Diagnosis of complicated acute rhinosinusitis

Acute rhinosinusitis is considered complicated if the infection spreads beyond the paranasal sinuses and nasal cavity into adjacent spaces (eg meninges, ocular space, periorbital space). Complicated acute rhinosinusitis is often bacterial (but rarely fungal). It is rare (approximately 3 per million of the population per year), usually occurs early in the course of the illness and is not prevented by antibiotic therapy for uncomplicated acute rhinosinusitisFokkens, 2020. Fungal rhinosinusitis is more likely to occur in patients with acute rhinosinusitis who have immune compromise (eg haematological cancer, neutropenia, diabetes in whom glycaemic targets are not achieved).

Clinical features indicating complicated acute rhinosinusitis are listed in Clinical features of acute rhinosinusitis that indicate spread of infection beyond the paranasal sinuses. In patients with swelling of the eyelids, assess for periorbital (preseptal) and orbital (postseptal) cellulitis. Diagnostic imaging (eg magnetic resonance imaging [MRI], computed tomography [CT]) may assist the diagnosis of complicated rhinosinusitisExpert Panel on Neurologic, 2017.

Figure 1. Clinical features of acute rhinosinusitis that indicate spread of infection beyond the paranasal sinuses. [NB1]

Clinical features of infection extending beyond the paranasal sinuses and nasal cavity into adjacent spaces (eg meninges, ocular space, periorbital space) include:

  • periorbital oedema or erythema, or swelling of eyelids [NB2]
  • altered mental state (eg acute-onset confusion, impaired consciousness)
  • diplopia or impaired vision
  • abnormal extraocular movements
  • proptosis or chemosis (swelling of conjunctivae)
  • pain with eye movement
  • cranial nerve palsies
  • meningism (eg neck stiffness, severe headache, photophobia).
Note:

NB1: If any of these features are present, intravenous antimicrobial therapy and urgent surgical referral are required.

NB2: Assess patients for periorbital and orbital cellulitis – for clinical features and management advice, including antibiotic therapy, see Assessment of periorbital (preseptal) and orbital (postseptal) cellulitis.