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ENT (Ear, Nose, Throat Conditions)

Sinusitis (Acute)

Inflammation of the lining of the paranasal sinuses, typically following a viral upper respiratory tract infection (URTI). May become secondarily infected by bacteria.

Also known as: Rhinosinusitis

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Referral and warning signs

When to refer

Refer to ENT Specialist/Hospital if: Severe symptoms. Suspected orbital or intracranial complications (see red flags). Failure to improve after course of appropriate antibiotics. Recurrent acute sinusitis (>4 episodes/year). Chronic sinusitis (>12 weeks).

Red flags

  • Severe headache.
  • Periorbital swelling, redness, proptosis, or ophthalmoplegia (suggests orbital complication).
  • Visual changes (decreased acuity, double vision).
  • Altered mental status, neck stiffness, photophobia (suggests intracranial complication).
  • High persistent fever (>39°C).
  • Swelling over the forehead (Pott's puffy tumour).

Signs and symptoms

  • Nasal blockage / congestion.
  • Nasal discharge (may be thick, purulent, discoloured - yellow/green).
  • Facial pain or pressure (over affected sinus - maxillary/cheek, frontal/forehead, ethmoid/between eyes). Pain may worsen on bending forward.
  • Reduced or loss of sense of smell (hyposmia/anosmia).
  • +/- Fever.
  • +/- Cough (especially worse at night due to postnasal drip).
  • +/- Headache.
  • +/- Toothache (maxillary sinusitis).
  • +/- Bad breath (halitosis).
  • Symptoms typically persist >7-10 days OR worsen after initial improvement ('double sickening') to suggest bacterial cause.

Risk factors

  • Viral URTI (common cold).
  • Allergic rhinitis.
  • Nasal polyps.
  • Deviated nasal septum / other anatomical blockage.
  • Dental infections (for maxillary sinusitis).
  • Immunodeficiency.
  • Smoking.
  • Cystic fibrosis.

Diagnosis

Clinical assessment

Diagnosis usually clinical based on characteristic symptoms (nasal block, discharge, facial pain/pressure, smell disturbance) and duration/pattern.

Investigations

  • Usually not needed for uncomplicated acute sinusitis.
  • Nasal Endoscopy (specialist - visualize sinus openings, purulence).
  • CT Scan of Sinuses: Reserved for recurrent, chronic, complicated cases, or pre-operative planning.

Diagnostic criteria

Clinical diagnosis based on symptom complex and duration. Bacterial sinusitis more likely if symptoms >10 days OR severe onset (high fever, purulent discharge, severe pain >3 days) OR worsening after initial improvement ('double sickening').

Differential diagnosis

  • Common Cold (viral URTI) (usually resolves <7-10 days, less facial pain).
  • Allergic Rhinitis (itchy nose/eyes, watery discharge, sneezing).
  • Migraine / Tension headache.
  • Dental pain.
  • Trigeminal neuralgia.
  • Nasal foreign body (unilateral foul discharge).

Management

Non-pharmacological management

  • Symptomatic Relief:
  • - Analgesia (Paracetamol, NSAIDs).
  • - Nasal Saline Irrigation.
  • - Steam Inhalation (limited evidence, but may provide comfort).
  • - Rest, adequate fluid intake.

Pharmacological treatment

  • Viral Rhinosinusitis (Most cases <10 days): Symptomatic relief only (as above). Antibiotics NOT indicated.
  • Acute Bacterial Rhinosinusitis (Suspected based on duration/severity): (LOC: HC2/3)
  • - Antibiotics: Consider if symptoms meet criteria for bacterial cause.
  • - First line: Amoxicillin 500mg PO TID for 7-10 days. (Child: 15mg/kg/dose TID).
  • - Alternatives: Doxycycline (adults), Amoxicillin-Clavulanate.
  • - Intranasal Corticosteroids (INCS): May reduce inflammation and symptoms, consider as adjunct (e.g., Fluticasone, Mometasone spray). (LOC: HC3/4)
  • - Nasal Decongestants (Topical/Oral): Limited role, short-term use only (3-5 days) for congestion relief (e.g., Oxymetazoline spray, Pseudoephedrine PO). (LOC: HC2/3)

Monitoring

Symptoms should improve within 7 days of starting antibiotics (if bacterial). Follow up if symptoms persist or worsen.

Complications

  • Rare but potentially serious:
  • Orbital complications (Preseptal/Orbital cellulitis, Abscess).
  • Intracranial complications (Meningitis, Brain abscess, Cavernous sinus thrombosis).
  • Chronic sinusitis.
  • Mucocele.
  • Osteomyelitis (Pott's puffy tumour - frontal sinus).

Prevention

  • Good hygiene (handwashing) to prevent URTIs.
  • Management of allergic rhinitis.
  • Smoking cessation.
  • Influenza vaccination.

Patient education

  • Explanation of sinusitis (viral vs bacterial).
  • Rationale for antibiotic use (only if bacterial suspected).
  • Importance of completing antibiotic course.
  • Symptomatic relief measures (analgesia, saline rinse, steam).
  • Limited use of decongestants.
  • Warning signs of complications requiring urgent review.

Uganda-specific notes

Often follows common cold. Differentiating viral from bacterial based on duration/severity is key to avoid unnecessary antibiotics. Amoxicillin is standard first-line. Access to CT scans and specialist ENT care limited.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 21, Section 21.2.4

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