Acute maxillary sinusitis

Essentials

  • Nasal blockage, rhinitis and pain/pressure over the cheeks are often present during a viral upper respiratory tract infection (URTI). These symptoms are caused by the viral infection and no antimicrobial therapy or further investigations are usually indicated [Evidence Level: C].
  • In adults and children aged over 7 years with URTI, the diagnosis of maxillary sinusitis is based on typical signs and symptoms as well as an ultrasonographic evaluation or x-rays.
  • A maxillary sinus puncture may be used to aid diagnosis if, for example, the results of imaging studies are inconclusive or if the patient has previously undergone maxillary sinus surgery.
  • Antimicrobial therapy should be considered if the symptoms have lasted for more than 10 days and secretions have been detected in the sinuses.
  • Maxillary sinusitis may be the cause of worsening symptoms of asthma.
  • In recurring maxillary sinusitis, any predisposing factors should be identified and, if necessary, the patient referred to an ENT specialist.
  • Rhinosinusitis in children: see (Rhinosinusitis in children).

Definition and epidemiology

  • Maxillary sinusitis refers to the inflammation of the mucosal lining of the maxillary sinuses, often with coexisting ethmoiditis and inflammation of the nasal mucosa.
  • Acute maxillary sinusitis is defined as an inflammation that has lasted less than 12 weeks. Chronic maxillary sinusitis is defined as more than 12 weeks of symptoms (see also (Chronic sinusitis)).
  • The condition is usually preceded by viral URTI; about 0.5–5% of cases result in subsequent maxillary sinusitis.
  • Predisposing factors include allergic or other chronic rhinitis, nasal polyps or other tumours in the nasal cavity, structural abnormalities of the middle nasal meatus or septum, dental root infection and, rarely, a foreign body.
  • Obstruction of the natural opening (ostium) and impaired ciliary function play a major role in the development of maxillary sinusitis.
Bacteriology

  • Haemophilus influenzae and Streptococcus pneumoniae – both account for about 30% of cases.
  • Other bacteria (e.g. Moraxella catarrhalis) account for about 10%.
  • The culture results are negative in about 30% of cases.

Symptoms

  • Facial pain, especially around the eyes and over the cheeks
  • Pain radiating to the canine teeth and molars of the upper jaw
  • Purulent nasal discharge, which manifests itself either as rhinorrhoea or postnasal drip
  • Prolonged cough (particularly in the mornings), rhinitis or nasal stuffiness
  • Hyposmia

Diagnosis

  • The symptoms of a viral common cold and a purulent sinusitis are quite similar. Bacterial aetiology is suggested by:
    • prolonged symptoms for more than 10 days
    • exacerbation of symptoms after the initial phase (becoming ill again)
    • severity of symptoms and of the general signs of infection (fever).
  • The presence of secretions may also be verified with the aid of maxillary sinus puncture and irrigation in case the results of imaging studies are inconclusive and the procedure is considered necessary in view of the symptoms, or if the patient has undergone maxillary sinus surgery.
  • Physical examination
    • Nasal discharge as well as mucosal oedema and erythema are seen particularly in the middle nasal meatus.
    • The middle nasal meatus is easier to examine after applying local anaesthesic and vasoconstrictor.
    • Purulent discharge may be seen flowing down on the back wall of the oropharynx.
  • Ultrasonography of the sinuses (Diagnosis of sinusitis) (pictures (1) (Investigation of maxillary sinuses by ultrasonography (close view))) is a relatively reliable diagnostic method in adults and children aged over 7 years, but it requires critical observation, experience and, occasionally, feedback from maxillary sinus puncture [Evidence Level: A].
    • If an ultrasonography examination repeatedly shows a back-wall-echo at a distance of 4–6 cm, the diagnostic accuracy for acute stasis of secretions is as good as 80–95%. The state of the mucous membranes (e.g. mucosal oedema) cannot be reliably evaluated with ultrasonography.
  • An x-ray examination of maxillary sinuses may reveal total opacity of the sinus (pictures (Maxillary sinusitis) (Maxillary sinusitis)) or a fluid level (picture (Fluid levels in maxillary sinuses)); these are both fairly reliable signs implying the retention of secretions within the sinus. In rhinitis, x-rays of the maxillary sinuses fairly often show mucosal oedema, but its significance in the diagnostic work-up is considerably smaller.
  • In an unclear situation, determination of ESR or CRP may be useful.

Treatment

  • If symptoms have persisted for more than 10 days, a 7 day course of antimicrobials may be indicated for patients with severe symptoms. When deciding on the treatment, consider that an acute maxillary sinusitis quite often resolves also spontaneously.
  • Isolated symptoms or examination findings cannot reliably identify the subgroup of patients who would benefit from antimicrobial therapy [Evidence Level: B].
  • Symptomatic treatment is recommended for those with mild or moderate symptoms, e.g. by analgesics and nasal glucocorticoid sprays.
    • Several international care guidelines recommend the use of glucocorticoid sprays both as adjunct therapy and prophylaxis of acute maxillary sinusitis [Evidence Level: A].
    • Nasal glucocorticoids are beneficial in maxillary sinusitis particularly for patients with allergic rhinitis and/or nasal polyposis.
    • Subjective benefit is also gained from nasal saline douching and nasal sprays.
  • It is worthwhile to include analgesics to the treatment regime in all patients if the clinical presentation warrants it.
  • Recommended antimicrobial therapy: see table T1.
  • Treatment of sinusitis in children: see (Rhinosinusitis in children).
  • Maxillary sinus irrigation, in addition to antimicrobial therapy, may be recommended to a patient with recurring, severe maxillary sinusitis.
  • If the first-choice drug proves to be ineffective, maxillary sinus puncture and irrigation could be considered. This will provide material for a bacterial culture, and often the symptoms improve fairly quickly after the stasis of secretions has been relieved.
  • Various adjunct therapies have been added to the antimicrobial therapy, including nasal decongestants and drugs that alter the viscosity of the mucus. There is little evidence on their efficacy on the treatment of maxillary sinusitis, but they may temporarily ease symptoms.

