Acute Rhinosinusitis

Also known as: Acute sinusitis

Inflammation of the nasal and paranasal sinus mucosa of less than 12 weeks duration, with complete resolution of symptoms. The nose and sinuses share a continuous mucosa, which is why rhinosinusitis rather than sinusitis is the accurate term.

Pathophysiology

Viral upper respiratory infection produces mucosal oedema at the osteomeatal complex, the narrow common drainage pathway for the maxillary, anterior ethmoid and frontal sinuses. Obstruction of the ostium impairs ciliary clearance, lowers intrasinus oxygen tension and raises carbon dioxide, and produces a stagnant secretion pool that favours bacterial proliferation. Ciliary beat frequency falls, mucus becomes more viscous, and the cycle perpetuates.

Anatomical drainage, which determines symptom localisation and complication risk

Maxillary, anterior ethmoid and frontal sinuses drain into the middle meatus through the osteomeatal complex.
Posterior ethmoid and sphenoid sinuses drain into the sphenoethmoidal recess and superior meatus.
The nasolacrimal duct drains into the inferior meatus.
The lamina papyracea separating the ethmoid from the orbit is paper thin and dehiscent in a proportion of people, which is why the ethmoid is the source of most orbital complications, particularly in children.
The frontal sinus posterior table abuts dura, and its diploic veins communicate with the dural venous sinuses, explaining intracranial complications and Pott puffy tumour.

Classification by duration and course

Acute viral rhinosinusitis, or common cold: symptoms less than 10 days.
Acute post viral rhinosinusitis: symptoms increasing after 5 days or persisting beyond 10 days, with less than 12 weeks total.
Acute bacterial rhinosinusitis: a subset of post viral disease, occurring in only 0.5 to 2 percent of viral upper respiratory infections in adults and 5 to 10 percent in children.
Recurrent acute rhinosinusitis: four or more episodes per year with complete resolution between.

Microbiology of bacterial disease

Streptococcus pneumoniae, non typeable Haemophilus influenzae, Moraxella catarrhalis, Streptococcus pyogenes, Staphylococcus aureus, and anaerobes in odontogenic disease. Nosocomial sinusitis in intubated and nasogastric tube fed intensive care patients involves Pseudomonas, Klebsiella and Staphylococcus aureus.

Predisposing factors

Viral infection, allergic rhinitis, anatomical variants including concha bullosa, a deviated septum, Haller cells and a large agger nasi cell, nasal polyps, dental disease and dental procedures, immunodeficiency, ciliary dyskinesia, cystic fibrosis, smoking, swimming and diving, nasal foreign body in children, and nasogastric or nasotracheal intubation.

Cardinal symptoms, requiring nasal obstruction or discharge plus at least one of facial pain or pressure and reduction or loss of smell:

Nasal blockage, congestion or obstruction.
Anterior or posterior nasal discharge, which may be clear, mucoid or purulent. Purulent discharge alone does not indicate bacterial infection, since neutrophil influx in viral disease produces the same colour change.
Facial pain, pressure or fullness, localised over the affected sinus and worse on bending forward.
Hyposmia or anosmia.

Site specific pain patterns

Maxillary: cheek and upper dental pain, sometimes with referred pain to the upper molars.
Frontal: forehead pain above the eye, often worse in the morning and on bending.
Ethmoid: pain between and behind the eyes, with medial canthal tenderness.
Sphenoid: vertex, occipital or deep retro orbital pain, frequently misdiagnosed as migraine or tension headache. Isolated sphenoid disease is the classical missed diagnosis.

Features suggesting bacterial rather than viral disease, at least three of:

Discoloured discharge with unilateral predominance.
Severe local pain with unilateral predominance.
Fever above 38 degrees Celsius.
Raised C reactive protein or erythrocyte sedimentation rate.
Double sickening, meaning deterioration after an initial improvement, which is the most useful single feature.

