87 Rhinosinusitis—Acute

Both the maxillary and frontal sinuses drain through narrow spaces, clefts and gaps between the ethmoid cells, into the middle meatus. The anterior ethmoid cells also drain into the middle meatus, but the posterior ethmoids drain into the superior meatus. Any condition narrowing or blocking these channels may lead to secretion retention and poor ventilation, thus predisposing to consequent infection. The commonest cause (98% according to the National Institute of Clinical Excellence) is viral acute rhinosinusitis (ARS) from common cold viruses. Viral ARS usually resolves of its own accord after 2 to 3 weeks but occasionally may progress to post-viral ARS. Post-viral ARS requires antibiotics and if inadequately treated may progress to chronic rhinosinusitis (CRS). There are specific definitions for the different types of rhinosinusitis and these are covered in Chapter 86, Rhinosinusitis—Appropriate Terminology. It should be appreciated that most patients with acute facial pain have a non-sinogenic cause.

87.1 Predisposing Factors

1. Local

a. Acute viral upper respiratory tract infection from common cold viruses or influenza.

b. Tonsillitis.

c. Pre-existing rhinitis (allergic, vasomotor, rhinitis medicamentosa, etc.).

d. Nasal polyps.

e. Nasal foreign body.

f. Nasal anatomical variations (septal deviation, abnormal uncinate process, middle turbinate or ethmoid bulla) narrow the infundibulum and may predispose to its occlusion when there is intercurrent disease.

g. Nasal tumour.

h. Dental extraction or infection (diseases of the upper premolars and upper first molar in particular, as these dental roots are particularly close to the maxillary sinus floor).

i. Swimming and diving.

j. Fractures involving the sinuses.

2. General

a. Debilitation.

b. Immunocompromise.

c. Mucociliary disorders (e.g. Kartagener’s syndrome, cystic fibrosis).

d. Atmospheric irritants (dust, fumes and tobacco smoke).

Acute inflammation of one or all the sinuses may occur (pansinusitis). The ethmoid and maxillary sinuses are clinically the most commonly affected, followed by the frontal and sphenoid sinuses in that order.

87.2 Pathology

Most cases follow a viral upper respiratory tract infection which involves all the respiratory epithelium including the paranasal sinuses. Such infections cause hyperaemia and oedema of the mucosa, which then block the ostia. There will be cellular infiltration and an increase in mucus production. The infections will also paralyse the cilia, leading to stasis of secretions predisposing to a secondary bacterial infection. The usual causative bacterial organisms are Streptococcus pneumoniae, Haemophilus influenzae (accounting for 70% of cases in adults), Streptococcus pyogenes, Moraxella catarrhalis and Staphylococcus aureus. Klebsiella pneumoniae, Escherichia coli and Streptococcus milleri may spread from a dental source. Acute fungal infections (e.g. mucormycosis and aspergillosis) are rare but may develop in immunocompromised or elderly diabetic patients.

87.3 Clinical Features

Stay updated, free articles. Join our Telegram channel

Join