Adult Sinusitis: Brief Review

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU

Nasal physiology

Mucociliary clearance can be tested by placing saccharin on the inferior turbinate and timing the onset of sweet taste in the mouth. The normal range is 7-11 minutes.

There is normal asymmetry of nasal mucosa swelling, with one side of nose swollen as a result of dilatation of veins in the inferior turbinate and the other side "open" - 80% of the population exhibits a nasal cycle, with reciprocal changes in airflow over 1-2 hours.


Sinus is a Latin word for “fold” or “pocket”. Paranasal sinuses have an embryogenic origin from the nasal passage and are an integral component of the airway. Drainage pathways of the sinuses are complex and can be blocked during inflammation. Ostia are the sinus openings in the nasal cavity. They are 2-6 mm wide.

Location of the openings of the sinuses

- Inferior meatus - opening of nasolacrimal duct.
- Middle meatus - frontal, maxillary and anterior ethmoids
- Superior turbinate - posterior ethmoids and sphenoid sinuses


Sinuses listen to the following radio channels: FM AM / PS SS

Frontal sinus, Maxillary sinus, and
Anterior ethmoids drain into Middle meatus

Posterior ethmoids and Sphenoid sinus drain into
Sphenoethmoidal recess above Superior turbinate


Approximately 31-35 million Americans are affected by sinusitis every year (15% of the population).

Sinusitis of less than 4 weeks’ duration is considered acute. Chronic sinusitis persists for more than 4 weeks.

Recurrent sinusitis is defined as 4 or more episodes of sinusitis per year. Each episode lasting 7-10 days and no symptoms during intervening periods.

Acute Exacerbation of Chronic Sinusitis is the sudden worsening of chronic sinusitis that returns to baseline with treatment.

The term sinusitis is often interpreted as reflecting simply a bacterial sinus infection but the disease can have a significant allergic component.

Sinusitis is mostly preceded by rhinitis and is rarely found without rhinitis.

The 1997 Rhinosinusitis Task Force thus proposed the term Rhinosinusitis instead of Sinusitis (reiterated in 2007 guidelines).

Acute Sinusitis

Symptoms for up to 4 weeks. Viral most of the time. Bacterial in less than 5%. Patients with allergic rhinitis (AR) are more susceptible to acute sinusitis.

Duration of symptoms and definition

Less than 4 weeks - acute sinusitis
4-12 weeks - subacute sinusitis
Longer than 12 weeks - chronic sinusitis

Complications of acute sinusitis

Orbital cellulitis
Subperiostal, intraorbital or eyelid abscess
Cavernous sinus thrombosis
Subdural, epidural or brain abscesses
Osteomyelitis of frontal bone (Potts puffy tumor)

Chronic Sinusitis

Symptoms for more than 12 weeks. Not an "infection."

Eosinophilic Sinusitis

Allergic Fungal Sinusitis (click to read the article)

Noneosinophilic Sinusitis

Noneosinophilic sinusitis is considered to have an infectious basis and is treated with antibiotics. Organisms found are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. If a patient has Pseudomonas aeruginosa or Staphylococcus aureus, cystic fibrosis should be considered in differential diagnosis.


A limited CT of sinuses costs about the same as a standard plain film sinus series but is much more useful.

CT scan findings do not correlate well with symptoms.

Upper airway endoscopy can identify anatomic or mechanical disorders of the upper airway. Anterior rhinoscopy is an examination of the nasal cavity performed with a nasal speculum under good illumination. Usually done with a rigid rhinoscope.

The gold standard for diagnosis of bacterial sinusitis is sinus puncture and culture.


Treatment of Acute Sinusitis

Over 70% of patients with acute rhinosinusitis improve after 7 days, with or without antimicrobial therapy.

NNT = 7: 7 patients must be treated to achieve one additional positive outcome at 7 to 12 days.
More adverse effects in treated group, number needed to harm (NNH) = 9.

Start antibiotics if no improvement by day 7 or patient has worsening at any time.

