ACUTE AND CHRONIC SINUSITIS

                                       ACUTE AND CHRONIC SINUSITIS

Definition:-

Inflammation of the sinus mucosa

• Usually associated with rhinitis .Rhinosiusitis may be better term because:
• Allergic or nonallergic rhinitis nearly always precedes sinusitis
• Sinusitis without rhinitis is rare
• Nasal discharge and congestion are prominent symptoms of sinusitis
• Nasal mucosa and sinus mucosa are similar and are contiguous

Normal sinus:

Sinus health depends on:

Mucous secretion of normal viscosity, volume, and composition,

normal mucociliary flow to prevent mucous stasis and subsequent infection;

and open sinus ostia to allow adequate drainage and aeration.

Developement of sinuses:

• Maxillary and ethmoid sinuses present at birth
• Frontal sinus developed by age 5 or 6
• Sphenoid sinus last to develop, 8-10

Physiologic imprtance of sinuses:-

• Provide mucus to upper airways
• Lubrication
• Vehicle for trapping viruses, bacteria, foreign material for removal
• Give characteristics to voice
• Lessen skull weight
• Involved with olfaction

Sinusitis:-Infectious or noninfectious inflammation of 1 or more sinuses.

4 paranasal sinuses, each lined with pseudostratified ciliated columnar epithelium and goblet cells

• Frontal
• Maxillary
• Ethmoid
• Sphenoid

Normal Water’s and Towne’ s Views of the sinuses:-

 

 

 

 

 

 

 

 

 

 

   
Lateral View Showing Normal Sphenoid Sinus :-

OSTEOMEATAL COMPLEX:-

• Ostiomeatal complex is that area under the middle meatus (airspace) into which the anterior ethmoid, frontal and maxillary sinuses drain
• Posterior ethmoids drain into the upper meatus
• Ostiomeatal complex is the functional relationship between the space and the ostia that drain into it

VIRAL RHINOSINUSITIS:-

• Most upper respiratory infections are viral
• Short lived, last less than 10 days
• Sinus mucosa as well as nasal mucosa is involved
• Most will clear without antibiotics
• Treatment: decongestants, nasal lavage, rest, fluids

Classification of bacterial sinusitis:-

• Acute bacterial sinusitis- infection lasting 4 weeks, symptoms resolve completely (children 30 days)
• Subacute bacterial sinusitis- infection lasting between 4 to 12 weeks, yet resolves completely (children 30-90 days)
• Chronic sinusitis- symptoms lasting more than 12 weeks (children >90 days)
• Some guidelines add treatment failure + a positive imaging study

DIFFERENTIATING SINUSITIS FROM RHINITIS

Sinusitis :-

• Nasal congestion
• Purulent rhinorrhea
• Postnasal drip
• Headache
• Facial pain
• Anosmia
• Cough, fever

Rhinitis :-

• Nasal congestion
• Rhinorrhea clear
• Runny nose
• Itching, red eyes
• Nasal crease
• Seasonal symptoms

Road to bacterial sinus infections:-

• Rhinitis
• Nasal congestion
• Rhinorrhea clear
• Runny nose
• Itching, red eyes
• Nasal crease
• Seasonal symptoms

  X-Ray Image of Sinuses with Maxillary Sinusitis:-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  Pathogenesis of nasal obstruction:-

• Viral upper respiratory infections
• Daycare centers
• Allergic and nonallergic stimuli
• Immunodeficiency disorders
• Immunoglobulin deficiency (IgA, IgG)
• Anatomic changes
• Deviated septum, concha bullosa, polyps

Allergic stimuli causing Rhinosinusitis:-

• Pollens
• Tree, grass, weeds
• House dust mite
• Animal danders
• Cat, dog, mice, gerbil, other animals with fur
• Molds
• Allergic foods and beverages

