermore, nasal microbiologic results may be misleading; even patients with viral illness may be colonized by common nasopharyngeal flora. For example, Staphylococcus aureus can be present in up to 30% of healthy adults, and fungi are almost ubiquitous.5,6

Uncertainty in diagnosis may lead to inappropriate antibiotics, therapeutics, and costly imaging.6 When to start antibiotics vexes providers the most. Viral infections most commonly afflict patients presenting with rhinosinusitis, and even in the case of bacterial rhinosinusitis, about two-thirds of patients will improve without any pharmaceutical intervention.5 However, if left untreated, serious bacterial rhinosinusitis may progress to life-threatening intracranial and extracranial suppurative complications.


During history-taking, noteworthy elements include the presence, character, and time course of symptoms as well as history of neurosurgery or sinonasal surgery. Specific relevant historical features and important comorbid conditions can be found in Table 11.1.

Examination of the sinonasal region includes an external evaluation of the nose, internal evaluation with anterior rhinoscopy and rigid nasal endoscopy, evaluation of facial soft tissues, orbits, oral cavity, and relevant neurologic function. Note edema, erythema, warmth, fluctuance, drainage, or changes in sensation of the facial soft tissues overlying the nasal, maxillary, and frontal regions. Orbital findings such as epiphora (ie, excessive tearing), lid abnormalities, proptosis, extraocular movements, visual acuity, light perception/sensitivity, pupil reactivity, and red desaturation should be assessed. The status of dentition and the presence of fistulae or palatal changes should be noted.

The workup of sinonasal pathology may include imaging in cases with a suspected complication or alternative diagnosis (eg, nonsinonasal causes of facial pain, potential malignant processes
signified by concomitant neurologic deficits).2 If an orbital or intracranial complication is suspected, suggested by severe headache, facial swelling, cranial nerve palsies, proptosis, impaired extraocular movements, or impaired visual acuity, contrast-enhanced CT is the initial imaging modality of choice.5,6 Depending on the presentation and the findings on initial CT imaging, magnetic resonance imaging (MRI) may be pursued. MRI often offers superior resolution of soft tissues, intracranial complications, and orbital complications/pathology.4,6