Sinusitis

From Wikipedia, the free encyclopedia

This is an old revision of this page, as edited by 72.219.56.68 (talk) at 09:45, 14 May 2010 (small grammar correction). The present address (URL) is a permanent link to this revision, which may differ significantly from the current revision.

Sinusitis
SpecialtyOtorhinolaryngology Edit this on Wikidata

Sinusitis is inflammation of the paranasal sinuses, which may be due to infection, allergy or autoimmune issues. Most cases are due to a viral infection and resolve over the course of 10 days. It is a common condition with more than 24 million cases occurring in the United States annually.[1]

Classification

By duration

Sinusitis can be acute (going on less than four weeks), subacute (4–8 weeks) or chronic (going on for 8 weeks or more).[2] All three types of sinusitis have similar symptoms, and are thus often difficult to distinguish. Acute sinusitis is very common. Roughly ninety percent of adults have had sinusitis at some point in their life.[3]

Acute sinusitis

Acute sinusitis is usually precipitated by an earlier upper respiratory tract infection, generally of viral origin. If the infection is of bacterial origin, the most common three causative agents are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis[4]. Haemophilus influenzae in the past was the most common bacterial agent to cause sinus infections. However since the introduction of Hib vaccine there has been a dramatic decrease in H.Influenza type B infections and usually the non-typable strains of H.influenza are seen now in the clinical setting. Other bacterial pathogens include other Staphylococcus aureus and other streptococci species, anaerobic bacteria and, less commonly, gram negative bacteria. Viral sinusitis typically lasts for 7 to 10 days,[4] whereas bacterial sinusitis is more persistent. Approximately 0.5% to 2% of viral sinusitis extends into bacterial sinusitis. One hypothesis postulates that the bacterial infection begins with nose blowing.[5]

Acute episodes of sinusitis can also result from fungal invasion. These infections are most often seen 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 Mucormycosis.[6]

Chemical irritation can also trigger sinusitis, commonly from cigarettes and chlorine fumes.[citation needed] Rarely, it may be caused by a tooth infection.[4]

Chronic sinusitis

Chronic sinusitis is defined by the fact that it lasts longer than three months and 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[4] and may include allergy, environmental factors such as dust or pollution, bacterial infection, or fungus (either 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. A combination of anaerobic and aerobic bacteria are observed, including Staphylococcus aureus and coagulase-negative Staphylococci. Typically antibiotics provide only a temporary benefit, although mechanisms involving hyperresponsiveness to bacteria have been proposed for sinusitis with polyps.

Symptoms may include any combination of the following: nasal congestion; facial pain; headache; night-time coughing; an increase in previously minor or controlled asthma symptoms; general malaise; thick green or yellow discharge; feeling of facial 'fullness' or 'tightness' which may worsen on bending over; dizziness, aching teeth, and/or halitosis. Each of these symptoms has multiple other causes. Unless complications occur, fever is not a feature of chronic sinusitis. Often chronic sinusitis can lead to Anosmia, a reduction in the ability to smell or detect odors.[citation needed] In a small number of cases, acute or chronic maxillary sinusitis is associated with a dental infection. Vertigo, lightheadedness, and blurred vision are not typical in chronic sinusitis and other causes should be sought.

Attempts have been made to provide a more consistent nomenclature 6 for subtypes of chronic sinusitis. Many patients have demonstrated the presence of eosinophils in the mucous lining of the nose and paranasal sinuses. As such the name Eosinophilic Mucin RhinoSinusitis (EMRS) has come into being. Cases of EMRS may be related to an allergic response, but allergy is often not documentable, resulting in further subcategorization of allergic and non-allergic EMRS.

A more recent, and still debated, development in chronic sinusitis is the role that fungus may play. Fungus can be found in the nasal cavities and sinuses of most patients with sinusitis, but can also be found in healthy people as well. It remains unclear if fungus is a definite factor in the development of chronic sinusitis and if it is, what the difference may be between those who develop the disease and those who do not. Trials of antifungal treatments have had mixed results.[4]

By location

There are several paired paranasal sinuses, including the frontal, ethmoid, maxillary and sphenoid sinuses. The ethmoid sinuses can also be further broken down into anterior and posterior, the division of which is defined as the basal lamella of the middle turbinate. In addition to the acuity of disease, discussed below, sinusitis can be classified by the sinus cavity which it affects:

Recent theories of sinusitis indicate that it often occurs as part of a spectrum of diseases that affect the respiratory tract (i.e., the "one airway" theory) and is often linked to asthma.[7][8] All forms of sinusitis may either result in, or be a part of, a generalized inflammation of the airway so other airway symptoms such as cough may be associated with it.

