Introduction Sinusitis occurs when your sinuses -- air filled cavities around your nose, eyes, and cheeks

- get inflamed. The inflammation is often due to an infection, caused by a virus (such as a cold), bacteria, or fungus. When your sinuses are inflamed, mucus can't drain. Eventually, the sinus cavities become blocked, making it harder for your body to heal the infection. Sinusitis can be acute (with symptoms lasting fewer than 8 weeks), chronic (with symptoms recurring or lasting longer than 8 weeks), or recurrent (with three or more acute episodes a year). Most cases of sinusitis are acute and caused by a cold. The Disease Process. Sinusitis is an infection that occurs if obstruction or congestion leads to bacterial growth in the paranasal sinuses. Among the many causes of such obstruction or congestion are the common cold, allergies, certain medical conditions, abnormalities in the nasal passage, and change in atmosphere. In any of these cases, sinusitis can develop as follows: Mucus drainage and airflow are blocked. Secretions build up, encouraging the growth of certain bacteria. The resulting infection, swelling, and inflammation create further blockage, which may cause the sinuses to close up completely.

Forms of Sinusitis. Sinusitis is classified as acute, subacute, or chronic, or recurrent. The classification is based on how long symptoms last: Acute: Less than 4 weeks Subacute: 4 - 12 weeks Chronic: 12 weeks or longer Recurrent: 3 or more acute episodes in 1 year

Anatomy Knowledge of the anatomy of paranasal sinuses is essential for understanding the pathophysiology and management of chronic sinusitis. The 4 pairs of paranasal sinuses are lined with ciliated, pseudostratified columnar epithelium. Goblet cells are interspersed among the columnar cells. The mucosa is attached directly to the bone. Involvement of the surrounding bone and further extension of the infection into the orbital and intracranial compartments can result from inadequate treatment of sinusitis and specific types of sinusitis (eg, fungal sinusitis). Sinuses help insulate the skull, reduce its weight, and allow the voice to resonate within it. The four major pairs of sinuses are the: 1. 2. 3. 4. Frontal sinuses (in the forehead), Maxillary sinuses (behind the cheek bones), Ethmoid sinuses (between the eyes) Sphenoid sinuses (behind the eyes).

The Frontal sinuses drain through their ostia located at the ostiomeatal complex lying lateral to the middle turbinate within the middle meatus.

The posterior ethmoid and sphenoid sinuses open into the superior meatus and sphenoethmoid recess, respectively. The maxillary ostium is connected to the nasal cavity by a narrow tubular passage called the infundibulum, located at the highest part of the sinus; hence, drainage from the maxillary sinus flows against gravity via mucociliary clearance. Because the floor of the maxillary sinus is the tooth-bearing part of the maxilla, dental infections can easily extend to the maxillary sinus. Although the nasal cavity is usually colonized with bacteria, the sinuses are typically sterile.

Disease Condition

A sinus infection occurs when a pathogenic microorganism (virus, bacterium, or a fungus) grows within a sinus and causes intermittent blockage of the sinus ostium. Drainage of mucus and pus often occur when the blockage is relieved. The drainage usually goes from the nasal passages to the throat or out the nostrils. Such infections also cause inflammation (an influx of immune cells and swelling of the sinus tissue) of one or more sinuses. This can to block the openings of the sinuses and leads to discomfort. Inflammation of the air cavities within the passages of the nose (paranasal sinuses) is referred to as sinusitis. Sinusitis can be caused by infection, but can also be caused by allergy and irritation of the sinuses. The sinuses are normally sterile under physiologic conditions. Secretions produced in the sinuses flow by ciliary action through the ostia and drain into the nasal cavity. In the healthy individual, flow of sinus secretions is always unidirectional (ie, toward the ostia), which prevents back contamination of the sinuses. In most individuals, the maxillary sinus has a single ostium (2.5 mm in diameter, 5 mm 2 in cross-sectional area) serving as the only outflow tract for drainage. This slender conduit sits high on the medial wall of the sinus cavity in a nondependent position.

