Rhinosinusitis

Aka: Rhinosinusitis, Sinusitis, Acute Sinusitis, Acute Rhinosinusitis, Sinus Headache

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II. Epidemiology

  1. Incidence: 31 Million cases per year in U.S.
    1. United States clinic office visits: 1%
    2. Incidence: 14% annually in adults (25% lifetime Incidence)
    3. Fifth most common indication for Antibiotic prescription in the U.S.
  2. Sinuses affected
    1. Maxillary Sinus
      1. Most commonly infected in adults
    2. Frontal Sinus
      1. Next most commonly infected in adults
      2. Absent in 10% population and very young children
      3. Higher risk for intracranial spread
    3. Ethmoid Sinus
      1. Most commonly infected in children
    4. Sphenoid Sinus
      1. Isolated infection is rare
      2. Higher risk for intracranial spread

III. Pathophysiology

  1. Background
    1. Viral Upper Respiratory Infections involve sinuses in 90% of cases
    2. Less than 1% of Upper Respiratory Infections evolve into documented Sinusitis
      1. Less than 10% of these documented Sinusitis cases are due to Bacterial superinfection
  2. Initial
    1. Mucosal inflammation of Paranasal Sinuses and nasal mucosa
      1. Nasal mucosa and sinus mucosa are contiguous and typically co-inflamed
    2. Sinus ostia irritation and edema
    3. Ciliary transport impaired by infection results in stasis of mucous
  3. Next
    1. Sinus ostia obstruction and stasis
    2. Subsequent sinus infection

IV. Types

  1. Acute Sinusitis
    1. Symptoms as long as 4 weeks
    2. Further subdivided into Bacterial or viral
  2. Subacute Sinusitis
    1. Symptoms persist between 4 to 12 weeks
  3. Chronic Sinusitis
    1. Persistent Symptoms beyond 12 weeks
  4. Recurrent Sinusitis
    1. Four or more episodes per year
    2. Each episode lasts 7 days or more
    3. Symptom free intervals last greater than 2 months

V. Risk Factors

  1. Ciliary Disorder
    1. Tobacco use or smoke exposure
    2. Cystic Fibrosis
    3. Kartagener Syndrome (primary ciliary Dyskinesia)
  2. Mechanical obstruction
    1. Nasal Polyps
    2. Septal deviation
    3. Hypertrophic middle turbinates or concha bullosa
    4. Nasal Foreign Body
    5. Inflammatory disorder
      1. Granulomatosis with Polyangiitis (previously known as Wegener's Granulomatosis)
      2. Sarcoidosis
  3. Mucosal edema and inflammation
    1. Preceding Upper Respiratory Infection or recurrent Upper Respiratory Infection
    2. Vasomotor Rhinitis
    3. Allergic Rhinitis and other hyperreactivity
      1. Allergens (e.g. pollens, molds, animal dander)
      2. Air pollutants
    4. Nonallergic (Samter's Triad)
      1. Asthma
      2. Nasal Polyps
      3. Aspirin sensitivity
  4. Iatrogenic causes
    1. Dental Infections and procedures
    2. Sinus Surgery
    3. Nasogastric Tubes
    4. Nasal Packing (e.g. Epistaxis)
    5. Mechanical Ventilation
  5. Immune disorder (predisposes to prolonged course, recurrence, fungal and other atypical infections)
    1. AIDS
    2. Congenital Hypogammaglobulinemia (IgA or IgG subclass deficiency)
    3. Post-Transplant with Immunosuppression
    4. Chemotherapy
    5. Diabetes Mellitus
    6. Chronic Corticosteroid use

VI. Causes

  1. Viral (most cases, 90 to 98% of all Rhinosinusitis)
    1. Rhinovirus (most common viral Sinusitis cause)
    2. Influenza
    3. Parainfluenza
    4. Adenovirus
    5. Coronavirus
    6. Respiratory Syncytial Virus
    7. Metapneumovirus
  2. Bacterial (superinfection of up to 2% of viral Upper Respiratory Infections)
    1. Acute Sinusitis
      1. Streptococcus Pneumoniae
      2. Haemophilus Influenzae
      3. Moraxella catarrhalis
    2. Chronic Sinusitis
      1. Anaerobes (>50%)
        1. Bacteroides
        2. Anaerobic Gram Positive Cocci
        3. Fusobacterium species
      2. Other less common causes
        1. Hemophilus Influenzae
        2. Pseudomonas Aeruginosa
        3. Escherichia coli
        4. Beta-hemolytic Streptococcus (e.g. Streptococcus Pyogenes)
        5. Neisseria causes
        6. Staphylococcus Aureus
          1. Not considered a significant cause of acute uncomplicated Sinusitis
  3. Fungal (Immunocompromised or Diabetes Mellitus)
    1. Aspergillus
    2. Mucormycosis
    3. Fungus