Signs and symptoms

Headache

Headache/facial pain or pressure of a dull, constant, or aching sort over the affected sinuses can be seen with either acute or chronic stages of sinusitis. This pain is typically localized to the involved sinus and may worsen when the affected person bends over or when in the supine position. Pain often starts on one side of the head and progresses to both sides.[9]

Acute and chronic sinusitis may be accompanied by thick purulent nasal discharge (usually green in colour and with or without blood) and localized headache (toothache) are present and it is these symptoms that can differentiate sinus related (or rhinogenic) headache from other headache phenomena such as tension headache and migraine headache. Infection of the eye socket is possible which may result in the loss of sight, accompanied with fever and severe illness. Another possible complication is the infection of the bones (osteomyelitis) of the forehead and other facial bones - Pott's puffy tumor.[9]

Recent studies suggest that up to 90% of "sinus headaches" are actually migraines.[10][11] The confusion occurs in part because migraine involves activation of the trigeminal nerves which innervate both the sinus region but also the meninges which surround the brain. As a result, direct determination of the site of pain origination can be confused on a cortical level. Additionally, nasal congestion is a not uncommon result of migraine headaches, due to the autonomic nervous stimulation that can also result in tearing (lacrimation) and a runny nose (rhinorrhea). A study found that patients with "sinus headache" respond to triptan migraine medications, and state dissatisfaction with their treatment when they are treated with decongestants or antibiotics.[12]

Complications

Due to the proximity of the brain to the sinuses, the most dangerous complication of sinusitis, particularly frontal and sphenoid sinusitis, is the spread of infection through the bones or by blood vessels by anaerobic bacteria to the brain. Abscesses, meningitis, and other life-threatening conditions may result. In extreme cases the patient may experience mild personality changes, headache, altered consciousness, visual problems, and, finally, seizures, coma, and possibly death.[9]

Causes

Factors which may predispose to developing sinusitis include: allergies; structural problems such as a deviated septum, small sinus ostia or a concha bullosa; nasal polyps; carrying the cystic fibrosis gene (research is still tentative); prior bouts of sinusitis as each instance may result in increased inflammation of the nasal or sinus mucosa and potentially further narrow the openings.[citation needed]

Second hand smmoke is the cause of about 40% of chronic rhinosinusitis.[13]

Pathophysiology

Biofilms are complex aggregates of extracellular matrix and inter-dependent microorganisms from multiple species, many of which may be difficult or impossible to isolate using standard clinical laboratory techniques. Bacteria found in biofilms may show increased antibiotic resistance when compared to free-living bacteria of the same species. It has been hypothesized that biofilm-type infections may account for many cases of antibiotic-refractory chronic sinusitis.[14][15][16] A recent study found that biofilms were present on the mucosa of 3/4 of patients undergoing surgery for chronic sinusitis.[17]

Diagnosis

Acute sinusitis

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 30% to 50% are bacterial sinusitis). Nosocomial acute sinusitis is confirmed with the help of CT scan of the sinuses.

Chronic sinusitis

For sinusitis lasting more than eight weeks,[2] criteria are lacking. A CT scan is recommended, but insufficient to confirm diagnosis. Nasal endoscopy, a CT scan, and clinical symptoms are used together.[4] A tissue sample for histology and cultures can also be used. Allergic fungal sinusitis are seen in a person with asthma and nasal polyps. Multiple biopsy is informative to confirm the diagnosis.[18]

Nasal endoscopy involves inserting a flexible fiber-optic tube with a light and camera at its tip into the nose to examine the nasal passages and sinuses. This is generally a completely painless (although uncomfortable) procedure which takes between five to ten minutes to complete.

Treatment

Conservative measures

Nasal irrigation may help with symptoms of chronic sinusitis.[19]

Antibiotics

The vast majority of cases of sinusitis are due to viral etiology and thus resolve without antibiotics.[4] However, if the symptoms are prolonged amoxicillin is a reasonable first choice[4] with amoxicillin/clavulanate (Augmentin) being indicated for patients who fail amoxicillin alone. Fluoroquinolones, and some of the newer macrolide antibiotics such as clarithromycin, and doxycycline, are used in patients who are allergic to penicillins.[20] Antibiotics are usually ineffective and overall may be no more effective than placebos: 60 to 90% of people do not experience resolution of symptoms.[21] Antibiotics may not improve the long-term clinical outcome for sinusitis.[22] When used a short-course (3–7 days) of antibiotics seems to be sufficient for patients who present without severe disease or any complicating factors.[23]

Corticosteroids

For unconfirmed acute sinusitis intranasal corticosteroids have not been found to be better than placebo either alone or in combination with antibiotics.[21] However for cases confirmed by radiology or nasal endoscopy their use either alone or in combination with antibiotics is supported.[24]