Most likely, the edema of the mucosa at these 1- to 3-mm openings becomes congested by some means (eg, allergy, viruses, chemical irritation) that causes obstruction of the outflow tract stasis of secretions with negative pressure, leading to infection by bacteria. Retained mucus, when infected, leads to sinusitis Another mechanism hypothesizes that because the sinuses are continuous with the nasal cavity, colonized bacteria in the nasopharynx may contaminate the otherwise sterile sinuses. These bacteria are usually removed by mucociliary clearance; thus, if mucociliary clearance is altered, bacteria may be inoculated and infection may occur, leading to sinusitis. Mucous stagnation in the sinus forms a rich medium for the growth of various pathogens. The early stage of sinusitis is often a viral infection that generally lasts up to 10 days and that completely resolves in 99% of cases. However, a small number of patients may develop a secondary acute bacterial infection that is generally caused by aerobic bacteria (ie, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis). Initially, the resulting acute sinusitis involves only one type of aerobic bacteria. With persistence of the infection, mixed flora, anaerobic organisms, and, occasionally, fungus[6] contributes to the pathogenesis, with anaerobic bacteria of oral flora origin often eventually predominating. In one study, these bacterial changes were demonstrated with repeated endoscopic aspiration in patients with maxillary sinusitis. Most cases of chronic sinusitis are due to acute sinusitis that either is untreated or does not respond to treatment.

History Patient history is extremely important in chronic rhinosinusitis (CRS) because of the broad overlap between sinus symptoms and other disease processes, as well as poor correlation between symptoms and endoscopic and radiographic findings. Chronic sinusitis manifests more subtly than acute sinusitis. Unless an appropriate history is taken, the diagnosis may be missed. The typical symptoms of acute sinusitis fever and facial painare usually absent in chronic sinusitis. Fever, when present, may be low grade. Patients with chronic sinusitis may present with the following symptoms: Nasal stuffiness Nasal discharge (of any character from thin to thick and from clear to purulent) Postnasal drip Facial fullness, discomfort, and headache Chronic unproductive cough Hyposmia Sore throat Fetid breath Malaise Easy fatigability Anorexia Exacerbation of asthma Dental pain Visual disturbances Sneezing Stuffy ears Unpleasant taste Fever of unknown origin

In pediatric settings, halitosis is reported more commonly by parents of younger children. Nasal obstruction with mouth breathing and associated sore throat may be present. In some individuals with chronic sinusitis, parents may note occasional and painless morning eye swelling. Older children may complain of loss of taste due to associated nasal obstruction and anosmia. Nocturnal symptoms may include snoring and coughing due to associated postnasal drip. The patient history should focus on the following key factors, beginning with consideration of major and minor diagnostic criteria: The presence of major symptoms (including purulent anterior nasal drainage, purulent-discolored posterior nasal drainage, nasal obstruction or blockage, facial congestion or fullness, facial pain or pressure, and hyposmia or anosmia) The presence of minor symptoms (including headache, ear pain or fullness, halitosis, dental pain, cough, fever, fatigue) Duration of symptoms Exacerbating and relieving factors History of previous nasal or paranasal sinus surgery Current medications Previous treatments and their duration Other confounding health problems (including asthma, allergy, and immunocompromising disorders) Active or passive tobacco smoke

Etiology Currently, etiologic studies of sinusitis are increasingly focusing on ostiomeatal obstruction, allergies, polyps, occult and subtle immunodeficiency states, and dental diseases. When sinuses become blocked, they provide a place for bacteria, viruses, and fungus to live and grow rapidly. Although a cold is most often the culprit, anything that prevents the sinuses from draining can cause sinusitis Acute sinusitis (sinus infection): Viruses or bacteria infect the sinus cavity, causing inflammation. Mucus production, nasal congestion, discomfort in the cheeks, forehead or around the eyes and headaches are common symptoms. Obstruction of the various ostia Impairment in ciliary function Increased viscosity of secretions Decrease in oxygenation in the sinuses Bacterial overgrowth

Chronic sinusitis (or chronic rhinosinusitis): More than just a series of infections, chronic sinusitis is a persistent process of inflammation of the sinuses. Allergic rhinitis: Allergens like pollen, dust mites, or pet dander cause the defenses in the nose and sinuses to overreact. Mucus, nasal stuffiness, sneezing, and itching result.