Amoxicillin should be first choice based on safety, efficacy, cost, and narrow spectrum. A 10-14 day course is commonly used (7 days beyond clinical improvement).

Treatment of Chronic Sinusitis

Saline lavage (Ann Fam Medicine, July 2006).

Intranasal steroids (INS)

Antihistamines – not useful, may worsen by drying mucosa. Only consider if significant allergic component.

Itraconazole (Sporanox) for fungal sinusitis (most commonly seen in the Southern states). Itraconazole use requires a close follow-up due to the risk of CHF, cardiac arrhythmias, liver dysfunction and peripheral neuropathy (foot drop). It has a "black box" warning for CHF patients.

Refer to ENT for chronic sinusitis. Balloon sinuplasty is a procedure gaining wider acceptance.

Nasal Polyps

Nasal polyps can be considered a form of chronic hyperplastic sinusitis and usually originate in the ethmoid sinuses. Malignant transformation is uncommon. Polyps can occupy the entire nasal cavity, thus producing a total blockage.

Nasal polyposis can be associated with allergic fungal sinusitis, cystic fibrosis (CF) and the triad of asthma, aspirin intolerance, and nasal polyps (Samter's triad in AERD). In cystic fibrosis, polyps show neutrophilic inflammation.

CF should always be considered in children with nasal polyps.

What is the triad of aspirin-exacerbated respiratory disease (AERD)?

Samter's triad include asthma, aspirin sensitivity, and nasal/ethmoidal polyposis:

Sensitivity to aspirin

Approximately 9% of the U.S. population has asthma - 9% of adult asthmatics have aspirin-exacerbated respiratory disease (AERD) (
Pediatric sinusitis (click the link to continue).

Surgical treatment of chronic sinusitis

Functional Endoscopic Sinus Surgery (FESS) is the surgical standard of care. FESS restores sinus drainage and provides some symptom improvement in close to 90% of selected patients.


Allergy and Immunology MKSAP, 3rd edition.

Pediatric sinusitis. Ellen R. Wald, MD. Audio-Digest Pediatrics, Volume 55, Issue 14, July 21, 2009.
Acute Bacterial Rhinosinusitis in Adults: Part II. Treatment. AFP, 2004.
Acute and Chronic Rhinosinusitis: Practical Clinical Treatment Strategies. Nancy Otto, PharmD. Medscape, 11/2008.
Acute Sinusitis: A Cost-Effective Approach to Diagnosis and Treatment. AFP, 1998.
Sinusitis Practice Guideline Aims to Improve Diagnosis, Cut Antibiotic Use. AFP, 2007.

Related Reading

FIT Corner Questions. Chapter 78 of the 6th edition of Middleton’s Allergy Principles and Practice, edited by N. Franklin Adkinson, et al. September 27, 2006. Chapter 78: Nasal Polyps and Sinusitis.
Allergic Fungal Sinusitis. Photoclinic. Consultant. Vol. 48 No. 9, August 1, 2008.
JAMA Patient Page: Acute Sinusitis, 2009.
Multi-symptom Asthma is Closely Related to Nasal Blockage, Rhinorrhea and Symptoms of Chronic Rhinosinusitis
Nucleotide-binding oligomerization domain (NOD)-like receptors (NLRs) have a potential role in chronic rhinosinusitis/polyps
Atrophic Rhinosinusitis: Progress Toward Explanation of an Unsolved Medical Mystery. Medscape, 2011.
SNOT-16 Assessment Tool for Acute Sinusitis takes 5 minutes - copyright protected by Washington University. Medscape, 2011.
Staphylococcus aureus biofilm and and superantigens are associated with chronic sinusitis, cause T-helper 2 skewing
Intranasal antinuclear autoantibodies (ANA) in patients with chronic rhinosinusitis with nasal polyps. JACI, 2011.
Chronic Sinusitis - JAMA Patient Page (PDF), 2011.
Mnemonics for sinusitis: PODS and C-PODS (end of PDF here)

Published: 07/10/2007
Updated: 04/29/2012

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