Surgery

For chronic or recurring sinusitis, referral to an otolaryngologist may be indicated for more specialist assessment and treatment, which may include nasal surgery. However, for most patients the surgical approach is not superior to appropriate medical treatment. Surgery should only be considered for those patients who do not experience sufficient relief from optimal medication.[25][26]

A relatively recent advance in the treatment of sinusitis is a type of surgery called functional endoscopic sinus surgery (FESS), whereby normal clearance from the sinuses is restored by removing the anatomical and pathological obstructive variations that predispose to sinusitis. This replaces prior open techniques requiring facial or oral incisions and refocuses the technique to the natural openings of the sinuses instead of promoting drainage by gravity, the idea upon which the Caldwell-Luc surgery was based.[27]

Another recently developed treatment is balloon sinuplasty. This method, similar to balloon angioplasty used to "unclog" arteries of the heart, utilizes balloons in an attempt to expand the openings of the sinuses in a less invasive manner. Its final role in the treatment of sinus disease is still under debate but appears promising.[citation needed]

A number of surgical approaches can be used to access the sinuses and these have generally shifted from external/extranasal approaches to intranasal endoscopic ones. The benefit of the Functional Endoscopic Sinus Surgery FESS is its ability to allow for a more targeted approach to the affected sinuses, reducing tissue disruption, and minimizing post-operative complications.[28]

For persistent symptoms and disease in patients who have failed medical and the functional endoscopic approach, older techniques can be used to address the maxillary sinus such as the Caldwell-Luc radical antrostomy (e.g. incision in the upper gum, opening in the anterior wall of the antrum, removal of the entire diseased maxillary sinus mucosa and drainage is allowed into inferior or middle meatus by creating a large window in the lateral nasal wall.)[29]

Other

Based on the recent theories on the role that fungus may play in the development of chronic sinusitis. Trials of antifungal treatments however have had mixed results.[4]

Epidemiology

It is a common condition with more than 24 million cases occurring in the United States annually.[1]