Red flags requiring urgent assessment and imaging

Periorbital oedema or erythema.
Displaced globe, proptosis.
Double vision, ophthalmoplegia, reduced visual acuity or colour vision, relative afferent pupillary defect.
Severe unilateral or bilateral frontal headache.
Frontal swelling, indicating Pott puffy tumour.
Signs of meningitis, focal neurological deficit, seizure, reduced consciousness.
Immunocompromise with facial pain, black nasal crusting or eschar, which suggests invasive fungal disease.

Examination

Anterior rhinoscopy showing mucosal oedema, purulent discharge in the middle meatus, and any polyps or foreign body.
Percussion tenderness over the affected sinus.
Examine the eyes fully: acuity, colour vision, pupils, eye movements and proptosis.
Examine the dentition and percuss the upper molars and premolars.
Assess for neck stiffness and neurological signs.

Uncomplicated acute rhinosinusitis is a clinical diagnosis. Imaging is neither necessary nor helpful and is positive in most people with a simple cold.

Nasal endoscopy where the diagnosis is uncertain, in unilateral disease, in recurrent disease, and in immunocompromised patients. It permits assessment of the middle meatus and directed culture.
Endoscopically guided middle meatal swab where culture is needed, which correlates well with antral puncture. A nasal vestibule swab is useless and grows skin flora.
Antral puncture for culture in intensive care patients, immunocompromised patients and treatment failures.
C reactive protein and full blood count where bacterial disease or a complication is suspected.
Blood cultures in septic patients.
Contrast enhanced computed tomography of the sinuses, orbit and brain, urgently, for any orbital or intracranial red flag. It defines subperiosteal and orbital abscess, bone erosion, and intracranial collections.
Magnetic resonance imaging with contrast for suspected intracranial extension, cavernous sinus thrombosis and to characterise soft tissue.
Non contrast computed tomography of the sinuses is reserved for recurrent disease, treatment failure and preoperative planning, and should not be performed during an acute uncomplicated episode.
Dental panoramic radiography or cone beam computed tomography where an odontogenic source is suspected, which accounts for around 10 to 40 percent of maxillary sinusitis and which will not resolve until the tooth is treated.

Differential diagnosis and the discriminating feature

Migraine and tension headache: no nasal obstruction or discharge, with photophobia, nausea and a positive family history. A large proportion of self diagnosed sinus headache is migraine.
Trigeminal neuralgia: brief lancinating pain in a trigeminal division, triggered by touch.
Dental disease: localised to a tooth, reproduced by percussion.
Temporomandibular dysfunction: joint tenderness, pain on chewing.
Nasal foreign body in a child: unilateral foul purulent discharge, which is the presentation until proven otherwise.
Invasive fungal sinusitis in the immunocompromised: pain out of proportion, mucosal anaesthesia, pale or black necrotic turbinate mucosa. A neutropenic or diabetic patient with facial pain requires immediate endoscopy and biopsy.
Sinonasal malignancy: unilateral obstruction, bleeding, cheek numbness in the infraorbital distribution, loosening teeth.
Granulomatosis with polyangiitis: crusting, septal perforation, saddle nose, haematuria.

Most acute rhinosinusitis is viral and self limiting. Antibiotics are massively overprescribed and provide marginal benefit in unselected patients.

Symptomatic treatment, which is the mainstay

Intranasal corticosteroid, which has the best evidence of any single agent for acute rhinosinusitis: mometasone furoate 200 micrograms per nostril twice daily, or fluticasone propionate 100 micrograms per nostril twice daily, for 14 to 21 days. Teach correct technique with the spray directed laterally toward the ipsilateral outer canthus, away from the septum, since septal directed spraying causes epistaxis and perforation and reduces efficacy.
Nasal saline irrigation with high volume isotonic or hypertonic solution, 240 mL per nostril once or twice daily, which improves mucociliary clearance and symptom scores.
Analgesia: paracetamol 1 g every 6 hours, maximum 4 g in 24 hours; ibuprofen 400 mg every 8 hours with food, maximum 2.4 g in 24 hours.
Topical decongestant: xylometazoline 0.1 percent or oxymetazoline 0.05 percent, one to two sprays per nostril twice daily for a maximum of 5 days. Beyond this, rebound congestion and rhinitis medicamentosa develop.
Oral decongestant: pseudoephedrine 60 mg three times daily for up to 5 days, avoided in hypertension, ischaemic heart disease, arrhythmia, hyperthyroidism, prostatic obstruction, narrow angle glaucoma and with monoamine oxidase inhibitors.
Steam inhalation, which is comforting but has little objective evidence and causes scald injuries in children.
Antihistamines have no role unless allergic rhinitis coexists, and their drying effect thickens secretions.
Mucolytics have weak evidence.