VII. Symptoms: General

  1. Sinus "aching" pain or pressure
    1. Location
      1. Frontal: Frontal Headache
      2. Maxillary: Mid-face, dental (upper teeth) pain
      3. Ethmoid: Retro-orbital pain
      4. Sphenoid: Nonspecific pain radiates top of head
    2. Provocative
      1. Pain increases on bending forward
      2. Pain increases in late morning
      3. Pain on mastication
  2. Foul Nasal Discharge or postnasal discharge
    1. Purulent yellow or green Nasal Discharge
    2. Discharge color does not indicate Bacterial cause
    3. Discharge for >10 days suggests Bacterial Sinusitis
  3. Associated Nasal Symptoms
    1. Decreased Sense of Smell (Hyposmia or Anosmia)
    2. Halitosis
    3. Snoring
    4. Mouth breathing
    5. Nasal or hyponasal speech
  4. Generalized symptoms
    1. Fatigue
    2. Fever
  5. Symptoms NOT correlating with Sinusitis
    1. Sore Throat (except with postnasal discharge)
    2. Sneezing
      1. More typical of Allergic Rhinitis

VIII. Symptoms: Red Flags (consider imaging and ENT referral)

  1. High Fever over 102.2 F (39 C) or peristent fever
  2. Visual complaints (e.g. Diplopia)
  3. Periorbital edema or erythema
  4. Mental status changes
  5. Severe facial or Dental Pain
  6. Infraorbital hypesthesia

IX. Signs

  1. Nasal Mucosa edema and erythema
    1. Contrast with Allergic Rhinitis (pale, boggy mucosa)
  2. Nasal exam to view pus discharge from lateral wall
    1. Instruments
      1. Nasal speculum (minimal visualization)
      2. Flexible Nasolaryngoscopy
      3. Rigid optical scope (Otolaryngology use)
    2. Middle Meatus (hiatus semilunaris)
      1. Drains Maxillary, Frontal, and Anterior Ethmoid
      2. Consider local Topical Decongestant application
    3. Superior Meatus (Rarely discharge is seen)
      1. Drains posterior Ethmoid Sinus
  3. Turbinates enlarged
  4. Sinus tenderness to percussion
  5. Sinus Transillumination in darkened room
    1. Frontal and Maxillary Sinus

X. Diagnosis: Cardinal Features of Bacterial Rhinosinusitis (IDSA)

  1. Treat as Sinusitis if at least 1 of 3 criteria present
  2. Onset with severe, IDSA Cardinal Signs or Symptoms
    1. High fever (>102.2 F or 39 C) AND
    2. Unilateral facial pain or pressure AND
    3. Purulent nasal drainage with obstruction of nasal passages AND
    4. Symptoms for at least 3 to 4 consecutive days from the start of the illness
  3. Persistent Acute Bacterial Rhinosinusitis symptoms >7 days without clinical improvement
  4. Double Sickening
    1. Initial viral Upper Respiratory Infection lasting 5 to 6 days and was improving
    2. Then, worsening findings (fever, Headache, increased Nasal Discharge) for at least 3 to 4 days
  5. References
    1. Chow (2012) Clin Infect Dis 54(8): e72-112 [PubMed]