References

  1. ^ a b Anon JB (2010). "Upper respiratory infections". Am. J. Med. 123 (4 Suppl): S16–25. doi:10.1016/j.amjmed.2010.02.003. PMID 20350632. {{cite journal}}: Unknown parameter |month= ignored (help)
  2. ^ a b http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/allergy/rhino-sinusitis/
  3. ^ Pearlman, AN.; Conley, DB. (2008). "Review of current guidelines related to the diagnosis and treatment of rhinosinusitis". Curr Opin Otolaryngol Head Neck Surg. 16 (3): 226–30. doi:10.1097/MOO.0b013e3282fdcc9a. PMID 18475076. {{cite journal}}: Unknown parameter |month= ignored (help)
  4. ^ a b c d e f g h i Leung, R.S.; Katial, R. (2008). "The Diagnosis and Management of Acute and Chronic Sinusitis" (PDF). Primary Care: Clinics in Office Practice. 35 (1): 11–24. doi:10.1016/j.pop.2007.09.002.
  5. ^ Gwaltney, Jr., J. M. (2000). "Nose Blowing Propels Nasal Fluid into the Paranasal Sinuses". Clinical Infectious Diseases 30: 387. doi:10.1086/313661
  6. ^ http://www.austinent.com/info/wiki/sinusitis.php
  7. ^ Grossman J (1997). "One airway, one disease". Chest. 111 (2 Suppl): 11S–16S. doi:10.1378/chest.111.2_Supplement.11S. PMID 9042022.
  8. ^ Cruz AA (2005). "The 'united airways' require an holistic approach to management". Allergy. 60 (7): 871–874. doi:10.1111/j.1398-9995.2005.00858.x. PMID 15932375.
  9. ^ a b c University of Maryland - Sinusitus Complications
  10. ^ Schreiber C, Hutchinson S, Webster C, Ames M, Richardson M, Powers C (2004). "Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache". Arch. Intern. Med. 164 (16): 1769–72. doi:10.1001/archinte.164.16.1769. PMID 15364670.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  11. ^ Mehle ME, Schreiber CP (2005). "Sinus headache, migraine, and the otolaryngologist". Otolaryngology—head and neck surgery: official journal of American Academy of Otolaryngology-Head and Neck Surgery. 133 (4): 489–96. doi:10.1016/j.otohns.2005.05.659. PMID 16213917.
  12. ^ Ishkanian, G (2007). "Efficacy of sumatriptan tablets in migraineurs self-described or physician-diagnosed as having sinus headache: A randomized, double-blind, placebo-controlled study". Clin Ther. 29 (1): 99–109. doi:10.1016/j.clinthera.2007.01.012. PMID 17379050. {{cite journal}}: |first2= missing |last2= (help); |first3= missing |last3= (help); |first4= missing |last4= (help); |first5= missing |last5= (help); Unknown parameter |month= ignored (help)
  13. ^ Tammemagi CM, Davis RM, S Benninger M, Holm AL, Krajenta R (2010). "Secondhand smoke as a potential cause of chronic rhinosinusitis: a case-control study". Arch. Otolaryngol. Head Neck Surg. 136 (4): 327–34. doi:10.1001/archoto.2010.43. PMID 20403847. {{cite journal}}: Unknown parameter |month= ignored (help)CS1 maint: multiple names: authors list (link)
  14. ^ Palmer JN (2005). "Bacterial biofilms: do they play a role in chronic sinusitis?". Otolaryngol. Clin. North Am. 38 (6): 1193–201, viii. doi:10.1016/j.otc.2005.07.004. PMID 16326178.
  15. ^ Ramadan H, Sanclement J, Thomas J (2005). "Chronic rhinosinusitis and biofilms". Otolaryngol Head Neck Surg. 132 (3): 414–7. doi:10.1016/j.otohns.2004.11.011. PMID 15746854.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  16. ^ Bendouah Z, Barbeau J, Hamad W, Desrosiers M (2006). "Biofilm formation by Staphylococcus aureus and Pseudomonas aeruginosa is associated with an unfavorable evolution after surgery for chronic sinusitis and nasal polyposis". Otolaryngol Head Neck Surg. 134 (6): 991–6. doi:10.1016/j.otohns.2006.03.001. PMID 16730544.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ Sanclement J, Webster P, Thomas J, Ramadan H (2005). "Bacterial biofilms in surgical specimens of patients with chronic rhinosinusitis". Laryngoscope. 115 (4): 578–82. doi:10.1097/01.mlg.0000161346.30752.18. PMID 15805862. {{cite journal}}: Unknown parameter |doi_brokendate= ignored (|doi-broken-date= suggested) (help)CS1 maint: multiple names: authors list (link)
  18. ^ Harrison's Manual of Medicine 16/e
  19. ^ Harvey R, Hannan SA, Badia L, Scadding G (2007). "Nasal saline irrigations for the symptoms of chronic rhinosinusitis". Cochrane Database Syst Rev (3): CD006394. doi:10.1002/14651858.CD006394.pub2. PMID 17636843.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  20. ^ Karageorgopoulos DE, Giannopoulou KP, Grammatikos AP, Dimopoulos G, Falagas ME. Fluoroquinolones compared with beta-lactam antibiotics for the treatment of acute bacterial sinusitis: a meta-analysis of randomized controlled trials. CMAJ. 2008; 178(7):845-54.PMID:18362380
  21. ^ a b Ian G. Williamson; et al. (2007). "Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis". JAMA. 298 (21): 2487–2496. doi:10.1001/jama.298.21.2487. PMID 18056902. {{cite journal}}: Explicit use of et al. in: |author= (help)
  22. ^ van Buchem, F. L. (8 March 1997). "Primary-care-based randomised placebo-controlled trial of antibiotic treatment in acute maxillary sinusitis". The Lancet. 349 (9053): 683–687. doi:10.1016/S0140-6736(96)07585-X. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  23. ^ Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta-analysis of randomized trials. Br J Clin Pharmacol. 2009; 67(2):161-71.PMID 19154447
  24. ^ Zalmanovici A, Yaphe J (2009). "Intranasal steroids for acute sinusitis". Cochrane Database Syst Rev (4): CD005149. doi:10.1002/14651858.CD005149.pub3. PMID 19821340.
  25. ^ Fokkens W, Lund V, Mullol J (2007). "European Position Paper on Rhinosinusitis and Nasal Polyps 2007". Rhinol Suppl. 16 (20): 67. doi:10.1017/S0959774306000060. PMID 17844873.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  26. ^ Tichenor, Wellington S. (2007-04-22). "FAQ - Sinusitis - WS Tichenor M.D." Retrieved 2007-10-28. {{cite web}}: Cite has empty unknown parameter: |coauthors= (help)
  27. ^ http://www.fasthealth.com/dictionary/c/Caldwell-Luc_operation.php
  28. ^ Stammberger H. Endoscopic endonasal surgery - Concepts in treatment of recurring rhinosinusitis. Part I. Anatomic and pathophysiologic considerations. Otolaryngol Head Neck Surg. 1986;94:143.
  29. ^ Bailey and Love

External links

Retrieved from "https://en.wikipedia.org/w/index.php?title=Sinusitis&oldid=362062804"