Sinusitis: Classification, Diagnosis, Treatment and Complications
Rhinosinusitis is inflammation of the nasal and paranasal sinus mucosa. Most acute cases are viral; bacterial infection is less common. Correct classification prevents unnecessary antibiotics and helps identify orbital or intracranial emergencies.
Nasal obstruction or discharge with facial pain or pressure or reduced smell. Duration, progression and red flags guide diagnosis.
Learning objectives
- Classify acute and chronic rhinosinusitis.
- Recognise bacterial patterns and complications.
- Select appropriate investigations and treatment.
Relevant anatomy and classification
The frontal, maxillary, ethmoid and sphenoid sinuses drain through narrow ostia. Mucosal oedema impairs ventilation and mucociliary clearance. Review nasal anatomy.
| Type | Typical duration |
|---|---|
| Acute | Up to 4 weeks, usually after a viral upper-respiratory infection. |
| Subacute | About 4–12 weeks. |
| Chronic | At least 12 weeks, with objective inflammation. |
| Recurrent acute | Distinct episodes with symptom-free intervals. |
Causes and risk factors
- Viral infection followed occasionally by bacterial superinfection.
- Allergic rhinitis, nasal polyps or anatomical obstruction.
- Dental infection, trauma, foreign body or impaired immunity.
- Smoking, pollution and impaired mucociliary clearance.
- Invasive fungal disease in severe immunosuppression or uncontrolled diabetes is an emergency.
Clinical features
- Nasal blockage with anterior or posterior discharge.
- Facial pressure or pain, sometimes worse on bending forward.
- Reduced smell, cough, headache, fever, dental pain or halitosis.
Acute bacterial disease is more likely with severe fever and purulent discharge, persistence without improvement beyond about 10 days, or worsening after initial improvement (“double sickening”). Purulent discharge alone does not prove bacterial infection.
Examination
Assess observations and general condition, then inspect the face, eyes, oral cavity and nose. Look for middle-meatal discharge, mucosal oedema, polyps and dental disease. Test visual acuity, pupils and eye movements if complications are possible.
Investigations
- Uncomplicated acute disease is usually clinical; routine imaging is unnecessary.
- Nasal endoscopy helps persistent, recurrent, unilateral or chronic symptoms.
- CT of the sinuses is used for chronic disease, surgical planning, suspected complication or atypical illness.
- Obtain targeted cultures in severe, immunocompromised or treatment-resistant disease rather than relying on an ordinary nasal swab.
See ENT investigations.
Management
Supportive care
- Analgesia, adequate fluids and saline nasal irrigation.
- Intranasal corticosteroid, especially with allergy or chronic inflammation.
- Avoid prolonged topical decongestant use because rebound congestion may occur.
Antibiotics
Most acute cases do not need antibiotics. Follow current local antimicrobial guidance when bacterial disease is strongly suspected, symptoms are severe, risk is high or complications are present. Choice, dose and duration depend on age, allergy, pregnancy, resistance patterns and severity.
Chronic rhinosinusitis
Regular saline irrigation and intranasal corticosteroids are foundational. Treat associated allergy, asthma and dental disease. ENT review may include endoscopy, CT and functional endoscopic sinus surgery when appropriate.
Complications and red flags
Urgently refer periorbital swelling, reduced vision, diplopia, ophthalmoplegia, severe frontal headache, meningism, altered consciousness, focal neurological deficit, forehead swelling or rapidly progressive illness.
| Group | Examples |
|---|---|
| Orbital | Preseptal or orbital cellulitis, subperiosteal abscess, orbital abscess, cavernous sinus thrombosis. |
| Intracranial | Meningitis, epidural or subdural empyema, brain abscess. |
| Osseous | Frontal bone osteomyelitis with Pott puffy tumour. |
Key examination points
- Rhinosinusitis affects both nasal and sinus mucosa.
- Most acute disease is viral and self-limiting.
- Persistence, severe onset or double worsening supports bacterial disease.
- CT is reserved for chronic, atypical, surgical or complicated cases.
- Eye and neurological signs require urgent specialist care.
References and further reading
For education only. Use current Uganda Clinical Guidelines and local antimicrobial protocols.