Allergic foods and beverages

Deviated septum: If the septum that divides the nose deviates too far too one side, airflow can be obstructed.

Physical injury to sinus Turbinate hypertophy: The ridges on the nasal septum are enlarged, potentially obstructing airflow. Deviated nasal septum Concha bullosa, Congenital atresia & Lymphoid hyperplasia Nasal structural changes found in Downs syndrome

Nasal polyps: Small growths called polyps sometimes grow in the nasal cavity, in response to inflammation. Asthma, chronic sinus infections, and allergic rhinitis can lead to nasal polyps.

Microorganisms are more often recognized as secondary invaders. Any disease process or toxin that affects cilia has a negative effect on CRS. Bacterial involvement The bacteria presumed to be involved in CRS differ from those involved in acute rhinosinusitis. The following bacteria have been reported in samples obtained through endoscopy or sinus puncture in patients with chronic sinusitis. The following bacteria have been reported in samples obtained through endoscopy or sinus puncture in patients with chronic sinusitis. Staphylococcus aureus (both methicillin-susceptible S aureus [MSSA] and methicillinresistant S aureus [MRSA] strains) Coagulase-negative staphylococci H influenzae M catarrhalis S pneumoniae Streptococcus intermedius Pseudomonas aeruginosa Nocardia species Anaerobic bacteria (Peptostreptococcus, Prevotella, Porphyromonas, Bacteroides , Fusobacterium species

Risk Factors Risk factors for sinusitis include: Having asthma Overuse of nasal decongestants Frequent swimming or diving Climbing or flying to high altitudes Nasal polyps (swellings in the nasal passage), nasal bone spurs, or other abnormalities such as a deviated septum or cleft palate Dental infection Exposure to air pollution and cigarette smoke Pregnancy Gastroesophageal reflux disease (GERD), in which stomach acid backs up into the esophagus Being in the hospital, especially if the reason you are in the hospital is related to a head injury or you needed a tube inserted into your nose (for example, a nasogastric tube from your nose to your stomach)

Prognosis Sinusitis does not cause any significant mortality by itself. However, complicated sinusitis may lead to morbidity and, in rare cases, mortality. Approximately 40% of acute sinusitis cases resolve spontaneously without antibiotics. The spontaneous cure for viral sinusitis is 98%. Patients with acute sinusitis, when treated with appropriate antibiotics, usually show prompt improvement. The relapse rate after successful treatment is less than 5%. In the absence of response within 48 hours or worsening of symptoms, reevaluate the patient. Untreated or inadequately treated rhinosinusitis may lead to complications such as meningitis, cavernous sinus thrombophlebitis, orbital cellulitis or abscess, and brain abscess. In patients with allergic rhinitis, aggressive treatment of nasal symptoms and signs of mucosal edema, which can cause obstruction of the sinus outflow tracts, may decrease secondary sinusitis. If the adenoids are chronically infected, removing them eliminates a nidus of infection and can decrease sinus infection.

Epidemiology An estimated 134 million Indians suffer from chronic sinusitis, the symptoms of which include but are not limited to debilitating headaches, fever and nasal congestion and obstruction. That's more than population of Japan. The National Institute of Allergy and Infectious Diseases' (NIAID) estimate does not even take into account those of us who suffer from acute sinusitis. Among Indians this disease is more widespread than diabetes, asthma or coronary heart disease. One in eight Indians suffer from chronic sinusitis caused by the inflammation of the nasal and throat lining, which results in the accumulation of mucus in the sinus cavity, and pressure build-up in the face, eyes and brain. What's worrying, say Mumbai doctors, is that the disease is likely to be higher in Mumbai given the pollution levels and unhealthy lifestyle of its citizens. Most people suffer silently until the varied symptoms begin to affect their productivity. More often than not, patients who start off with a mild sinus infection do not realize that symptoms, which last beyond 12 weeks, could be an indication that they suffer from sinusitis. "Add to this, our culture of self-diagnosis and medication, often resulting in a delay in seeking appropriate treatment for something that could have easily been treated.