Non-allergic stimuli causing rhinosinusitis:-

• Tobacco smoke
• Perfumes
• Cleaning solutions
• Burning candles
• Cosmetics
• Car exhaust, diesel fumes
• Hair spray
• Cold air
• Dry air
• •Changes in barometric pressure
• •Auto exhaust
• •Gas, diesel fuel
• •Nonallergic foods
• •Nonallergic beverages

Causes of ciliary dysfunction:-

•Immotile cilia syndrome

•Prolonged exposure to cigarette smoke

•Common cold viruses causing URI

•Increased viscosity of mucus

•Medications

–First generation antihistamines (non sedating do not affect)

–Anticholinergics

–Aspirin

–Anesthetic agents

–Benzodiazepines

Diseases slowing ciliary function:-

•Allergic and nonallergic rhinitis

•Rhinosinusitis

•Aging rhinitis

•Cystic fibrosis

•Any disease causing obstruction, crusting of the mucosa

Causes of mechanical obstruction:-

•Deviated nasal septum

•Concha bullosa

•Foreign body

•Nasal polyps

•Congenital atresia

•Lymphoid hyperplasia

•Nasal structural changes found in Downs syndrome

Vasculitides,autoimmune and granulomatous diseases:-

•Churg-Strauss vasculitis

•Systemic lupus erythematosis

•Sjogren’s syndrome

•Sarcoidosis

•Wegener granulomatosis

Other predisposing conditions:-

•Physical trauma

•Scuba diving

•Foreign body

•Cleft palate

•Dental disorders

•Any patient with chronic fatigue, fever, general malaise/aching or headaches should be evaluated for sinusitis

Acute Bacterial sinusitis:-

•Usually begins with viral upper respiratory illness

•Symptoms initially improve, but then …

•Symptoms become persistent or severe

•Persistent… 10-14 days but fewer than 4 weeks

•Severe…temperature of 102°, purulent nasal discharge for 3-4 days, child appears ill

•Disease clears with appropriate medical treatment.

PHYSICAL FINDINGS:-

•Mucopurulent nasal discharge

•Swelling of nasal mucosa

•Mild erythema

•Facial pain (unusual in children)

•Periorbital swelling

Maxillary sinusitis:-

•Etiology-viral,bacterial rhinitis,dentogenic,trauma.

•Symptoms-facial pain,toothache,facial heaviness,facial redness.

•Signs-tenderness over canine fossa,mucopus in the middle meatus

FRONTAL SINUSITIS:-

•Etiology-viral and bacterial rhinitis,trauma,adjacent sinus infections

•Symptoms-heaviness of head in creasing on stooping down,office headache-peak during midday.

•Signs-tenderness on the floor of the frontal sinus,mucopus on the anterior middle meatus.

ETHLOID SINUSITIS:-

•Associated with infection of the other sinuses.

•Pain inbetween the eyes,eyelid edema.

SPHENOID SINUSITIS:-

•Isolated involvement is rare

•Headache in the occiput or the vertex.

•Look for any predisposing causes in the nasopharynx

Treatment of acute sinusitis:-

•Antihistamines recommended if allergy present

–Oral or topical

•Decongestants

–Oral or topical

•Antibiotic when indicated (bacteria)

•Nasal irrigation

•Guaifenesin 200-400 mg q4-6 hrs

•Hydration

DECONGESTANTS:-

•Topical nasal sprays (limit use to 3-7 days)

–Phenylephrine

–Oxymetazoline

–Naphthazoline

–Tetrahydrozoline

–Zylometazoline

•Topical nasal spray (unlimited daily use)

–Ipatropium

•Oral

–Pseudoephedrine 30-60 mg

–Phenylephrine 2-4 times/day

Antibiotics for Acute Bacterial Sinusitis:-

•Amoxicillin 500 mg tid for 10-14 days

–First line choice in most areas

–Local differences in antibiotic resistance occur

•Where beta-lactanase resistance is an issue

– Amoxicillin/clavulanate

–Cefuroxime

–Cefpodoxime

–Cefprozil

Additional Antibiotics for Acute Bacterial Sinusitis:-

•Amoxicillin should be considered because of its efficacy, low cost, side-effect profile, and narrow spectrum (45-90 mg/kg/d in children; 500 mg tid or qid in adults for 10 to 14 days)

•If penicillin-allergic clarithromycin or azithromycin

•Erythromycin does not provide adequate coverage

•Trimethoprim/suflamethoxazole and erythro/sulfisoxazole have significant pneumococcal resistance

Nasal Irrigation:-

•Washes away irritants

•Moistens the dry nose

•Waterpik with nasal irrigator

•Ceramic irrigators

•Enema bucket with normal saline and sodium.

