Sinusitis

Clinical Features
- stuffy nose, followed by the slow onset of increased sinus pressure

- malaise, toxicity, headache, possibly a slightly elevated temperature, and usually a normal WBC count.

- as the disease progresses over two to three days, symptoms become more pronounced and severe.

- associated pain to the eye and orbit is a constant, dull ache with no throbbing. It may worsen if the patient bends over, coughs or strains.

- patients with chronic sinusitis usually have: allergic rhinitis, which is signaled by itchy/watery eyes, seasonal variation in symptoms and a family history of the disorder.

- acute sinusitis symptoms: facial pain or tenderness, colored nasal discharge, headache, decreased sense of smell, maxillary toothache, cough (usually daytime), fever, malodorous breath and occasional periorbital swelling. Less common findings include middle ear effusion, swelling of the face and nasal bleeding.²⁴

- ethmoid sinusitis: headache is a prominent symptom, located either behind or between the eyes with radiation to the temporal region. The eyes may be tender to pressure, and extreme tenderness on palpation of the medial and superior aspects of the orbit may be present. The patient may experience discomfort with eye movement.

- frontal sinusitis: may cause a frontal headache, which radiates behind the eyes to the vertex of the skull. The pain is generally constant and tends to feel like a pressure sensation. There is also point tenderness on the undersurface of the medial aspect of the superior orbital rim, which is the floor of the frontal sinus. Often, the pain is not present in the early morning after a night of rest. It usually appears one or two hours after waking, increases for three or four hours and becomes less severe in the late afternoon or evening. Apply finger pressure upward toward the floor of the sinus, where the sinus wall is thin, or perform palpation directly over the frontal sinus. Swelling caused by tumors or retained secretions (mucoceles) may cause a downward bulge in the floor of the frontal sinus. Transillumination of the frontal sinuses is done by placing a light source below the supraorbital rim, under the floor of the frontal sinus, at the upper inner angle of the orbit. This technique helps assess light transmission into the lower forehead.

- sphenoid sinusitis: causes pain at the occiput or vertex, yet frontotemporal, retro-orbital or facial pain is more common. It may also travel from the orbit to the mastoid area. The pain is described as constant, and if it occurs retrobulbarly, quite severe. This type of severe retro-orbital pain can cause photophobia and tearing.

- maxillary sinusitis: 10% of maxillary sinusitis is generally secondary to dental root infection. Simultaneous finger pressure over both maxillae exemplifies differences in tenderness.Perform transillumination by placing the light source over the middle of the infraorbital rim.

Examination and Testing
- thorough patient history and physical examination to establish either acute or chronic sinusitis
- an evaluation of vision, pupils, extraocular muscle function, exophthalmometry, slit lamp and funduscopy helps identify any secondary periorbital, orbital or ocular complications
- evaluation of the head and neck should be performed.