Revision 45 for 'Acute sinusitis'

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Acute sinusitis

Acute sinusitis is an acute inflammation of the paranasal sinus mucosa that lasts less than four weeks and can occur in any of the paranasal sinuses. If the nasal cavity mucosa is also involved then the term rhinosinusitis may be used.

Clinical presentation

Fever, headache, postnasal discharge of thick sputum, nasal congestion and an abnormal sense of smell.

Pathology

Etiology

Usually following a viral upper respiratory tract infection. Dental caries, periapical abscess and oroantral fistulation lead to a spread of infection to the maxillary sinus. Cystic fibrosis and allergy are risk factors.

Other anatomical variants that may predispose to the inflammation include nasal septal deviation, a spur of the nasal septum and/or frontoethmoidal recess variants.

Radiographic features

An air-fluid level is the most typical imaging finding. However, it is only present in 25-50% of patients with acute sinusitis 4.

Plain radiograph

Opacification of the sinuses and air-fluid level best seen in the maxillary sinus. It does not allow assessment of the extent of inflammation and its complications.

CT

Most common method of evaluation. Better anatomical delineation and assessment of inflammation extension, causes and complications.

Peripheral mucosal thickening, air-fluid level, gas bubbles within the fluid and obstruction of the ostiomeatal complexes are recognized findings.

Rhinitis, often associated with sinusitis, is often characterized by thickening of the turbinates with obliteration of the surrounding air channels. This should not be confused with the normal nasal cycle.

MRI

Signal characteristics of the affected regions include

  • T1: mucosal thickening is isointense to soft tissue and fluid is hypointense
  • T2: both mucosal thickening and fluid are, to a variable degree, hyperintense
  • T1 C+ (Gd): inflamed mucosa enhances whilst fluid does not
Ultrasound

Although not the primary mode of investigation, sonography may be used to screen for maxillary sinusitis; the perturbation of the normal air/fluid ratio in sinusitis alters the acoustic impedance of the usually aerated space. Normal and abnormal maxillary sinus features may be differentiated as follows:

  • normal maxillary sinus
    • a series of horizontal reverberation artifacts extend into the far field, dimishing with each successive iteration, parallel to the prominent near field linear echogenic cortex of the maxilla 9
    • the far field is ill-defined, and the posterior wall of the sinus is not visible
  • abnormal maxillary sinus
    • complete sinusogram 5
      • sagittal insonation reveals the absence of horizontal reverberation artifacts, replaced by an anechoic space
      • posterior wall appears in the far field as an echogenic stripe 
      • transverse insonation reveals this echolucent space bordered by the medial and lateral walls
      • this indicates the sinus is fluid-filled, and is highly suggestive of sinusitis in the appropriate clinical context
    • partial sinusogram
      • sagittal visualization of a portion of the posterior wall, with adjacent horizontal reverberation artifacts
      • medial/lateral walls obscured 
      • nonspecific finding, but increased specificity if partial sinusogram present while semi-supine and absent when supine 6
        • this indicates an air-fluid level, and is considered positive for sinusitis
        • presence when both semi-supine and supine thought to be indicative of mucosal thickening 7

Treatment and prognosis

Conservative medical treatment until the inflammation subsides and treatment of the cause, e.g. dental caries. If it becomes chronic sinusitis, functional endoscopic sinus surgery may be considered.

Complications

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