Rhinosinusitis: (Sinusitis)

Presentation

After a viral infection or with chronic allergies, the patient may complain of a dull facial pain, which is usually unilateral, gradually increases over a couple of days, is exacerbated by sudden motion of the head or bending over with the head dependent, may radiate to the upper molar teeth (through the maxillary antrum), and may increase with eye movement (through the ethmoid sinuses). Often there is a sensation of facial congestion and stuffiness. The child with sinusitis often has a cough, rhinorrhea, and fetid breath. The patient’s voice may have a resonance similar to that of an individual with a “stopped up” nose and may complain of a foul taste in the mouth or reduced sense of smell. Stuffy ears and impaired hearing are common because of associated otitis media with effusion and eustachian tube dysfunction. A colored nasal discharge is a particularly sensitive finding. Fever is present in only half of all patients with acute infection and is usually low grade. A high fever and severe headache usually indicate a serious complication, such as meningitis or another diagnosis altogether. Transillumination of sinuses in the acute care setting is usually unrewarding, but tenderness may be elicited on gentle percussion or firm palpation over the maxillary or frontal sinuses or between the eyes (ethmoid sinuses). Swelling and erythema may exist. Pus may be visible draining below the nasal turbinates (most often in the middle meatus) with a purulent yellow-green appearance, sometimes with a foul-smelling discharge from the nose or running down the posterior pharynx.