AAO-HNSF Primary Care Otolaryngology Handbook

CHAPTER 8

sinusitis. A CT scan will generally show the presence (or absence) of an abscess, which is always accompanied by ethmoid sinusitis. If an abscess is present, it will require surgical drainage as soon as possible, so the patient should be referred to an otolaryngologist. However, if the condition is severe ethmoid sinusitis without abscess, it may be treated with intravenous antibiotics and nasal flushes with decon- gestant nose drops. Severe ethmoid sinusitis will often resolve with nonoperative therapy, but if the patient’s condition worsens, then surgery is indicated. Sphenoid Sinusitis Sphenoid sinusitis can cause ophthalmoplegia , meningitis, and even cavernous sinus thrombosis. Cavernous sinus thrombosis is a complica- tion with even more grave implications than meningitis or brain abscess, and carries a mortality of approximately 50 percent. The veins of the face that drain the sinuses do not have valves, and may drain posteriorly into the cavernous sinus. Infectious venous thrombophlebitis can spread into the cavernous sinus from a source on the face or in the sinus. The most common cause of this serious infection is rhinosinusitis. The nerves that run through the cavernous sinus are the oculomotor (III), trochlear (IV), and first and second divisions of the trigeminal (V) and the abducens (VI). A patient who has double vision and rhinosinusitis should be assumed to have cavernous sinus thrombosis until it is ruled out by a CT scan and/or magnetic resonance imaging. The preferred treatment is high-dose intravenous antibiotics and surgical drainage of the paranasal sinuses. Anticoagulation is also a consideration in the treatment regimen. Pediatric Rhinosinusitis All children suffer from an occasional bout of rhinosinusitis. Like adults, most of these are viral, are of short duration, and require no therapy. Ninety percent of nasal congestion will begin to improve in 7–10 days. Parents, however, can demand antibiotic treatment because of the nasal drainage (often green, yellow, or gray), and when they cannot leave their sick child in daycare. It is important to reassure parents that these episodes are normal, and to resist the temptation to treat mucus with antibiotics. In pediatric patients, the diagnosis of acute bacterial rhinosinusitis is made with the same criteria as in adult patients—persistent URI symp- toms lasting beyond 10 days or worsening within 10 days after an initial improvement. It may also be diagnosed in children who present with severe symptoms of concurrent fever (temperature >39ºC/102.2ºF) and

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Primary Care Otolaryngology