Diagnosis and treatment

Physical Examination

Physical examination in patients with chronic sinusitis may reveal various findings. It should include a complete head and neck examination (lymphadenopathy) to confirm the diagnosis and to rule out more serious disorders. Sinus palpation is performed to evaluate tenderness or swelling. Pain or tenderness on palpation over frontal or maxillary sinuses may be noted. Transillumination of maxillary or frontal sinuses may be useful; it lacks sensitivity but may have value in experienced hands. An oral cavity and oropharynx examination is used to evaluate the integrity of the palate and the condition of dentition and to look for evidence of postnasal drip. Oropharyngeal erythema and purulent secretions may be noted. Dental caries may be present. Anterior rhinoscopy, with the use of a nasal speculum, is used to evaluate the condition of the nasal mucosa and to look for purulent drainage or evidence of polyps or other nasal masses. Other contributing factors to CRS that can be evaluated are nasal septal deviation and turbinate hypertrophy. The nasal examination should be carried out both before and after the use of a topical decongestant. The nasal examination can be supplemented with the use of nasal endoscopy (if available). Endoscopic (rhinoscopic) examination findings include the following: Nasal mucosal erythema, edema Purulent secretions Nasal obstruction due to deviated nasal septum or hypertrophied turbinates Nasal polyps

Ear examination for the presence of middle ear fluid that may be the sign of a mass in the nasopharynx is indicated. Ocular examination for spread of disease to the orbit and function of ocular musculature is indicated. Ophthalmic manifestations include the following: Conjunctival congestion Lacrimation Proptosis, extraocular muscle palsies, and visual disturbances (when complicated by orbital extension)

Laryngeal examination is used to look for other confounding upper airway pathology including laryngeal-pharyngeal reflux (LPR). Lung examination is performed to determine if coexisting lower airway disease is present. Cranial nerve examination is performed to look for underlying sinus malignancy or neurological disorder.

Physical Findings Mucopurulent nasal discharge Swelling of nasal mucosa Mild erythema Facial pain (unusual in children) Periorbital swelling

Objectives of Treatment of Acute Bacterial Sinusitis Decrease time of recovery

Prevent chronic disease Decrease exacerbations of asthma or other secondary diseases Do so in a cost-effective way!

Treatment of Acute Sinusitis Antihistamines recommended if allergy present Decongestants 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 Treatment of Acute, Uncomplicated Sinusitis Antibiotic may not be indicated Many are viral Benefit of antibiotics are only moderate Weigh factors of cost, side effects, antibiotic resistance, and antibiotic reactions 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 Commercial buffered sprays Bulb syringe

1/4 tsp of salt to 7 ounces water Waterpik with lavage tip 1 tsp salt to reservoir Disposable enema bucket 2 tsp salt, 1 tsp soda per quart of water Washes away irritants Moistens the dry nose Waterpik with nasal irrigator Ceramic irrigators Enema bucket with normal saline and soda Hose-in-the-nose-- $2.50

With enema bucket/hose. Add 2 teaspoons of salt and 1 tsp of baking soda to a quart of warm water Over tub, sink, or in shower lean over, head tilted slightly downward and to side place hose in upper nostril (fluid may return from either nostril or through mouth) run in 1/2 solution. Turn head to opposite side and repeat process. Use once, twice daily or as often as needed 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 Have patient sit at your eye level in darkened room (the darker the better) Let eyes get accustomed to dark Place bright light (transilluminator) over inferior orbital ridge to look at maxillary sinuses, under superior orbital rim for frontal sinuses Look at palate for presence/absence of transilluminated light Rhinoscopy Aids in Diagnosing Nasal polyps Septal deviation Concha bullosa Eustachian tube dysfunction Causes of hoarseness Adenoid hyperplasia Tumors MRI Imaging Not used for imaging suspected acute sinusitis Suspected fungal sinusitis

Suspected tumors

Bacteria Involved in Acute Bacterial Sinusitis Streptococcus pneumoniae 30% Haemophilus influenza 20% Moraxella catarrhalis 20% Sterile 30% Rational for Starting Rx with Amoxicillin In the absence of risk factors, i.e. attendance in daycare center, recent antibiotics, age younger than 2 80% of patients will respond to amoxicillin Give Rx for 5 days with a refill -- if responding treat for 10 to 14 days, if not, switch to another Reasons to Use Alternative Antibiotics No response to amoxicillin within 3-5 days Recent treatment with amoxicillin for other causes Symptoms present for more than 30 days Recurrent sinus infections Secondary Antibiotics for Acute Sinusitis Cefdinir (Omnicef) Cefuroxime (Ceftin) Cephpodoxime (Vantin) Azithromycin Clarithromycin