Antibiotics

Indications, rather than routine prescription:

Severe symptoms with fever above 38 degrees Celsius and severe unilateral facial pain.
Symptoms worsening after initial improvement, that is double sickening.
Symptoms failing to improve after 10 days.
Immunocompromise, poorly controlled diabetes, cystic fibrosis.
Any suspected complication, where intravenous therapy is required.

Regimens:

Amoxicillin 500 mg to 1 g orally three times daily for 5 to 7 days as first line in adults where local resistance permits. In children, amoxicillin 40 to 50 mg/kg per day divided twice or three times daily.
Co amoxiclav 625 mg orally three times daily, or 1 g twice daily, for 5 to 7 days, preferred where beta lactamase producing Haemophilus and Moraxella are prevalent, in recent antibiotic exposure, in treatment failure, in severe disease, and in odontogenic infection where anaerobic cover matters. Children: 45 to 90 mg/kg per day of the amoxicillin component divided twice daily.
Doxycycline 200 mg on day 1 then 100 mg daily, for 5 to 7 days, in penicillin allergy in adults. Avoid in children under 8 years and in pregnancy.
Clarithromycin 500 mg twice daily or azithromycin as alternatives, accepting substantial pneumococcal resistance in many settings.
Levofloxacin 500 mg daily or moxifloxacin 400 mg daily are reserved for severe disease or failure of first line therapy in penicillin allergic patients, given quinolone adverse effects.
Add metronidazole 400 mg three times daily where an odontogenic source or anaerobic infection is likely, unless co amoxiclav is being used.
Duration is 5 to 7 days in adults and 10 days in children. Longer courses confer no benefit in uncomplicated disease.
Failure at 72 hours requires reassessment, endoscopically guided culture and imaging rather than a further blind course.

Odontogenic sinusitis

Will not resolve with sinus treatment alone. Requires dental assessment with extraction, root canal treatment or removal of a displaced root or implant, together with antibiotics with anaerobic cover. Refer to maxillofacial or dental services in parallel with medical treatment.

Surgical intervention in acute disease

Rare and reserved for:

Failure of maximal medical therapy with persistent severe symptoms.
Any orbital or intracranial complication.
Immunocompromised patients with suspected invasive fungal disease, where urgent endoscopic biopsy and debridement is required.
Antral washout or endoscopic drainage for a sinus empyema.

Orbital complications and their management

Classified by extent:

Preseptal cellulitis: lid oedema and erythema with normal acuity, normal eye movements and no proptosis. Treated with oral or intravenous antibiotics depending on severity, with close observation.
Orbital cellulitis: proptosis, chemosis, painful and restricted eye movements, with the potential for visual loss. Admit. Intravenous ceftriaxone 2 g every 12 hours in adults or 50 mg/kg every 12 hours in children plus metronidazole 500 mg every 8 hours or 7.5 mg/kg every 8 hours, with vancomycin where methicillin resistant Staphylococcus aureus is a concern. Add intranasal decongestant and steroid. Hourly visual acuity, colour vision and pupil checks. Urgent ophthalmology involvement.
Subperiosteal abscess: requires contrast computed tomography. Small medial abscesses in children under 9 years without visual compromise may be managed medically with close observation for 24 to 48 hours. Drainage is indicated for visual deterioration, large abscess, non medial location, age over 9 years, failure to improve within 48 hours, or any doubt.
Orbital abscess and cavernous sinus thrombosis require immediate surgical drainage and intensive care management. Cavernous sinus thrombosis presents with bilateral eye signs, cranial nerve III, IV, V1, V2 and VI palsies, and requires anticoagulation discussion.
Endoscopic drainage of the ethmoid with abscess evacuation is the usual approach, with an external Lynch incision reserved for lateral or superior collections.