XI. Diagnosis: Findings Most Suggestive of Bacterial Cause

  1. See Sinusitis Prediction Rules
  2. Symptoms persist beyond 10 days
    1. Under 10 days of symptoms, viral Sinusitis predominates
    2. By day 10, 40% of Sinusitis resolves spontaneously
    3. However, persistent symptoms >7 days is among the criteria for treatment (see above)
    4. Only 0.5% of viral URIs develop into Bacterial Sinusitis
      1. Low (1997) CMAJ 156:S1-S14 [PubMed]
  3. Symptoms worsen after 5-7 days ("double sickening")
    1. Typical course: Onset, then improvement, then worse again
  4. Purulent Nasal Discharge
  5. Maxillary tooth or facial pain (especially if unilateral)
  6. Unilateral Maxillary Sinus tenderness
  7. Foul Smelling odor (Cocosmia)
  8. References
    1. Hickner (2001) Ann Intern Med 134:498-505 [PubMed]
    2. Lanza (1997) Otolaryngol Head Neck Surg 117:S1-7 [PubMed]

XII. Labs

  1. C-Reactive Protein (cRP)
    1. cRP >15 mg/dl is supportive of Acute Bacterial Rhinosinusitis
  2. Culture of nasal mucosa
    1. Not cost effective or helpful in management
    2. Does not correlate with sinus mucosa cultures
  3. Endoscope directed micro-swab culture
    1. Swab of hiatus semilunaris
    2. Protected from nasal contamination
    3. Accuracy: 80-85% compared with antral puncture

XIII. Imaging

  1. Indications for Imaging
    1. Imaging is not needed in routine cases (esp. Acute Sinusitis)
      1. Does not differentiate viral from Bacterial cause
      2. Empiric therapy for 1-2 courses is appropriate
    2. Complicated Sinusitis (esp. Immunocompromised patients)
    3. Chronic or recurrent Sinusitis
    4. Sinusitis refractory to maximal medical therapy
      1. Example: Amoxicillin course for 10 days followed by Levaquin course for 10-14 days
  2. Sinus XRay (not recommended)
    1. Single Waters' View XRay is sufficient
    2. Indication (rarely indicated unless CT not available)
      1. Complicated Acute Sinusitis
      2. Suspected Chronic Sinusitis
  3. Sinus CT without contrast (gold standard)
    1. Indications (cases refractory to maximal medical therapy)
      1. Define Sinus Anatomy prior to Sinus Surgery
      2. Osteomeatal complex Occlusion
      3. Chronic Sinusitis
      4. Recurrent Sinusitis
      5. Allergic Fungal Sinusitis
      6. Suspected Orbital Cellulitis (perform with IV contrast)
    2. Findings
      1. Mucosal thickening >5mm is consistent with sinus infection
      2. Non-contrast CT
        1. Demonstrates fluid and mucosal edema, as well as bony destruction
        2. Fat stranding (increased density) may be present in para-sinus spaces
      3. CT-Contrast CT
        1. Necrotic tissue and fluid does not contrast enhance
        2. Inflamed, thickened mucosa contrast enhances
          1. Mucosa, fluid and soft tissue may be indistinguishable without contrast
        3. Consider IV contrast in complicated cases (e.g. vascular complications, Cavernous Sinus Thrombosis)
  4. Sinus MRI
    1. No advantage over Sinus CT except for complicated cases (e.g. neoplasm)
      1. More False Positive results
    2. Indications
      1. Suspected neoplasm
      2. Orbital or intracranial extension
      3. Fungal Sinusitis
    3. Views: T1 Weighted Images with IV gadolinium
      1. Fluid, air, bone are black
      2. Fat is white, but black with fat suppression
      3. Contrast-enhanced mucosa is bright white
      4. Necrotic tissue will not enhance and will appear as black
  5. Bedside Sinus Ultrasound (Maxillary SinusPOCUS)
    1. Can identify air fluid levels in Maxillary Sinus
    2. Negative result could drive non-Antibiotic management
    3. Tierney (2018) South Med J 111(7): 411-7 [PubMed]

XIV. Complications

  1. Orbital Cellulitis (and Periorbital Cellulitis)
  2. Meningitis
  3. Extradural abscess
  4. Subdural Empyema
    1. Subdural Abscess, especially associated with Frontal Sinusitis
  5. Brain Abscess
  6. Pott's Puffy Tumor
    1. Osteomyelitis of Frontal Bone or Maxillary Bone
  7. Cavernous Sinus Thrombosis
  8. Fungal Sinusitis
    1. Sudden fulminant progression has a high mortality (>50%)
    2. Risk of intracranial spread (hematogenous or from adjacent bony destruction)
  9. Hospitalization for severe Rhinosinusitis complications
    1. Adult: 1 in 32,000
    2. Child: 1 in 12,000
    3. El Mograbi (2019) Ann Otol Rhinol Laryngol 128(6): 563-8 [PubMed]
    4. Hansen (2012) Fam Pract 29(2): 147-53 [PubMed]

