C h a p t e r 2 2
Respiratory Tract Infections, Neoplasms, and Childhood Disorders
541
Acute rhinosinusitis may be of viral, bacterial, or
viral–bacterial etiology. In most cases, bacterial infection
is preceded by a viral upper respiratory infection, which
in turn leads to inflammation and obstruction of the
ostiomeatal complex. Rhinovirus is the most common
viral pathogen.
Haemophilus influenzae
,
Streptococcus
pneumoniae,
and
Moraxella catarrhalis
make up the
majority of community-acquired bacterial pathogens.
In contrast to acute infections, the pathogens found in
chronic rhinosinusitis are usually a mixture of aero-
bic and anaerobic bacteria, including
Staphylococcus
aureus
, coagulase-negative
Staphylococcus
, and anaero-
bic gram-negative bacilli. Although the mechanisms that
contribute to the chronicity of the disorder are uncer-
tain, mucociliary dysfunction, mucostasis, hypoxia,
and release of microbial products are thought to play
a role. Allergies may also play an important role in the
pathogenesis of chronic rhinosinusitis. In immunocom-
promised persons, such as those with human immuno-
deficiency virus (HIV) infection, the sinuses may become
infected with gram-negative species and opportunistic
fungi. In persons in this group, particularly those with
leukopenia, the disease may have a fulminant and even
fatal course.
Manifestations.
The symptoms of acute viral rhinosi-
nusitis often are similar to those of the common cold
and allergic rhinitis
7–12
(discussed in Chapter 16). They
include facial pain, headache, purulent nasal discharge,
decreased sense of smell, and fever. A history of a pre-
ceding common cold and the presence of purulent nasal
drainage, pain on bending, unilateral maxillary pain,
and pain in the teeth are common findings with involve-
ment of the maxillary sinuses. The symptoms of acute
viral rhinosinusitis usually resolve within 5 to 7 days
without medical treatment. Acute bacterial rhinosi-
nusitis is suggested by symptoms that worsen after 5
to 7 days or persist beyond 10 days, or symptoms that
are out of proportion to those usually associated with
a viral upper respiratory tract infection. Persons who
are immunocompromised, such as those with leukemia,
aplastic anemia, bone marrow transplant, or HIV infec-
tion, may present with fever of unknown origin, rhinor-
rhea, or facial edema. Often, other signs of inflammation
such as purulent drainage are absent.
In persons with chronic rhinosinusitis, the only
symptoms may be nasal obstruction, a sense of fullness
in the ears, postnasal drip, hoarseness, chronic cough,
and loss of taste and smell. Sinus pain often is absent;
instead, the person may complain of a headache that
is dull and constant. Persons with chronic rhinosinus-
itis may have superimposed bouts of acute rhinosinus-
itis. The mucosal changes that occur during acute and
subacute forms of rhinosinusitis as usually reversible;
whereas, those that occur during chronic rhinosinusitis
may be irreversible.
Diagnosis.
The diagnosis of rhinosinusitis usually is
based on symptom history and a physical examination
that includes inspection of the nose and throat. Headache
due to sinusitis needs to be differentiated from other
types of headache. Sinusitis headache usually is exagger-
ated by bending forward, coughing, or sneezing. Physical
examination findings in acute bacterial sinusitis include
turbinate edema, nasal crusts, purulent drainage, and
failure of transillumination of the maxillary sinuses.
Transillumination is done in a completely darkened room
by placing a flashlight against the skin overlying the
infraorbital rim, directing the light inferiorly, having the
Frontal sinus
Frontal sinus
Frontal sinus
Maxillary sinus
Maxillary sinus
Maxillary ostium
Ethmoid sinuses
Cranial cavity
Orbit
Anterior ethmoid
Middle turbinate
Osteomeatal complex
Inferior turbinate
Superior turbinate
Middle turbinate
Inferior turbinate
Nasal septum
Sphenoidal
sinus
A
B
C
FIGURE 22-1.
Paranasal sinuses.
(A)
Frontal view showing the
frontal, ethmoid, and maxillary sinuses.
(B)
Cross-section of
nasal cavity (anterior view).The shaded area is the osteomeatal
complex, which is the final common pathway for drainage of
the anterior ethmoid, frontal, and maxillary sinuses.
(C)
Lateral
wall, left nasal cavity showing the frontal sphenoidal sinuses
and the superior, middle, and inferior turbinates.
