CAUSES, SYMPTOMS AND TREATMENT OF SINUSITIS..

                                

• Sinusitis: An inflammatory condition involving the four paired structures surrounding the

nasal cavities, the paranasal sinuses.

• Sinusitis can result from non infectious or infectious factors. Non infectious causes

include allergy, barotraumas (from deep sea diving or air travel), chemical irritants,

granulomatous diseases, autoimmune diseases and impaired mucous clearance due to

altered mucous content. Infectious causes can be viral, bacterial or fungal. In hospital

setting, nasotracheal intubation is a major risk factor for nosocomial infections in

intensive care units.

• Newer classifications of sinusitis refer to it as rhinosinusitis, taking into account the

thought that inflammation of the sinuses cannot occur without some inflammation of the

nose as well (rhinitis).

o Factors which may predispose to developing sinusitis include: allergies; structural

problems such as a deviated septum, smoking, prior bouts of sinusitis as each instance

may result in increased inflammation of the nasal or sinus mucosa and potentially

further narrow the openings

Epidemiology of Sinusitis

• Sex

o Sinusitis occurs equally in males and females

• Age

o Sinusitis is more commonly seen in young or middle-aged adults.

o Sinusitis is rare in children younger than 1 year because the sinuses are poorly

developed prior to that age.

Classification of Sinusitis by Duration

• Sinusitis can be acute (going on less than four weeks)

• Subacute (4–12 weeks) or

• Recurrent acute (more than four acute episodes per year)

• Chronic (going on for 12 weeks or more)

• Acute sinusitis is very common. Roughly ninety percent of adults have had sinusitis at

some point in their life.

Acute Sinusitis

• Acute sinusitis is usually precipitated by an earlier upper respiratory tract infection. Viral

infections are the commonest causes of infectious sinusitis: (rhinovirus, influenza virus,

and parainfluenza virus).

o Bacterial causes for community acquired infections commonly are: Streptococcus

pneumoniae

o Haemophilus influenzae

o Moraxella catarrhalis (in 20% of children but less often in adults)

• S. pneumonia and Haemophilus influenzae account for more than 50-60% of cases.

• Other rare community bacterial pathogens include staphylococcus aureus and other

streptococci species, anaerobic bacteria and, less commonly, gram negative bacteria

• Nosocomial bacterial sinusitis are commonly caused by: Staphylococcus aureus,

Pseudomonas aeroginosa, Serratia marcescens, Klebsiella pneumonia and Enterobacter

species.

• Distinguishing viral from bacterial sinusitis in the ambulatory setting is very difficult.

Viral sinusitis typically lasts for 7 to 10 days, whereas bacterial sinusitis is more

persistent

• Approximately 0.5% to 2% of viral sinusitis are complicated by bacterial sinusitis

• Acute episodes of sinusitis can also result from fungal invasion in patients with diabetes

or other immune deficiencies (such as AIDS or transplant patients on anti-rejection

medications) and can be life threatening

• In type I diabetes, ketoacidosis causes sinusitis by mucomycosis

• Chemical irritation can also trigger sinusitis

• Commonly from cigarettes and chlorine fumes

• Rarely, it may be caused by a tooth infection

Chronic Sinusitis

• The pathogenesis of this condition is poorly understood. It is thought to be due to the

impairment of mucociliary clearance from repeated infections rather than due to

persistent bacterial infection.

• It is a complicated spectrum of diseases that share chronic inflammation of the sinuses in

common.

• It is divided into cases with polyps and cases without, and the former is sometimes called

chronic hyperplastic sinusitis.

• The causes are poorly understood and may include allergy, environmental factors such as

dust or pollution, bacterial infection, or fungus (allergic, infective, or reactive).

• Non allergic factors such as vasomotor rhinitis can also cause chronic sinus problems.

Abnormally narrow sinus passages (such as a deviated septum), which can impede

drainage from the sinus cavities could also be a factor.

• Combinations of anaerobic and aerobic bacteria are observed, including staphylococcus

aureus and coagulase-negative Staphylococci.

Symptoms

• Nasal congestion

• Facial pain

• Headache

• Fever

• General malaise

• Thick green or yellow discharge

• Vertigo or lightheadedness

• Blurred vision

• Feeling of facial 'fullness' or 'tightness' which worsens on bending over

• Aching teeth

• Halitosis

• Decreased sense of smell

Signs of Sinusitis

• Purulent secretions in the middle meatus may be seen using a nasal speculum and a

directed light.

• Fever is seen in fewer than 2% of individuals with sinusitis.

• Facial tenderness to palpation is present.

• Complete opacification of maxillary or frontal sinuses may be seen on transillumination.

Diagnosis of Acute Sinusitis

• Usually sinusitis is diagnosed by a clinician based on history and physical examination.

• Bacterial and viral acute sinusitis are difficult to distinguish however, disease duration

fewer than 7 days is considered as a viral whereas more than 7 days are considered as a

bacterial sinusitis (usually only 40% to 50% of patients meeting the criteria for bacterial

infection are true bacterial sinusitis).

Diagnosis of Chronic Sinusitis

• For sinusitis lasting more than 6-12 weeks

Investigations

• Investigations for sinusitis are done at some hospital levels and these include

o CT scan is recommended, but insufficient to confirm diagnosis

o Nasal endoscopy, a CT scan and clinical symptoms are used together

o A tissue sample for histology and cultures can also be used

o Multiple biopsy is informative to confirm the diagnosis

Differential Diagnosis

• Sinusitis needs to be differentiated from a viral upper respiratory infection (URI) or

allergic rhinitis.

• Symptoms of allergic rhinitis are often seasonal and may include clear watery anterior

and posterior nasal discharge, sneezing, and itchy eyes and nose.

• Cases of viral rhinosinusitis are often difficult to differentiate from acute bacterial

rhinosinusitis

• The latter usually presents with a high fever, acute facial pain, swelling or erythema,

sinus tenderness, symptoms of sinusitis lasting greater than 10 days, or symptoms that

worsen after initial improvement

Management/treatment of acute sinusitis

• Conservative measures

• Medication such as acetaminophen and ibuprofen can relieve some of the symptoms

associated with sinusitis, such as headaches, pressure, fatigue and pain.

• Antibiotics

o The vast majorities of cases of sinusitis are due to viral etiology and thus resolve

without antibiotics.

o However, if the symptoms are prolonged amoxicillin (500mg 8hrly for five days) is a

reasonable first choice with amoxicillin/clavulanate (Augmentin 500mg 8hly for five

days) being indicated for patients who fail amoxicillin alone.

o Fluoroquinolones, and some of the newer macrolide antibiotics such as

clarithromycin, and doxycycline, are used in patients who are allergic to penicillins.

o Still, 60 to 90% of people do not experience resolution of symptoms with antibiotics.

o Antibiotics may not may not improve the long-term clinical outcome for sinusitis

Treatment/Management of Chronic Sinusitis

o Treatment of chronic bacterial sinusitis is challenging. Conservative measures include

repeated courses of antibiotics and administration of intranasal glucocorticoids.

o Nasal irrigation may help with symptoms of chronic sinusitis

• Surgical treatment

o For chronic or recurring sinusitis, referral to an otolaryngologist may be indicated for

more specialist assessment and treatment, which may include nasal surgery.

o However, for most patients the surgical approach is not superior to appropriate

medical treatment.