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Acute sinus infections are uncommon compared with viral rhinitis, but they still affect nearly 20 million Americans annually, accounting for over 2 billion dollars in health care expenditures for sinusitis annually Because sinusitis usually has followed an acute respiratory infection and because media advertisements often use the term sinusitis when rhinitis would be more accurate, it is understandable that patients and clinicians alike sometimes confuse these entities Symptoms usually began more than a week before presentation and are typically unilateral Sinusitis usually is a result of impaired mucociliary clearance and obstruction of the osteomeatal complex Diseases that swell the nasal mucous membrane, such as viral or allergic rhinitis, are usually the underlying cause To emphasize the importance of intranasal obstruction in the pathogenesis of sinusitis, otolaryngologists are more commonly using the term rhinosinusitis or acute bacterial rhinosinusitis to describe this disease Edematous mucosa causes obstruction of the sinus drainage tract, resulting in the accumulation of mucous secretion in the sinus cavity that becomes secondarily infected by bacteria The typical pathogens of bacterial sinusitis are the same as those that cause acute otitis media: S pneumoniae, other streptococci, H influenzae and, less commonly, S aureus and M catarrhalis It should be kept in mind that about 25% of healthy asymptomatic individuals may, if sinus aspirates are cultured, harbor such bacteria as well

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It is usually possible to make the diagnosis of acute sinusitis on clinical grounds alone Although more sensitive than clinical examination, routine radiographs are not costeffective and are not recommended by the Agency for Health Care Policy and Research However, they may be helpful when clinically based criteria are difficult to evaluate or when symptoms of more serious infection are noted When necessary, limited noncontrast coronal CT scans are more cost-effective and provide more information than conventional sinus films CT provides a rapid and effective means to assess all of the paranasal sinuses, identify areas of greater concern (such as bony dehiscence, periosteal elevation, or maxillary tooth root exposure within the sinus), and to direct therapy Occasionally, a CT scan may be indicated to exclude acute bacterial sinusitis While reasonably sensitive, CT scans are not specific Swollen soft tissue and fluid may be difficult to distinguish when opacification of the sinus is complete Sinus abnormalities can be seen in most patients with an upper respiratory infection, while bacterial sinusitis develops in only 2% Thus, sinusitis is a clinical diagnosis for which CT may be helpful in confirming, denying, or monitoring If malignancy, opportunistic infection, or intracranial extension of malignancy or infection is suspected, MRI

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Because the maxillary sinus is the largest of the paranasal sinuses and its ostia into the nose is superiorly placed, thereby failing to take advantage of gravity, it is the most

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with gadolinium should be ordered instead of, or in addition to, CT MRI will distinguish tumor from inflammation and inspissated mucus far better than CT, as well as better delineating tumor extent with respect to adjacent structures such as the orbit, skull base, and palate Bone destruction can be demonstrated as well by MRI as by CT For adequate management of disease, both MRI and CT may be indicated when surgical intervention is being considered

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As two-thirds of untreated patients will improve symptomatically within 2 weeks, appropriate criteria for the use of antibiotics are symptoms lasting more than 10 14 days or severe symptoms, including fever, facial pain, and periorbital swelling Administration of antibiotics does, however, reduce by 50% the incidence of clinical failure and, coupled with clinical criteria-based diagnosis, represents the most cost-effective treatment strategy Symptoms may be improved with oral or nasal decongestants (or both) eg, oral pseudoephedrine, 30 120 mg per dose, up to 240 mg/d; nasal oxymetazoline, 005%, or xylometazoline, 005 01%, one or two sprays in each nostril every 6 8 hours for up to 3 days Double-blinded studies exist to support numerous antibiotic choices A summary of recent national guidelines for the treatment of acute sinusitis can be found in Table 8 2 Selection of antibiotics is usually empiric and based on a number of factors, including regional patterns of antibiotic resistance, antibiotic allergy, cost, and patient toler-