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Referral and warning signs
When to refer
Refer to ENT Specialist/Hospital if: Severe symptoms. Suspected orbital or intracranial complications (see red flags). Failure to improve after course of appropriate antibiotics. Recurrent acute sinusitis (>4 episodes/year). Chronic sinusitis (>12 weeks).
Red flags
- Severe headache.
- Periorbital swelling, redness, proptosis, or ophthalmoplegia (suggests orbital complication).
- Visual changes (decreased acuity, double vision).
- Altered mental status, neck stiffness, photophobia (suggests intracranial complication).
- High persistent fever (>39°C).
- Swelling over the forehead (Pott's puffy tumour).
Signs and symptoms
- Nasal blockage / congestion.
- Nasal discharge (may be thick, purulent, discoloured - yellow/green).
- Facial pain or pressure (over affected sinus - maxillary/cheek, frontal/forehead, ethmoid/between eyes). Pain may worsen on bending forward.
- Reduced or loss of sense of smell (hyposmia/anosmia).
- +/- Fever.
- +/- Cough (especially worse at night due to postnasal drip).
- +/- Headache.
- +/- Toothache (maxillary sinusitis).
- +/- Bad breath (halitosis).
- Symptoms typically persist >7-10 days OR worsen after initial improvement ('double sickening') to suggest bacterial cause.
Risk factors
- Viral URTI (common cold).
- Allergic rhinitis.
- Nasal polyps.
- Deviated nasal septum / other anatomical blockage.
- Dental infections (for maxillary sinusitis).
- Immunodeficiency.
- Smoking.
- Cystic fibrosis.
Diagnosis
Clinical assessment
Diagnosis usually clinical based on characteristic symptoms (nasal block, discharge, facial pain/pressure, smell disturbance) and duration/pattern.
Investigations
- Usually not needed for uncomplicated acute sinusitis.
- Nasal Endoscopy (specialist - visualize sinus openings, purulence).
- CT Scan of Sinuses: Reserved for recurrent, chronic, complicated cases, or pre-operative planning.
Diagnostic criteria
Clinical diagnosis based on symptom complex and duration. Bacterial sinusitis more likely if symptoms >10 days OR severe onset (high fever, purulent discharge, severe pain >3 days) OR worsening after initial improvement ('double sickening').
Differential diagnosis
- Common Cold (viral URTI) (usually resolves <7-10 days, less facial pain).
- Allergic Rhinitis (itchy nose/eyes, watery discharge, sneezing).
- Migraine / Tension headache.
- Dental pain.
- Trigeminal neuralgia.
- Nasal foreign body (unilateral foul discharge).
Management
Non-pharmacological management
- Symptomatic Relief:
- - Analgesia (Paracetamol, NSAIDs).
- - Nasal Saline Irrigation.
- - Steam Inhalation (limited evidence, but may provide comfort).
- - Rest, adequate fluid intake.
Pharmacological treatment
- Viral Rhinosinusitis (Most cases <10 days): Symptomatic relief only (as above). Antibiotics NOT indicated.
- Acute Bacterial Rhinosinusitis (Suspected based on duration/severity): (LOC: HC2/3)
- - Antibiotics: Consider if symptoms meet criteria for bacterial cause.
- - First line: Amoxicillin 500mg PO TID for 7-10 days. (Child: 15mg/kg/dose TID).
- - Alternatives: Doxycycline (adults), Amoxicillin-Clavulanate.
- - Intranasal Corticosteroids (INCS): May reduce inflammation and symptoms, consider as adjunct (e.g., Fluticasone, Mometasone spray). (LOC: HC3/4)
- - Nasal Decongestants (Topical/Oral): Limited role, short-term use only (3-5 days) for congestion relief (e.g., Oxymetazoline spray, Pseudoephedrine PO). (LOC: HC2/3)
Monitoring
Symptoms should improve within 7 days of starting antibiotics (if bacterial). Follow up if symptoms persist or worsen.
Complications
- Rare but potentially serious:
- Orbital complications (Preseptal/Orbital cellulitis, Abscess).
- Intracranial complications (Meningitis, Brain abscess, Cavernous sinus thrombosis).
- Chronic sinusitis.
- Mucocele.
- Osteomyelitis (Pott's puffy tumour - frontal sinus).
Prevention
- Good hygiene (handwashing) to prevent URTIs.
- Management of allergic rhinitis.
- Smoking cessation.
- Influenza vaccination.
Patient education
- Explanation of sinusitis (viral vs bacterial).
- Rationale for antibiotic use (only if bacterial suspected).
- Importance of completing antibiotic course.
- Symptomatic relief measures (analgesia, saline rinse, steam).
- Limited use of decongestants.
- Warning signs of complications requiring urgent review.
Uganda-specific notes
Often follows common cold. Differentiating viral from bacterial based on duration/severity is key to avoid unnecessary antibiotics. Amoxicillin is standard first-line. Access to CT scans and specialist ENT care limited.
References
- Uganda Clinical Guidelines (UCG) 2023
Chapter 21, Section 21.2.4