Sinusitis resident survival guide
Synonyms and keywords:approach to bacterial sinusitis, approach to viral sinusitis, approach to sinusitis, sinusitis workup, sinusitis management

# Overview
Rhinosinusitis is the inflammation of the nasal mucosa and paranasal sinuses. The terms sinusitis and rhinosinusitis are used interchangeably, although rhinosinusitis is preferred because inflammation of the paranasal sinuses rarely ever occurs without concurrent inflammation of the nasal mucosa.  The cause of rhinosinusitis is mostly infectious, although it can be associated with other medical conditions such as allergies. The diagnosis is primarily clinical and imaging and other diagnostic studies are not necessary for diagnosis.

# Causes

## Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- There are no known causes of life-threatening causes of sinusitis.

## Common Causes
Infectious causes of rhinosinusitis include viruses, bacteria, and fungi:
- Viruses
Rhinovirus
Influenza virus
Parainfluenza virus
- Rhinovirus
- Influenza virus
- Parainfluenza virus
- Bacteria
Streptococcus pneumoniae
Haemophilus influenzae
Moraxella catarrhalis
Streptococcus pyogenes
Staphylococcus aureus: common in chronic sinusitis
Pseudomonas aeruginosa: common in nosocomial sinusitis, cystic fibrosis patients and the immunocompromised
Anaerobes: Prevotella, Fusobacterium and Peptostreptococcus: common in chronic sinusitis
- Streptococcus pneumoniae
- Haemophilus influenzae
- Moraxella catarrhalis
- Streptococcus pyogenes
- Staphylococcus aureus: common in chronic sinusitis
- Pseudomonas aeruginosa: common in nosocomial sinusitis, cystic fibrosis patients and the immunocompromised
- Anaerobes: Prevotella, Fusobacterium and Peptostreptococcus: common in chronic sinusitis
- Fungi
Aspergillus species
Fusarium species
The Mucorales
- Aspergillus species
- Fusarium species
- The Mucorales

# Diagnosis and Treatment
- The diagnosis of sinusitis according to The Infectious Diseases Society of America is based on the presence of at least 2 major or 1 major and 2 minor of the following symptoms:
- The clinical criteria for the diagnosis of bacterial sinusitis according to The American Academy of Otolaryngology, Head, and Neck Surgery is based on the fullfillment of all the following:
- Persistent symptoms
Nasal congestion, rhinorrhea, or cough
10 days duration without improvement
- Nasal congestion, rhinorrhea, or cough
- 10 days duration without improvement
- Severe symptoms
Temperature 38.5C for 3-4 days
Purulent rhinorrhea for 3-4 days
- Temperature 38.5C for 3-4 days
- Purulent rhinorrhea for 3-4 days
- Worsening symptoms
Return of symptoms after initial resolution
New or recurrent fever, increased rhinorrhea, or increase in cough
- Return of symptoms after initial resolution
- New or recurrent fever, increased rhinorrhea, or increase in cough
- Shown below is an algorithm summarizing the diagnosis and treatment of sinusitis according to the American Academy of Otolaryngology, Head, and Neck Surgery guidelines:
- The diagnosis of sinusitis according to them is based on the presence of at least 2 major or 1 major and 2 minor of the following symptoms:

# Do's
- During retrieval of history, ask for the exposure to toxins, toxic waste, wood, immersion in contaminated water, solvents, gas or oil refineries, leather tanning, textiles, drug addictions, and chronic administration of intranasal drugs.
- During retrieval of history, ask for prior upper respiratory infections, use of tobacco, anatomic anomalies, acid reflux disease, and immunologic state.
- Look after major and minor signs of sinusitis:,
Major: purulent rhinorrhea, nasal obstruction, facial pain, hyposmia, anosmia, and fever
Minor: headache, cough, halitosis, fatigue, otalgia, and dental pain
- Major: purulent rhinorrhea, nasal obstruction, facial pain, hyposmia, anosmia, and fever
- Minor: headache, cough, halitosis, fatigue, otalgia, and dental pain
- During physical examination look for purulent nasal discharge, rhinolalia, edema, periorbital erythema, and pain to palpation and percussion to the front maxillary region.
- Be aware of orbital pain, visual disturbances, facial erythema, and meningitis signs, since these patients should be sent urgently to the emergency department.

# Don'ts
- Avoid inappropriate use of antibiotics in acute presentations since the vast majority of these infections are viral.
- Avoid ordering imaging studies in cases where the diagnosis is well established clinically.
- Avoid the use of decongestants, antihistamines, topical steroid sprays when unnecessary.