XV. Management

  1. See Acute Sinusitis Management
  2. Referral Indications
    1. See Red Flag Symptoms above

XVI. References

  1. Broder (2018) Crit Dec Emerg Med 32(10): 12-3
  2. Aring (2011) Am Fam Physician 83(9): 1057-63 [PubMed]
  3. Aring (2016) Am Fam Physician 94(2): 97-105 [PubMed]
  4. Butler (2025) Am Fam Physician 111(1): 47-53 [PubMed]
  5. Chow (2012) Clin Infect Dis 54(8):e72-e112 [PubMed]
  6. Giebink (1994) Pediatr Infect Dis J 13(suppl 1):S55-8 [PubMed]
  7. Hadley (1997) Otolaryngol Head Neck Surg 117:S8-S11 [PubMed]
  8. Lanza (1997) Otolaryngol Head Neck Surg 117:S1-7 [PubMed]
  9. Masood (2007) Postgrad Med J 83(980): 402–408 +PMID:17551072 [PubMed]
  10. Osguthorpe (2001) Am Fam Physician 63:69-76 [PubMed]
  11. Rosenfeld (2007) Otolaryngol Head Neck Surg 137(3 suppl): S1-31 [PubMed]
  12. Slavin (1991) J Allergy Clin Immunol 88:141-146 [PubMed]
  13. Williams (1993) JAMA 270:1242-6 [PubMed]

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Related Studies

Ontology: Sinus headache (C0037195)

Concepts Finding (T033)
SnomedCT 162210000, 366967004, 367191001, 4969004
LNC LA15137-5
English SINUS HEADACHE, Headache sinus, headaches sinus, headache sinus, Headache;sinus, sinus headache, Sinus headaches, Sinus headache, Sinus headache (finding)
Italian Cefalea sinusale
Dutch hoofdpijn sinus, sinus hoofdpijn
French Céphalée au cours d'une sinusite, CEPHALEE D'ORIGINE SINUSIENNE, Céphalée d'origine sinusienne
Portuguese Cefaleia sinusal, CEFALEIA SINUSITICA, Cefaleia de sinusopatia
Spanish Cefalea por sinusitis, SENOS, DOLOR, cefalea sinusal (hallazgo), cefalea sinusal, Cefalea sinusal
Japanese 副鼻腔炎に伴う頭痛, ﾌｸﾋﾞｸｳｴﾝﾆﾄﾓﾅｳｽﾞﾂｳ
German SINUS KOPFSCHMERZ, Sinuskopfschmerzen
Czech Sinusální bolest hlavy
Hungarian Sinus fejfájás
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Sinusitis (C0037199)

Definition (MSH) Inflammation of the NASAL MUCOSA in one or more of the PARANASAL SINUSES.
Definition (MEDLINEPLUS)

Sinusitis means your sinuses are inflamed. The cause can be an infection or another problem. Your sinuses are hollow air spaces within the bones surrounding the nose. They produce mucus, which drains into the nose. If your nose is swollen, this can block the sinuses and cause pain.

There are several types of sinusitis, including

  • Acute, which lasts up to 4 weeks
  • Subacute, which lasts 4 to 12 weeks
  • Chronic, which lasts more than 12 weeks and can continue for months or even years
  • Recurrent, with several attacks within a year

Acute sinusitis often starts as a cold, which then turns into a bacterial infection. Allergies, nasal problems, and certain diseases can also cause acute and chronic sinusitis.

Symptoms of sinusitis can include fever, weakness, fatigue, cough, and congestion. There may also be mucus drainage in the back of the throat, called postnasal drip. Your health care professional diagnoses sinusitis based on your symptoms and an examination of your nose and face. You may also need imaging tests. Treatments include antibiotics, decongestants, and pain relievers. Using heat pads on the inflamed area, saline nasal sprays, and vaporizers can also help.