Intracranial complications

Meningitis, extradural and subdural empyema, frontal lobe abscess, and superior sagittal or cavernous sinus thrombosis. Pott puffy tumour is a frontal subperiosteal abscess with underlying osteomyelitis, presenting as a boggy frontal swelling, and always indicates the need for imaging of the brain since intracranial extension coexists in around half. Management is combined neurosurgical and rhinological, with high dose intravenous ceftriaxone plus metronidazole plus vancomycin, drainage of collections, and endoscopic or open sinus surgery for source control.

Follow up and prevention

Review non resolving cases at 10 to 14 days with endoscopy.
Investigate recurrent disease with computed tomography between episodes, allergy testing, immunoglobulin levels and specific antibody responses, and consider ciliary and cystic fibrosis testing.
Smoking cessation, treatment of allergic rhinitis, influenza and pneumococcal vaccination, and correction of significant anatomical obstruction reduce recurrence.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Recurrent Tonsillitis

Repeated discrete episodes of acute tonsillitis with complete resolution between episodes. It is defined by frequency and severity thresholds because these determine whether tonsillectomy delivers benefit that exceeds its risk.

Why recurrence happens

Bacterial biofilms within the tonsillar crypts, which resist antibiotic penetration and host clearance and reactivate with each viral trigger.
Beta lactamase producing organisms in the crypts, principally Haemophilus influenzae, Staphylococcus aureus, Moraxella catarrhalis and anaerobes, which inactivate penicillin locally even when the pathogen is a susceptible Streptococcus pyogenes. This is the mechanism of apparent penicillin failure in a patient with a penicillin sensitive organism.
Streptococcal carriage, in which the organism colonises without invading, with viral illnesses producing symptoms that are then attributed to the streptococcus.
Impaired local immunity and, occasionally, systemic immunodeficiency.
High exposure settings: young children, day care, teachers, healthcare workers, large households.

Threshold criteria, commonly known as the Paradise criteria, which define the group in whom tonsillectomy has demonstrated benefit:

Seven or more adequately documented episodes in the preceding year, or
Five or more episodes per year in each of the preceding 2 years, or
Three or more episodes per year in each of the preceding 3 years.

Each episode must have been clinically significant, with sore throat plus at least one of temperature above 38.3 degrees Celsius, cervical lymphadenopathy, tonsillar exudate, or a positive test for group A streptococcus, and each must have been treated appropriately and documented at the time.

The evidence position, stated honestly

Tonsillectomy in children meeting the strict criteria reduces episodes by around three per year in the first year, with the difference narrowing thereafter. In adults, the reduction in days with sore throat is smaller but still meaningful. Many children improve spontaneously with time regardless of surgery. The decision is therefore a genuine balance of a modest, temporary benefit against a real risk of haemorrhage and a painful recovery, and it belongs to the informed patient or family.

Repeated well demarcated episodes, each with sore throat, fever, odynophagia and lymphadenopathy, resolving completely.
Complete wellness between episodes, which distinguishes this from chronic tonsillitis.
Repeated courses of antibiotics with initial response and subsequent recurrence.
Days lost from school or work, which is a legitimate part of the surgical indication and should be quantified.
Family disruption and, in adults, occupational consequences.

Assessment that determines the decision

Document the number of episodes, with dates and treatments, from records rather than from memory. Patient and parental recall substantially overestimates frequency, and a proportion of reported episodes were viral upper respiratory infections or self limiting sore throats.
Where the history is uncertain, a period of prospective documentation over 6 to 12 months using a symptom diary and clinical confirmation of each episode is a legitimate and often decisive approach.
Assess for the alternative explanations: PFAPA syndrome with strikingly regular episodes and complete wellness between, tonsilloliths causing halitosis and discomfort mistaken for infection, chronic tonsillitis with persistent symptoms, and recurrent viral pharyngitis.

