A 17-year-old female came to clinic with an 8 day continuous history of moderate rhinorrhea, nasal congestion and bad breath. She was taking pseudoephedrine which decreased the nasal congestion and she felt somewhat better. One day ago the rhinorrhea changed from clear and watery, to yellow-greenish and thick.
Last night she began to have acute onset of pain in her left face, upper teeth and behind her eye. She also complains of a headache that is frontal and does not radiate. The pain worsens with bending over or tapping on the affected areas. The pain is somewhat responsive to acetaminophen.
She has no fever. She has minor coughing because of the rhinorrhea and she also complains of some “popping” sounds in her ears occasionally. She is otherwise healthy.
The pertinent physical exam shows a female who appears to have upper airway congestion with teary eyes and needing to clear her nose of yellow-green discharge.
She has a de-nasal voice. She is tender to palpation over her frontal sinuses bilaterally and left maxillary sinus. Her conjunctiva are mildly injected. She has copious drainage in her nose with extremely swollen and red turbinates.
Her pharynx is slightly red with nasal discharge. Her tympanic membranes show a small amount of fluid bilaterally with normal landmarks and movement.
She has minor anterior cervical lymphadenopathy. Her lungs are clear and the rest of her examination is negative.
The diagnosis of of left maxillary and bilateral frontal actue sinusitis is made. The patient is begun on Azithromycin for 10 days because of a history of hives with penicillin. The physician recommends continuing the pseudoephedrine as the patient states it has been helping with the symptoms and to try nasal saline to see if it helps symptomatically.
The patient will return if the symptoms worsen or change.
Sinusitis is defined as the inflammation of the paranasal sinuses, that are usually sterile, due to bacterial infection. Rhinosinusitis (RS) is a term currently used to describe inflammation believed to begin in the nasal epithelium (rhinitis).
Duration of symptoms classify RS: acute is between 10-30 days, subacute is between 30 and 90 days, chronic is more than 90 days, and recurrent lasts less than 30 days but recurs after an asymptomatic time period of 10 or more days.
Acute RS is diagnosed by history and is defined as symptoms lasting longer than 10 days or worsening of symptoms between 7 to 10 days of illness. As separate upper respiratory infections (URIs) can run consecutively, it is important to distinguish between one episode or more than one episode of symptoms.
Acute RS symptoms include nasal discharge, coughing and halitosis. Adolescent and older children may also have face pain and/or pressure, headaches, dental pain in the maxilla, throat clearing and pharyngitis.
A less common presentation of acute RS is high fever along with severe URI symptoms lasting 3 to 4 days concurrently. The illness is more likely to be viral if the fever precedes the URI symptoms.
Physical examination may or may not assist in diagnosis. Pressure on the sinus that elicits tenderness or purulent discharge seen coming from the middle meatus on nasal examination are more consistent with sinusitis caused by bacteria. The definitive diagnostic treatment is direct aspiration, but most cases are diagnosed by history and physical examination.
Chronic RS is associated with environmental pollution including tobacco smoke, recurrent viral URI, allergic and nonallergic rhinitis, ciliary dyskinesia, cystic fibrosis, immunodeficiency, gastroesophageal reflux, and anatomic abnormalities.
The common organisms causing acute RS are the same as for otitis media:
- Streptococcus pneumoniae
- Haemophilus influenzae, non-typeable
- Moraxella catarrhalis
- Staphylococcus aureus – more likely with chronic RS
- Anaerobic organisms – more likely with chronic RS and include Peptococcus species, Peptostreptococcus species and Bacteroides species
- Pseudomonas aeruginosa – in patients with cystic fibrosis
- Fungus – in patients who are immunocompromised
Amoxicillin is the drug of choice with penicillin-allergic patients being treated with second or third generation cephalosporins or a macrolide antibiotic.
Other treatment regimens may be indicated depending on initial response to treatment. Most patients have some improvement within 3 days. The optimal therapy duration is not known but common treatment durations include 7, 10, 14, and 28 days.
Questions for Further Discussion
1. What are some of the potential complications of sinusitis?
2. What are the indications for radiologic imaging for sinusitis?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
American Academy of Pediatrics Clinical Practice Guideline. Management of Sinusitis. Pediatrics. 2001:108:798-808. Available from the Internet at: http://www.aap.org/policy/0106.html (cited 12/18/2006).
Taylor A. Sinusitis. Pediatr Rev. 2006 Oct;27(10):395-7.
Sharma G. Sinusitis. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic2108.htm (rev. 7/17/2006, cited 12/18/2006).
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
January 22, 2007