NIH: National Institute of Allergy and Infectious Diseases

Definition (MSHCZE) Zánět vedlejších nosních paranazálních dutin. Je způsobena větš. bakteriální infekcí, která se šíří z nosu a k jejímuž rozvoji přispívá zduření nosní sliznice. Akutní s. se vedle celkových příznaků (zvýšená teplota, únava, malátnost) projevuje bolestí hlavy (pod okem, v čele, v záhlaví – podle postižené dutiny) a hnisavým výtokem z nosu. Bolest sílí při předklonu hlavy a zesiluje i při došlápnutí. K diagnostice se používá rinoskopie, sinusoskopie, rentgenové vyšetření, diafanoskopie, ultrasonografie. Chronická s. vzniká z nevyléčeného zánětu akutního nebo se od počátku vyvíjí plíživě. Má formu hnisavou nebo polypózní. Vzniká častěji při některých současných změnách na horních cestách dýchacích (nosní polypy aj.), vlivem zevního prostředí či snížené odolnosti organismu. Má méně nápadné příznaky, ale svým přetrváváním nepříznivě působí na celý organismus. Komplikace mohou být celkové a místní. Z celkových se uplatňuje všeobecné působení zánětu, u chronických s. jde o jeden z možných zdrojů fokální infekce. Místní komplikace zahrnují jednak vliv na záněty okolních struktur vč. jejich chronicity (rhinitis či pharyngitis chronica). Závažné mohou být komplikace při šíření zánětu do orbity, popř. lebky. Častěji se objevují např. záněty průdušek a průduškové astma – tzv. sinobronchiální syndrom. Léčba s. zahrnuje klid, dostatečné zvlhčování vzduchu, obklady, nosní kapky ke zmírnění zduření sliznice, antibiotika. V těžších případech je nutné provést punkci dutin s jejich výplachem. V případě chronických zánětů se někdy provádějí i chirurgické zákroky v oblasti nosní dutiny (septoplastika, polypektomie, mukotomie aj.). (cit. Velký lékařský slovník online, 2013 http://lekarske.slovniky.cz/ )
Definition (NCI) An acute or chronic inflammatory process affecting the mucous membranes of the paranasal sinuses.
Definition (NCI_CTCAE) A disorder characterized by an infectious process involving the mucous membranes of the paranasal sinuses.
Definition (CSP) inflammatory process of the mucous membranes of the paranasal sinuses that occurs in three stages: acute, subacute, and chronic; results from any condition causing ostial obstruction or from pathophysiologic changes in the mucociliary transport mechanism.
Concepts Disease or Syndrome (T047)
MSH D012852
ICD10 J32
SnomedCT 195649005, 275483004, 36971009
English Sinusitides, SINUSITIS, sinusitis (diagnosis), sinusitis, Sinus infection, Sinusitis NOS, Sinusitis [Disease/Finding], sinus infection, Sinusitis, Sinus Infection, Sinusitis (disorder), infected; sinus, infection; sinus, inflammation; nasal sinus, inflammation; sinus, nasal sinus; inflammation, sinus; infected, sinus; infection, sinus; inflammation, Sinusitis, NOS, Unspecified sinusitis
French SINUSITE, Sinusite SAI, Infection des sinus, Sinusite
Portuguese SINUSITE, Sinusite NE, Infecção dos seios paranasais, Sinusite
Spanish SINUSITIS, Sinusitis NEOM, Infección de senos paranasales, sinusitis (trastorno), sinusitis, Sinusitis
German SINUSITIS, Sinusitis NNB, Sinusinfektion, Sinusitis, Nasennebenhöhlenentzündung, Nebenhöhlenentzündung
Dutch sinusitis NAO, sinusinfectie, geïnfecteerd; sinus, infectie; bijholte, neusbijholte; infectie, neusbijholte; ontsteking, ontsteking; neusbijholte, ontsteking; sinus, sinus; geïnfecteerd, sinus; ontsteking, sinusitis, Sinusitis
Italian Sinusite NAS, Infezione sinusale, Sinusite
Japanese 副鼻腔炎, 副鼻腔炎ＮＯＳ, 副鼻腔感染, ﾌｸﾋﾞｸｳｶﾝｾﾝ, ﾌｸﾋﾞｸｳｴﾝ, ﾌｸﾋﾞｸｳｴﾝNOS
Swedish Bihåleinflammation
Czech sinusitida, vedlejší nosní dutiny - zánět, zánět paranazálních dutin, zánět vedlejších nosních dutin, Zánět paranazální dutiny, Sinusitida NOS, Sinusitida
Finnish Sinuiitti
Russian SINUSIT, СИНУСИТ
Croatian SINUSITIS
Polish Zapalenie zatok przynosowych
Hungarian Sinus fertőzés, Sinusitis k.m.n., sinusitis
Norwegian Sinusitt, Bihulebetennelse
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute sinusitis (C0149512)