Red flags requiring investigation beyond the throat

Unilateral tonsillar enlargement, ulceration, induration or a neck mass in an adult, indicating malignancy.
Recurrent infections at multiple sites, chronic diarrhoea, failure to thrive, indicating immunodeficiency.
Pallor, bruising and lymphadenopathy, indicating haematological malignancy.
Recurrent oral ulceration with cyclical fever in a young child, indicating PFAPA syndrome.
Recurrent oral ulceration with genital ulceration and uveitis, indicating Behçet disease.

Documented episode history, which is the diagnosis.
Throat swab culture during an episode to establish the pathogen and its sensitivities, which guides antibiotic choice for subsequent episodes and identifies beta lactamase producing organisms.
Full blood count with differential.
Immunoglobulin G, A and M with subclasses, and specific antibody responses to pneumococcal and tetanus vaccination, where the pattern suggests immunodeficiency or where infections occur at other sites.
HIV testing in the appropriate context.
Anti streptolysin O and anti DNase B titres, which are of limited value acutely but which distinguish true recurrent infection with a rising titre from carriage with a static titre.
Consider PFAPA in a child under 5 years with regular episodes; a trial of a single dose of prednisolone 1 to 2 mg/kg at episode onset, which aborts the episode within hours, is both diagnostic and therapeutic.
Examination under anaesthesia with biopsy or tonsillectomy for unilateral disease in an adult.

Non surgical management, which should be exhausted first in patients not meeting criteria

Treat each episode adequately with a full 10 day course of phenoxymethylpenicillin where streptococcal, since incomplete courses contribute to recurrence.
Where episodes recur despite penicillin, use an agent stable to beta lactamase: co amoxiclav 625 mg three times daily for 10 days, or clindamycin 300 mg four times daily for 10 days, which penetrates the tonsil well, is active against anaerobes and biofilm associated organisms, and has the best evidence for eradication in recurrent disease.
Analgesia, hydration and symptomatic care as for acute tonsillitis.
Address modifiable factors: smoking cessation including passive exposure, treatment of reflux, management of allergic rhinitis and mouth breathing, and dental hygiene.
Watchful waiting for 6 to 12 months in children not clearly meeting criteria, since spontaneous improvement is common and the difference between surgical and non surgical groups narrows over time.
Long term antibiotic prophylaxis is not recommended for recurrent tonsillitis.

Tonsillectomy

Indications:

Meeting the frequency and severity thresholds above with documented episodes.
Recurrent peritonsillar abscess, or a single abscess in a patient with a history of recurrent tonsillitis.
Obstructive sleep apnoea from tonsillar hypertrophy, which is a separate and stronger indication.
Suspected malignancy, unilateral enlargement, or the need for tissue diagnosis.
PFAPA syndrome, where tonsillectomy is curative in the majority.
Recurrent tonsillitis with a documented complication such as rheumatic fever or streptococcal glomerulonephritis.
Chronic tonsillitis with persistent symptoms and halitosis unresponsive to conservative measures.
Tonsillitis causing febrile convulsions.

Preoperative assessment

Full blood count and, where there is a bleeding history or family history, a coagulation screen and von Willebrand studies. Routine coagulation screening in all patients has low yield; a structured bleeding history is more informative.
Sickle cell screening where relevant.
Assess for obstructive sleep apnoea, which changes the anaesthetic and postoperative plan and may require overnight monitoring.
Defer surgery for at least 3 to 4 weeks after an acute episode, since operating on an acutely inflamed tonsil increases bleeding and pain, though a hot tonsillectomy is occasionally performed for recurrent abscess.