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 Quality-of-Life Issues Fatigue Concentration Nuisance Sleep disturbance Emotional well being Social interactions Missing school/work Halitosis Decreased production Impaired studying Sniffing/snorting Blowing nose

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

Treatment of Chronic Sinusitis Nasal steroid spray Guafenesin Decongestants Steam inhalation Nasal irrigation Antibiotics with exacerbations

Bacteria Involved in Chronic Sinusitis Role of Viruses is Unknown Streptococcus pneumoniae Haemophilus influenza Moraxella catarrhalis Staph aureus Coagulase negative staphylococcus Anerobic bacteria

Transition of Bacteria Rom Acute to Chronic Sinusitis In one study, while initial aspirates showed strep pneumoniae, H. influenzae, and M catarrhalis, subsequent cultures showed Porphyromonas, Peptostreptococcus, and aerobic organisms found to be increasingly resistant to antibiotics Sinus Aspiration and Culture Correlation of routine nasal culture and sinus culture are poor Endoscopically guided aspiration of cultures from medial meatus do correlate with sinus culture Recommendations Made for Antibiotic Prophylaxis in ABS Has not been evaluated as has its use in otitis media Increasing evidence of antibiotic resistance is an issue May be tried in chronic or recurrent disease Complications of Sinusitis Orbital Diplopia, proptosis Periorbital erythema, swelling Bone Periosteal abscesses Brain Intracranial abscesses causing neurologic symptoms

The Sinusitis-Asthma Connection Mechanism is not understood Evidence is compelling Failure to control upper airway inflammation leads to suboptimal asthma control Correcting the rhinosinusitis results in better asthma control Indications for Referral Allergy testing, possible immunotherapy Sinus aspiration for bacterial culture Surgical intervention Correct obstructive process Drain sinus abscesses Consideration to remove nasal polyps Indications for Hospitalization Acutely ill child or adult with high fever, severe head pain Suspected sphenoid sinusitis Anytime complications of eye, bone or intracranial structures are present The Recommendations The recommendations cited are those proposed by a task force of the American Academy of Pediatrics in consultation with other groups regarding the evaluation, diagnosis, and treatment of patients aged 1-21 years with sinus diseaseexpert opinion was used when insufficient data could be found. Recommendation 1 The diagnosis of acute bacterial sinusitis is based on clinical criteria with patients presenting with URI symptoms that are either persistent or severe.

Recommendation 2a Imaging studies are not necessary to confirm a diagnosis of clinical sinusitis in children younger than 6 years (older than age 6 years is controversial) Children with persistent symptoms (>10 days, < 30 days) predicted abnormal radiographs 80% of the time Children < 6 symptoms predicted 88% of the time Normal x-ray suggests ABS is not present 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 Recommendation 3 Antibiotics are recommended for the management of acute bacterial sinusitis to achieve a more rapid clinical cure Patients must meet requirements of persistent or severe disease Response improved with doses >Minimal Inhibition Concentration No EB Recommendations Found for Use of Adjunctive Therapy in ABS, May be Helpful Nasal saline irrigation Oral decongestants Oral or nasal antihistamines Topical decongestants Mucolytic agents Topical steroids

Sinusitis
Lifestyle These measures can help reduce congestion in your sinuses: Using a humidifier Using a saline nasal spray Inhaling steam 2 - 4 times per day (for example, sitting in the bathroom with the shower running) Quickly treating allergic and asthma attacks Silicea -- for individuals with chronic congestion accompanied by head pain that tends to be worse in the right eye; this pain is worsened by cold, movement, light, noise, and mental concentration (such as when studying), but relieved by heat and pressure Spigelia -- for sinusitis with sharp pains on the left side of the face, generally coming on after exposure to cold, wet weather; symptoms are aggravated by warmth, light, noise, and movement, but are relieved by cold compresses or cool water on the face and when the individual is lying down with the head propped up

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