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Acute sinusitis affects millions of persons in the United States every year and is among the most common reasons for physician visits, prompting over 3 million visits annually. Patients with sinusitis present with congestion and blockage of the nasal passages, usually in response to viral infection or allergic rhinitis but occasionally to other stimuli. The paranasal sinuses become inflamed, and mucus cannot drain properly, providing an environment where bacteria, or rarely fungus, can thrive. Suggestive symptoms of acute rhinosinusitis (ARS) include nasal congestion and obstruction, purulent nasal discharge, maxillary tooth discomfort, and facial pain or pressure that is worse or localized to the sinuses when bending forward. Other signs and symptoms include fever, fatigue, cough, hyposmia or anosmia, ear pressure or fullness, headache, and halitosis. Patients may also have signs and symptoms of eustachian tube dysfunction (e.g., ear pain, fullness or pressure, hearing loss, or tinnitus) (Patel & hwang, 2019). Sinus cavity opacity on transillumination suggests sinusitis. Facial tenderness to palpation or percussion may be present and most easily appreciated over the frontal or maxillary sinuses. Diagnosis of acute cases of sinusitis is usually established clinically. However, imaging or endoscopy should be considered if symptoms fail to improve within 7 days of diagnosis or worsen during the initial management of acute bacterial rhinosinusitis. Laboratory tests: to determine underlying condition if suspected (e.g., nasal cytology allergic rhinitis, HIV test, sweat chloride test for cystic fibrosis). Imaging include  X-ray of sinuses (poor sensitivity): decreased transparency of sinus, air-fluid levels may be seen; CT of sinuses (imaging modality of choice) may show soft tissue swelling, mucoperiosteal thickening, and air-fluid levels, bony erosions and extension in cases of invasive mucormycosis infection and fungus balls in the case of chronic aspergillosis infection. MRI may be considered to confirm soft tissue extension in invasive disease. Nasal endoscopy may reveal mucosal erythema and edema, with sinus ostia and nasal passages blocked by discharge, necrotic mucosa in the case of invasive mucormycosis infection. Biopsy and culture may be performed (hyphae in fungal disease, eosinophils in allergic sinusitis) (Bickley, Szilagyi, & Hoffman, 2017).

The differential diagnoses of sinusitis include allergic rhinitis and migraine.  Allergic rhinitis differentiating signs and symptoms include ocular and/or nasal pruritus, sneezing, rhinorrhea, headache, purulent discharge, and facial pain/pressure are less common. Differentiating test include allergen skin-prick testing: wheal and flare reaction after specific allergen is introduced into the skin is 3 mm larger than negative (saline) control. In vitro-specific IgE determination: specific allergen response. Migraine differentiating signs and symptoms include reports a history of "recurrent sinus infection" in which moderate-severe headache is the most prominent symptom, sensitivity to light or noise, aura, nausea, symptoms decrease if sitting/lying in a quiet, dark room and absence of purulent nasal discharge. Diagnosis is clinical; there are no differentiating tests. Radiologic tests may exclude features of acute bacterial sinusitis. 

Chronic sinusitis is a relatively common diagnosis throughout the US. In patients with an otherwise unremarkable medical history the treatment is typically supportive, requiring only clinical evaluation.

Reference

Bickley, L., Szilagyi, P., & Hoffman, R. (2017). Bates guide to physical examination and history taking. Philadelphia: Wolters Kluwer.

Patel, Z., Hwang, P. (2019). Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis. Retrieved from  https://www.uptodate.com/contents/acute-sinusitis-and-rhinosinusitis-in-adults-clinical-manifestations-and-diagnosis