When Medical Therapy for Acute Bacterial Sinusitis Fails…:-

•Assess for chronic causes

–Identify allergic and nonallergic triggers

•Allergy testing, nasal smears for eosinophilia

–Consider other medical conditions associated with sinusitis

–Rhinolaryngoscopy

–Imaging studies

Sinus x-rays

CT scanning (limited, coronal views)

Sinus Transillumination:-

•Helpful in older children and adults

•Normal transillumination decreases chance of pus in the sinus

•No light reflex suggests mucopurulent material or thickening of nasal mucosa

•Inexpensive screening tool

 

Bacteria Involved in Acute Bacterial Sinusitis:-

•Streptococcus pneumoniae 30%

•Haemophilus influenza 20%

•Moraxella catarrhalis 20%

•Sterile 30%

Chronic Sinusitis:-

•Symptoms present longer than 8 weeks or 4/year in adults or 12 weeks or 6 episodes/year in children

•Eosinophilic inflammation or chronic infection

•Associated with positive CT scans

•Poor (if any) response to antibiotics

Sx of Chronic Sinusitis:-

•Nasal discharge

•Nasal congestion

•Headache

•Facial pain or pressure

•Olfactory disturbance

•Fever and halitosis

•Cough (worse when lying down)

Conditions Causing Chronic Sinusitis:-

•Allergic and nonallergic rhinitis

•Uncorrected anatomic conditions

•Ciliary dyskinesia

•Cystic fibrosis

•Tumors

•Immunodeficiency disorders

–IgA, IgM

•Granulomatous diseases

Evaluation of Chronic Sinusitis:-

•CT or MRI scanning

–Anatomic defects, tumors, fungi

•Allergy testing

–Inhalants, fungi, foods

•Sinus aspiration for cultures

–Bacterial

-Fungal

•Immunoglobulins

Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown:-

•Streptococcus pneumoniae

•Haemophilus influenza

•Moraxella catarrhalis

•Staph aureus

•Coagulase negative staphylococcus

•Anerobic bacteria

Conservative treatment of Chronic Sinusitis:-

•Nasal steroid spray

•Guafenesin

•Decongestants

•Steam inhalation

•Nasal irrigation

•Antibiotics with exacerbations

Surgical treatment:-

•Maxillary sinusitis-Antral puncture,Intranasal antrostomy,Caldwell Luc operation.

•Frontal-Trephination,Howarths operation,Osteoplastic flap operation

•Ethmoids-Intranasal and External ethmoidectomy

•Sphenoid-Sphenoidotomy

•Functional Endoscopic sinus surgery

Recommendation 2b:-

•CT scans of the paranasal sinuses should be reserved for:

–Patients in whom surgery is being considered as a management strategy

–Patients who do not respond to medical regimes which include adequate antibiotic use

–Assisting in diagnosis of anatomical changes interfering with airflow or drainage

Recommendations for CT Scans:-

•Patients presenting with complications of sinusitis

–Neurologic symptoms, diplopia, periorbital or facial swelling with or without erythema

•Patients with sinus symptoms accompanied by severe, boring, mid-head pain

–Rule out sphenoid sinusitis

Summary:-

•Acute and chronic sinusitis is one of the most common diseases treated in family practice

•It is important to treat sinusitis aggressively to prevent chronic symptoms or development of serious complications

•The underlying causes of chronic sinus disease should be sought out and corrected