Sinusitis

Inflammation of the paranasal sinuses due to viral, bacterial, or fungal infection or allergic reactions.

Most types of sinusitis begin before old age, commonly in patients with disorders of the respiratory mucosa. In patients with long-standing allergic rhinosinusitis, symptoms generally abate with age. Nonetheless, sinusitis is common among the elderly. Causes include dental infections, obstruction due to a nasal polyp, and upper respiratory tract infections. In the elderly, a common cause of acute sinusitis is the packing used for treatment of epistaxis.

Symptoms, Signs, and Diagnosis

Symptoms are similar in elderly and younger patients. The area over the affected sinus may be tender and swollen. Facial pain occurs in various sites depending on which sinus is affected. Patients report congestion and may have bad breath, a general feeling of malaise, and yellow or green purulent rhinorrhea. The nasal mucosa is red and swollen, and a purulent exudate may be present. Fever and chills suggest that the infection has spread beyond the sinuses. A malodorous, purulent nasal discharge suggests a dental root abscess that has erupted into a maxillary sinus.

If a patient has nasal or cheek swelling, unilateral or bilateral nasal obstruction, and a purulent or bloody discharge, the cause may be nasal or sinus neoplasia, rather than sinusitis. Sinus x-rays should be obtained, and if indicated, a biopsy should be performed.

The affected sinus appears opaque on x-rays, but CT provides better definition of the extent and degree of sinusitis. If the maxillary sinus is affected, x-rays of the teeth may be needed to exclude a dental root abscess. If an abscess is present, the affected tooth may require extraction.

Treatment

Treatment is aimed at improving drainage and controlling the infection. Inhaling steam (eg, during a hot shower), using a saline nasal wash, blowing the nose, and drinking 6 to 8 glasses of water a day may help. Topical vasoconstrictors (eg, phenylephrine, oxymetazoline) used as a nasal spray may relieve congestion but should not be used > 7 days. Systemic vasoconstrictors (eg, pseudoephedrine) are less effective, can cause adverse effects in the elderly, and should be avoided.

Antibiotics should be given for at least 10 to 12 days if acute bacterial sinusitis is suspected. The initial antibiotic of choice is amoxicillin with or without clavulanate; alternatively, clarithromycin, azithromycin, or cefuroxime may be used. For chronic sinusitis, a broad-spectrum antibiotic should be used for acute flare-ups. Antibiotic therapy is usually effective. If it is not, surgical drainage may be necessary.