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Sinusitis: Diagnosis

How to make diagnosis Sinusitis?

How to diagnose sinusitis is based on anamnesis to get history, physical examinations, and supporting examinations. The diagnosis of sinusitis in adults is based on two or more symptoms, one of which must be a blockage (nasal congestion) or the appearance of nasal secretions with or without tenderness on the face, and impaired olfactory function.

The diagnosis of sinusitis in children is made based on two or more symptoms, one of which must be in the form of a blockage (nasal congestion) or the appearance of nasal secretions with or without facial tenderness or coughing. Positive supporting examination results also support making diagnose.

History

By anamnesis, sinusitis patients complain of typical symptoms including nasal congestion, purulent nasal mucus production, pain in the face, and disruption to smell. Even systemic symptoms or other symptoms such as headaches, weakness, fever, sore throat, cough, and halitosis, also accompany.

Ask the duration of symptoms experienced by the patient to find out whether acute or chronic sinusitis. Explore the risk factors that might cause sinusitis, such as the history of allergic asthma/rhinitis, smoking, systemic disease, history of toothache (especially in the maxilla), history of previous sinusitis diagnosis, and history of treatment.

Physical Examinations

Measure vital signs and physical examination of the head region of the neck. Perform pain assessments using a visual analog scale (VAS). VAS value 0-3 indicates mild pain; value 4-7 indicates moderate pain; VAS value 8-10 indicates severe pain.

a. Inspection
watch for swelling on the face. Swelling in the cheek area to the lower eyelid with skin discoloration to redness can be suspected as the presence of maxillary sinusitis. Swelling in the upper eyelid may be caused by frontal sinusitis. Also, see changes in the face such as protrusion of the eyeball, abnormal movement of the eyeball, and a stiff neck examination.

Inspection with anterior rhinoscopy can find edema conchae, hyperemic nasal mucosa, and purulent nasal secretions. By posterior rhinoscopy can find postnasal drip or infection of the teeth.

b. Palpation
Palpate is performed by pressing on several areas of the face. Tenderness in the cheek area can indicate maxillary sinusitis, and on the forehead may be caused by frontal sinusitis. Ethmoid sinusitis can cause tenderness in the medial canthus area of ​​the eye. In sphenoid sinusitis, patients usually feel the pain that radiates to the vertex, occipital, and mastoid. Pain can be felt on percussion examination of teeth in the maxilla, which may be caused by maxillary sinusitis.

Supporting Examinations

Examinations that can be performed to support the making diagnosis of sinusitis include:

a. Transillumination
The transillumination examination is only for the maxillary and frontal sinuses. This examination is carried out in a dark room, and if the radiological is not available.

How to do the Transillumination test?
To examine the maxillary sinus, the patient sits and tilts his head back while opening his mouth. The examiner attaches a penlight/otoscope/transilluminator to the cheeks in the maxillary sinus area and then turns it on. Normally the sinus appears hollow, and the light shines through giving a reddish glow. When inflamed and blocked with secretions and mucus, the light fails to shine through, and the sinus appears opaque. Then it can be suspected of thick fluid, thickening of the mucosa, or a mass that fills the sinus cavity. Compare the results of the right and left maxillary sinus examination.

To examining the frontal sinus, a penlight/otoscope/transilluminator is attached to the medial part of the orbit below the eyebrow with light directed towards the top. Pay attention to the light that appears in the area of ​​the frontal sinus, compare between the right and left frontal sinuses. Dark light can be caused due to sinusitis or sinus that is not developing.

b. Nasal Endoscopy
Nasal endoscopy can be carried out with or without the administration of decongestants. Nasal endoscopy provides better visualization for evaluating the medial and superior meatus and nasopharyngeal area. Nasal endoscopy can be performed on pediatric and adult patients but not necessarily in first-level health facilities.
Evaluation using nasal endoscopy can see the condition of the mucosa,  and assess characteristics such as the presence or absence of polyps, edema, and secretions. Nasal endoscopy also used in the postoperative evaluation to assesses whether there is scarring or crusting. For evaluation of chronic sinusitis, nasal endoscopy can be done at the 3rd, 6th, 12th, and 24th months after the first diagnosis.

c. Radiology
Radiological examination is not always needed. Imaging tests are usually only done in patients with chronic sinusitis or atypical symptoms and to rule out differential diagnoses. Before conducting a radiology examination, the clinician must consider the ratio of benefits and risks of exposure to radiation. Imaging techniques that can be done to support the making diagnosis of sinusitis are X-rays, ultrasonography, MRI, and CT-scan.

1) X-ray
X-ray examinations can be done in Waters position (evaluation of maxillary and frontal sinuses), Caldwell position (ethmoid visualization), and lateral position (for evaluation of adenoids and sphenoid). Sinusitis is characterized by diffuse opaque features in the sinus cavity, thickening of the mucosa (> 4 mm), or the presence of air-fluid levels.

2) Ultrasonography
Ultrasonography has a limitation that is only to evaluate the maxillary sinus. Ultrasonography can detect fluid, mucosal thickening, or soft tissue mass in the sinus cavity.

3) MRI
MRI examination is used if a tumor is suspected, intracranial complications, or fungal infections in more complex cases of sinusitis.

4) CT scan
CT scan is a recommended imaging technique for sinusitis. CT scan is performed on patients who do not experience improvement after getting adequate therapy or in chronic sinusitis.

CT scan is useful for establishing the diagnosis of acute or allergic invasive fungal sinusitis, and rule out other diagnoses such as tumors. CT scan should be carried out before endoscopic sinus surgery, especially if there are complications of sinusitis involving the periorbital or intracranial area.

d. Laboratory blood tests
Laboratory blood tests do not have a specific feature of sinusitis. Blood tests can be useful in sinusitis associated with allergic rhinitis, cystic fibrosis, or immunodeficiency. Complete blood tests can be within normal limits, or leukocytosis occurs in acute bacterial sinusitis. The results of blood counts and C-reactive protein can increase in sinusitis but are not specific.

e. Other tests
Other tests that can be done are nasal cytology (to exclude allergic rhinitis, sensitivity to aspirin, and nasal polyposis), nasal secretion culture, and skin tests for allergies.

Diagnosis criteria

There are diagnostic criteria that can assist clinicians in establishing a diagnosis of acute and chronic sinusitis.

Acute Sinusitis
The diagnosis of acute sinusitis can be established if it meets at least 2 major criteria or 1 major criterion plus ≥ 2 minor criteria.

Major Criteria:
- Purulent anterior nasal discharge
- Posterior nasal discharge that is purulent or discolored
- Congestion or nasal obstruction
- Congestion or full sense of the facial region
- Hyposmia or anosmia
- Fever (for chronic sinusitis)

Minor Criteria
- Headache
- Complaints in the form of ear pain, feeling full, or depressed
- Halitosis
- Toothache
- Fever (for subacute or chronic sinusitis)
- Fatigue.

Chronic sinusitis
Chronic sinusitis can be established if there are at least 2 cardinal symptoms for 12 consecutive weeks, supplemented with objective evidence from physical examination or support.

Criteria for Diagnosing Chronic Sinusitis
There are at least 2 cardinal symptoms for 12 consecutive weeks:
- Nasal obstruction
- Nasal drainage
- Pain or pressure on the face
- Hyposmia or anosmia

AND
Objective Evidence on Examination
On physical examination: mucopurulent drainage, edema, or polyps in the meatus medius
On radiology: evidence of sinusitis on plain radiographs or CT scan

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