Table 1. Antimicrobial therapy in maxillary sinusitis
Drug Dosage (treatment period 7 days, unless otherwise mentioned)
First-line drugs
  • Amoxicillin
  • Penicillin V
  1. 500 mg three times daily or 750 mg two to three times daily
  2. 1.5 million IU twice daily
Second-line drugs
  • Doxycycline
  • Amoxicillin clavulanate
  1. Starting dose 150–200 mg, then 100–150 mg once daily
  2. 750–875 mg twice daily
Others
  • Sulphadiazine/trimethoprim
  1. 500/160 mg 1 tablet twice daily
  1. First and second generation cephalosporins
  • Cefalexin
  • Cefuroxime axetil
  1. 750 mg twice daily
  2. 250 mg twice daily
  1. Macrolides
  • Azithromycin
  • Clarithromycin
  • Roxithromycin
  1. 500 mg once daily, treatment period 3 days
  2. 250 mg twice daily or 500 mg once daily
  3. 150 mg twice daily
Maxillary sinus puncture and irrigation

  • Local anaesthesia is provided with a cotton-tipped swab that has been soaked in a solution of 4% lidocaine, into which 2–3 drops of adrenaline (1:1,000) has been added for each 5 ml. The swab is placed below the inferior nasal concha to the point of puncture, which will have bone contact. The anaesthesia will take about 20 minutes to become effective.
  • Local anaesthesia may also be provided with EMLA® cream [Evidence Level: B].
  • The puncture is carried out using a straight needle with stylet. The site of puncture is laterally at the inferior nasal meatus 2–3 cm from the nasal orifice.
  • Normal saline at 37°C is injected into the maxillary sinus after which it flows out through the natural opening (ostium) to the nasal meatus.
  • Increased resistance felt during the injection may be due to viscous mucus or obstructed ostium. However, pressure must not be increased by force as it will cause pain and may result in complications.
    • Resistance may be lowered by anaesthetising the middle nasal meatus, which will reduce the mucosal oedema around the ostium.
    • It is also possible to insert another puncture needle into the sinus through which the irrigation fluid may be evacuated in cases where the ostium does not become patent even after the local anaesthesia.
  • No air must be present in the irrigation syringe as any air injected with pressure into the sinus could predispose the patient to an air embolus.
  • Complications
    • Bleeding usually stops spontaneously. Should bleeding persist the inferior nasal meatus can be re-anaesthetised and a piece of absorbable haemostatic material placed in the inferior meatus.
    • If the patient’s cheek swells up during the procedure the tip of the irrigation needle is outside the maxillary sinus. Should this happen the irrigation must be stopped and the patient prescribed a course of antibiotics.
    • Any irrigation fluid in the tissues will be absorbed within a few weeks.
    • If the patient’s eye or eyelids swell during the procedure, the needle has entered the orbit. As above, the irrigation must be stopped immediately and the patient sent to an ENT emergency department.

Evidence Summaries

Follow-up

  • If the symptoms resolve completely no follow-up is indicated.
  • If symptoms persist despite treatment
    • Sinus puncture and irrigation should be considered to obtain culture material, to confirm diagnosis and to remove retained secretions.
    • If indicated, antimicrobial therapy in accordance with sensitivity testing should be prescribed.
    • If purulent secretions are aspirated, the sinus puncture is repeated with an interval of about one week.
    • Any predisposing factors should be identified (see above).
      • Allergic or other chronic rhinitis (history, allergy tests)
      • Mucosal oedema, polyps, septal deviation (anterior rhinoscopy)
      • Dental health (odontogenic maxillary sinusitis)

Indications for referral to specialist

  • Symptomatic maxillary sinusitis persisting after 12 weeks despite appropriate treatment
  • At least 3–4 recurring episodes of maxillary sinusitis a year
  • Nasal polyps in a patient with chronic maxillary sinusitis
  • A suspicion of a complication

Surgery

  • Surgical treatment may be considered for the management of prolonged or frequently recurring maxillary sinusitis (Chronic sinusitis).
  • Endoscopic paranasal procedures carried out through the nostrils (functional endoscopic sinus surgery, FESS): see (Chronic sinusitis)

Management after maxillary surgery

References

1. Thomas M, Yawn BP, Price D ym. EPOS Primary Care Guidelines: European Position Paper on the Primary Care Diagnosis and Management of Rhinosinusitis and Nasal Polyps 2007 - a summary. Prim Care Respir J 2008;17(2):79-89.  [PMID:18438594]


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