Surgical technique

Cold steel dissection with ligature or bipolar haemostasis has the lowest rate of secondary haemorrhage and remains the technique against which others are compared.
Bipolar diathermy dissection is faster with less primary bleeding but higher secondary haemorrhage rates and more postoperative pain.
Coblation, using bipolar radiofrequency in a saline field at 60 to 70 degrees Celsius, produces less thermal injury, less pain and faster recovery than diathermy, with haemorrhage rates that are technique and operator dependent.
Intracapsular tonsillectomy, or tonsillotomy, removing tonsil tissue while leaving a rim of capsule, produces markedly less pain and lower haemorrhage rates and is well established for obstructive hypertrophy. Its role in recurrent infection is more limited, since residual tissue may become reinfected, and it should be used with that caveat explained.
Ensure meticulous haemostasis, particularly at the inferior pole.
Avoid excessive diathermy in the tonsil bed, which increases pain and delays healing.

Postoperative care

Regular analgesia for at least 7 to 10 days, prescribed as a scheduled regimen rather than as required, since pain peaks around days 4 to 7 as the slough separates. Undertreated pain leads to poor oral intake and readmission.
Paracetamol 1 g every 6 hours in adults, or 15 mg/kg every 6 hours in children.
Ibuprofen 400 mg every 8 hours in adults, 10 mg/kg every 8 hours in children. Nonsteroidal anti inflammatory drugs do not increase the risk of post tonsillectomy bleeding requiring intervention and should be used, since withholding them causes worse pain and worse intake.
Avoid codeine entirely in children after tonsillectomy, given deaths in ultrarapid metabolisers, particularly those with obstructive sleep apnoea. Where a stronger opioid is required in a child, use morphine at a carefully calculated dose with appropriate monitoring.
Encourage normal diet and normal activity, since eating promotes separation of slough and reduces infection.
Adequate hydration.
Chewing gum and normal oral hygiene.
Advise 2 weeks off school or work and avoidance of crowded places, since infection precipitates secondary haemorrhage.

Haemorrhage

Primary haemorrhage, within 24 hours, occurs in around 0.5 to 1 percent and requires return to theatre for haemostasis in most cases.
Secondary haemorrhage, typically days 5 to 10, occurs in 2 to 5 percent overall and is associated with infection and slough separation.
Any bleeding after tonsillectomy requires assessment in hospital. A small herald bleed frequently precedes a major one, and patients discharged after a minor bleed sometimes return exsanguinating.
Management: admit, intravenous access, bloods including full blood count and crossmatch, intravenous fluids, and antibiotics with co amoxiclav 1.2 g every 8 hours since infection is usually the driver. Tranexamic acid 1 g intravenously three times daily.
Hydrogen peroxide gargles for minor ooze.
Return to theatre for bleeding that is active, recurrent or significant, or where the patient is unstable. In a child, the threshold should be low, since children compensate and then decompensate abruptly.
Airway management in an actively bleeding patient is hazardous. Anticipate a full stomach of swallowed blood, prepare suction and a difficult airway trolley, involve the most experienced anaesthetist available, and consider a rapid sequence induction with the patient in the head down lateral position.

Other complications

Dehydration and readmission for pain and poor intake, which is the commonest reason for readmission.
Velopharyngeal insufficiency, particularly where adenoidectomy is performed simultaneously in a patient with a submucous cleft.
Taste disturbance from lingual nerve or glossopharyngeal branch injury.
Dental and lip injury from the mouth gag.
Temporomandibular joint pain.
Cervical spine injury with atlantoaxial subluxation, particularly in Down syndrome, and Grisel syndrome, that is non traumatic atlantoaxial rotatory subluxation presenting with torticollis and neck pain after pharyngeal surgery or infection.
Catastrophic haemorrhage from injury to an aberrant internal carotid artery, which is rare but which is the reason for careful dissection in the correct plane.

Follow up

Routine follow up is not required after uncomplicated tonsillectomy. Review histology in every adult specimen and in any unilateral or suspicious tonsil. Advise the patient that sore throats will still occur but should be less frequent and less severe, and that pharyngitis without tonsils remains possible.

Acute Rhinosinusitis

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management