Internal Medicine

0521779407-19 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:21

1352 Sinusitis

■Nasal obstruction

■Fever (variable)

■Malaise or fatigue headache

■Dental pain

■Ear pressure or fullness

■Cough

■Halitosis

■Reduced resonance of voice, or “hyponasal voice” due to inflamma-

tion in sinuses

Physical Examination

■Nasal speculum: erythema, edema, purulent discharge, nasal polyps

■Nasal endoscopy with fiberoptic scope: offers more sensitive exam

and better localization of site of involvement: erythema, edema,

purulent discharge, nasal polyps

■Oral cavity: purulent discharge sometimes visible on posterior pha-

ryngeal wall

■Facial: in acute cases, tenderness may be present over frontal or

maxillary sinuses and edema or swelling around eyes (may indicate

extension of infection and should be investigated)

■Be wary of orbital, intracranial complications (mental status

change, periorbital swelling,proptosis, visual acuity change, severe

headache, meningismus)

■Complications less common with chronic sinusitis

■Mucocele or mucopyocele can occur with chronic infection

■Rhinosinusitis Classification

➣Acute: <4 weeks often preceded by a viral URI

➣Recurrent acute 4 or more episodes/year resolution of symptoms

between episodes

➣Subacute: 4–12 weeks intermediate classification

➣Chronic: >12 weeks may have acute exacerbations

tests

Laboratory

■CBC, immunologic evaluation, blood cultures as clinically indicated

Radiography

■Uncomplicated sinusitis: coronal CT of sinuses: 3 mm cuts, bone

windows, no contrast

■If complications suspected:

➣Coronal and axial CT of sinuses and brain

➣3 mm cuts, soft tissue and bone windows, with contrast