The bacteriology of sinusitis has been well documented. The results have been consistent for decades, with the most common organisms isolated in acute sinusitis being Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Since the vaccination of children with the seven-valent pneumococcal vaccine became commonplace after its introduction in 2000, there has been a decline in the recovery rate of S. pneumoniae and a corresponding increase in H. influenzae. Individual resistance to antibiotics has increased. The spectrum of organisms widens in chronic sinusitis to include anaerobic bacteria, Staphylococcus aureus, and gram-negative organisms, particularly Pseudomonas aeruginosa. Much research has been dedicated to the role of biofilm formation in the pathophysiology of chronic rhinosinusitis. A biofilm is a complex polysaccharide matrix synthesized by bacteria that is protective of bacterial colonies and renders them somewhat resistant to antibiotic therapy. Pseudomonas aeruginosa is a known biofilm former in patients with chronic rhinosinusitis. Anaerobic isolates are more common when the etiology of the infection is thought to be odontogenic.

Diagnosis

Diagnosis of sinusitis is based on history and physical examination with radiographic support in certain cases. The physical examination consists of anterior rhinoscopy before and after topical decongestion. Any purulent drainage or edema in the area of the middle meatus should be documented as well as the general appearance of the nasal mucosa. Nasal endoscopy allows a more detailed examination of the nasal cavity. Palpation of the paranasal sinuses may elicit focal tenderness. Transillumination of the sinuses may be helpful in adults if the exam is normal or completely absent but is not reliable in children.

Distinguishing between bacterial sinusitis and viral upper respiratory infection may be difficult but is important in planning a treatment strategy. A set of standardized definitions for rhinosinusitis based on symptom profile and duration is well accepted. Symptoms are described as major or minor and include facial pain, nasal obstruction, nasal discharge/postnasal drip, hyposmia/anosmia, purulence on examination (major), and headache, halitosis, dental pain, fatigue, cough, and ear pain/pressure (minor). Rhinosinusitis is acute when symptoms last 4 weeks or less, subacute when symptoms are present for 4 to 12 weeks, and chronic for symptoms present longer than 12 weeks. Recurrent acute rhinosinusitis occurs in patients with four or more episodes per year with disease-free intervals in between. An acute exacerbation of chronic sinusitis is defined as a sudden worsening of symptoms with return to baseline after treatment. If the onset of an acute sinusitis is severe, with fever of at least 39°C and purulent nasal discharge for at least 3 to 4 consecutive days at the beginning of the illness, consideration to starting treatment earlier than the usual 7 to 10 days of symptoms should be entertained.

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