Otolaryngology: Acute nose and sinus infections

Acute coryza

The common cold is the result of viral infection but secondary bacterial infection may supervene. It is self-limiting and no treatment is required other than an antipyretic, such as paracetamol. Discourage the prolonged use (more than 5 days) of vasoconstrictor nose drops owing to their harmful effect on the nasal mucosa (rhinitis medicamentosa). Many patients use menthol inhalations, systemic decongestants and a variety of cough linctus preparations, and find these helpful in controlling symptoms, but evidence of any sustained benefit is weak.

Nasal vestibulitis

Both children and adults may be carriers of pyogenic staphylococci, which can produce infection of the skin of the nasal vestibule. The site becomes sore, fissured and crusted. Treatment consists of topical antibiotic/antiseptic ointment. Consider systemic flucloxacillin in more severe cases. In children with persistent vestibulitis look for a nasal foreign body.

Furunculosis

An abscess in a nasal hair follicle is rare but must be treated seriously as it can spread rapidly and lead to cavernous sinus thrombosis and meningitis. The tip of the nose becomes red, tense and painful. Give systemic antibiotics without delay. Drainage may be necessary but should be deferred until the patient has had adequate antibi- otic treatment for 24 h. In recurrent cases, exclude immunodeficiency.

Acute sinus infection

Aetiology

Most cases of acute sinusitis are secondary to acute viral illness, e.g. coryza, which causes nasal mucosal oedema and interferes with ventilation and mucous clearance from the sinuses. The paranasal sinuses become infected as part of generalized in- fection of the nose and sinus mucosa rhinosinusitis. Usually more than one sinus is involved (pan-sinusitis; Fig. 18.1). Bacterial infection supervenes causing puru- lent rhinorrhoea. The causative organisms are usually pyogenic, e.g.Streptococcus pneumoniae, Haemophilus influenzae or Staphylococcus pyogenes. Anaerobes may be involved especially in dental infections.

Many patients have a background of rhinitis, often allergic in origin, which predisposes them to episodes of ostiomeatal complex obstruction and sinus infection.

In about 10% of cases of maxillary sinusitis the infection is dental in origin and has spread from the upper molars or premolars. Occasionally, infection follows the entry of infected material, e.g. after diving – water is forced through the ostium into the sinus.

Figure 18.1 Coronal CT scan showing left-sided ethmoidal and maxillary sinusitis.

Clinical features

• Nasal obstruction.

• Nasal discharge (rhinorhoea).

• A feeling of ‘congestion’ in the nose and face.

• Facial pain. In maxillary sinusitis the pain is mainly over the cheeks; ethmoidal and frontal sinusitis cause periorbital pain and headache, and sphenoidal sinusi- tis causes severe deep-seated headache.

• Pyrexial illness.

• Mucopus in the nose.

• Tenderness over the involved sinuses.

• Cheek swelling may indicate a dental abscess.

The diagnosis should be made clinically. Acute sinusitis typically resolves but may recur.

X-rays are not needed but CT scanning can be very helpful if there are complica- tions.

Treatment

• Adequate analgesia

• Antibiotics. If the nasal discharge is mucopurulent, Cefaclor is a useful first-line.

• Vasoconstrictor nose drops, such as 1% ephedrine or 0.05% oxymetazoline, will aid drainage of the sinus. Use these sparingly and only for short periods (3–5 days is enough).

• Surgery: If the ostiomeatal complex is completely obstructed there may be severe pain due to retained pus (empyaema). Initial treatment is medical but surgery may be necessary. Drainage of the sinuses is nowadays by endoscopic surgery of the ostiomeatal area under the middle turbinate functional endoscopic sinus surgery (FESS). Developments in endoscopic instruments now allow inspection of the sinus ostia and interior of the paranasal sinuses.

Ostial enlargement and removal of polyps and cysts can be performed. The ostiomeatal complex under the middle turbinate is opened up. This allows a more ‘physiological’ drainage of the antrum than was possible before the development of endoscopic endonasal surgery and ‘antral washout’ insertion of a trochar into the antrum via the nasal cavity with aspiration of the contents of the antrum is now rarely performed. Apiration of an empyaema by whatever means brings dramatic relief.

Refer immediately if you suspect complications e.g. severe headache, neurological changes or eye changes

Complications of acute rhinosinusitis

Complications may arise if the infection spreads beyond the bony walls of the si- nuses (Fig. 18.2). These are rare in Western communities but still a significant cause of morbidity and mortality worldwide. Beware of the patient with sinusitis who develops severe headache, swinging pyrexia or neurological signs:
• Orbital complications (cellulitis or abscess) are characterized by marked oedema of the eyelids, diplopia, redness and swelling of the conjunctiva (chemosis). Proptosis indicates severe orbital involvement. Commence intravenous antibiotics immediately and ask for an urgent ENT opinion. Resolution usually follows intensive antibiotic therapy but surgical drainage is required urgently if there is any change in vision. Loss of colour discrimination is an early sign of impending visual loss.
• Meningitis, extradural and subdural abscesses may occur and should be treated as neurosurgical emergencies.
• Cerebral abscess (frontal lobe). Any patient with a history of recent frontal sinus infection headaches or who exhibits any abnormality of behaviour should be suspected of a frontal lobe abscess.
• Osteomyelitis of the frontal bone is characterized by persistent headache and oedema of the scalp in the vicinity of the frontal sinus. X-ray signs are late, and by the time they become apparent osteomyelitis is well established. Intensive antibiotic therapy combined with removal of diseased bone is necessary.
• Cavernous sinus thrombosis is very rare. Proptosis, chemosis (corneal oedema) and ophthalmoplegia characterize this dangerous complication (Fig. 18.3).
• Poor sinus drainage can cause a bony swelling as secretions build up in the obstructed sinus- ‘mucocoele’. (Fig. 18.4) Treatment is surgical.

Orbital cellulitis. (b) Resolving orbital cellulitis.

References

1. Flint PW, Francis HW, Haughey BH, Lesperance MM, Lund VJ, Robbins KT, Thomas JR, editors. Cummings otolaryngology: head and neck surgery. 7th ed. Philadelphia: Elsevier; 2021.

2. Watkinson JC, Clarke RW, editors. Scott-Brown's otorhinolaryngology and head and neck surgery. 8th ed. Boca Raton: CRC Press; 2018.

3. Chan Y, Goddard JC, editors. KJ Lee's essential otolaryngology: head and neck surgery. 12th ed. New York: McGraw Hill; 2019.

4. Loscalzo J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, editors. Harrison's principles of internal medicine. 21st ed. New York: McGraw Hill LLC; 2022.

5. UpToDate. Waltham, MA: UpToDate Inc. uptodate.com (Accessed: July 2026).

6. Medscape Drugs & Diseases. New York: WebMD LLC. medscape.com (Accessed: July 2026).

7. American Academy of Otolaryngology–Head and Neck Surgery. Clinical practice guidelines. Alexandria, VA: AAO-HNS. entnet.org (Accessed: July 2026).

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