Concepts Disease or Syndrome (T047)
ICD9 461.9, 461
ICD10 J01 , J01.9, J01.90
SnomedCT 155501004, 195653007, 266378004, 195649005, 155498004, 15805002
English Acute sinusitis, unspecified, SINUSITIS ACUTE, acute sinusitis (diagnosis), acute sinusitis, Sinusitis acute NOS, acute infection of sinus, acute inflammation of sinus, Sinusitis;acute, sinusitis acute, acute sinus infection, Acute sinusitis NOS (disorder), Sinusitis (& acute), Sinusitis (& acute) (disorder), Acute sinusitis, Acute infection of sinus, Acute inflammation of sinus, Acute inflammation of nasal sinus, Acute sinusitis (disorder), acute; sinusitis, sinusitis; acute, Acute infection of nasal sinus, NOS, Acute inflammation of nasal sinus, NOS, Acute sinusitis, NOS, Acute sinusitis NOS
Italian Sinusite acuta, Sinusite acuta NAS, Sinusite acuta, non specificata
Dutch sinusitis acuut NAO, acute sinusitis, niet-gespecificeerd, acuut; sinusitis, sinusitis; acuut, Acute sinusitis, niet gespecificeerd, acute sinusitis, Acute sinusitis
French Sinusite aiguë, non précisée, Sinusite aiguë SAI, Sinusite aiguë
German akute Sinusitis, unspezifisch, Sinusitis akut NNB, Akute Sinusitis, nicht naeher bezeichnet, Akute Sinusitis, akute Sinusitis
Portuguese Sinusite aguda NE, Sinusite aguda
Spanish Sinusitis aguda no especificada, Sinusitis aguda NEOM, sinusitis aguda, SAI, sinusitis aguda, SAI (trastorno), inflamación aguda de seno paranasal, sinusitis aguda (trastorno), sinusitis aguda, Sinusitis aguda
Japanese 急性副鼻腔炎、詳細不明, 急性副鼻腔炎, 急性副鼻腔炎ＮＯＳ, ｷｭｳｾｲﾌｸﾋﾞｸｳｴﾝｼｮｳｻｲﾌﾒｲ, ｷｭｳｾｲﾌｸﾋﾞｸｳｴﾝNOS, ｷｭｳｾｲﾌｸﾋﾞｸｳｴﾝ
Czech Akutní sinusitida, blíže neurčená, Akutní sinusitida, Akutní sinusitida NOS
Korean 급성 굴염, 상세불명의 급성 굴염
Hungarian Sinusitis acuta k.m.n., heveny sinusitis, k.m.n., acut sinusitis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Rhinosinusitis (C0948780)

Concepts Disease or Syndrome (T047)
SnomedCT 281971000009108
Dutch rhinosinusitis
French Rhinosinusite
German Rhinosinusitis
Italian Rinosinusite
Portuguese Rinossinusite
Spanish Rinosinusitis
Japanese 副鼻腔炎, ﾌｸﾋﾞｸｳｴﾝ
English rhinosinusitis (diagnosis), rhinosinusitis, Rhinosinusitis, Rhinosinusitis (disorder)
Czech Rinosinusitida
Hungarian Rhinosinusitis
Derived from the NIH UMLS (Unified Medical Language System)

Ontology: Acute rhinosinusitis (C2317131)

Concepts Disease or Syndrome (T047)
SnomedCT 431231008
English Acute rhinosinusitis, Acute rhinosinusitis (disorder), rhinosinusitis acute, Acute rhinosinusitis (diagnosis)
Spanish rinosinusitis aguda (trastorno), rinosinusitis aguda
Derived from the NIH UMLS (Unified Medical Language System)

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