Sinusitis Disease

DESCRIPTION

Acute sinusitis is a symptomatic inflammation of the paranasal sinuses of less than 4 weeks duration occurring as a result of impaired drainage and retained secretions. Subacute when symptomatic from 4-12 weeks. Chronic when symptomatic for greater than 12 weeks. Acute exacerbation of chronic disease when worsening of already symptomatic patient.

System(s) affected: Pulmonary
Genetics: No known genetic pattern
Incidence/Prevalence in USA:
- 16% of population annual diagnosis of sinusitis
- Fifth leading reason for antibiotic prescriptions
- Approximately 5% of office visits for young adults
- Incidence of both acute and chronic sinusitis increases in the latter part of childhood
- Incidence increases up to age 75 and then decreases
Predominant age: All ages
Predominant sex: Both sexes equally

SIGNS AND SYMPTOMS

Symptoms predictive of bacterial sinusitis:
- Preceding URI symptoms, particularly if seemed to be spontaneously resolving with acute return of symptoms ("double-sickening")
- History of colored nasal discharge or postnasal drip
- Unilateral facial pain or pressure which is worse with bending forward or with cough or sneezing
- Maxillary toothache
- Nasal congestion
- In young children, URI symptoms, clear or purulent nasal discharge and persistent cough, persisting > 10-days
Other associated symptoms:
- Headache
- Retro-orbital pain
- Otalgia
- Hyposomia
- Halitosis
- Chronic cough
Symptoms indicating urgency:
- Orbital pain
- Visual disturbances, especially diplopia
- Periorbital swelling or erythema
- Facial swelling or erythema
- Mentation change
Predictive physical examination findings:
- Purulent rhinorrhea
Other associated signs:
- Edematous nasal mucosa
- Nasal obstruction/polyps
Signs indicating urgency or complications:
- Visual changes
- Abnormal extraocular movements
- Periorbital edema or erythema
- Change in mental status

CAUSES

Infectious
- Viral - vast majority are viral
- Bacteria in acute sinusitis (Strep. pneumoniae, H. influenzae, Branhamella [Moraxella] catarrhalis)
- Bacteria in chronic sinusitis (S. aureus, Pseudomonas, other gram negatives, gram positive aerobes)
- Fungal (Aspergillus most common)

RISK FACTORS

Viral upper respiratory infection
Age < 10 or > 50
Anatomical abnormalities
- Tonsillar and adenoid hypertrophy
- Turbinate hypertrophy
- Deviated septum
- Nasal polyps
- Cleft palate
Nasotracheal intubation
Barotrauma
Dental infections and procedures
Trauma
Immunodeficiency & HIV disease
Cystic fibrosis
Asthma and allergies

LABORATORY

Sedimentation rate > 10 mm/hr
C-reactive protein greater than 10 mg/L

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Inflammation
Edema
Thickened mucosa
Impaired ciliary function
Inflammatory metaplasia to ciliated columnar cells
Relative acidosis and hypoxia within sinuses
Polyps

SPECIAL TESTS

Nasal endoscopy

IMAGING

Plain sinus radiographs (not routinely ordered)
- May be helpful when only 2-3 associated signs and symptoms are present
- Look for air-fluid levels, sinus opacity, mucosal thickening (> 6 mm in children or > 8 mm in adults). Only helpful in determining the presence of maxillary sinusitis. May miss ethmoid or sphenoid inflammation.
Limited coronal CT of sinuses
- Most useful in evaluation of chronic sinusitis (3-4 annual episodes or failure to respond to medical therapy)

DIAGNOSTIC PROCEDURES

History and physical exam sufficient for majority of cases of sinusitis
Transnasal endoscopic or sublabial maxillary antrum aspiration culture are gold standards, but generally performed only in selected cases

APPROPRIATE HEALTH CARE

Outpatient
Hospitalization for complications (meningitis, orbital cellulitis or abscess, brain abscess)

GENERAL MEASURES

Adequate hydration (8-10 glasses water daily)
Steam inhalation 20-30 minutes tid or use of facial steamer
Saline irrigation or saline nose drops
Sleep with head of bed elevated
Avoid exposure to cigarette/cigar/pipe smoke, fumes
Avoid dehydrants (caffeine and alcohol)
Antibiotics indicated when purulent rhinorrhea or worsening symptoms last more than 5-10 days

SURGICAL MEASURES

If medical therapy fails, consider sinus irrigation to wash out inspissated material
Functional endoscopic sinus surgery is the preferred treatment for medically recalcitrant cases
Absolute surgical indications:
- Massive nasal polyposis
- Acute complications: subperiosteal or orbital abscess, frontal soft tissue spread of infection
- Mucocele or mucopyocele
- Invasive or allergic fungal sinusitis
- Suspected obstructing tumor
- CSF rhinorrhea

ACTIVITY

Adequate rest, otherwise no restrictions

DIET

No special diet

PATIENT EDUCATION

Call back if no significant improvement within one week, symptoms worsen, or symptoms such as headache, neck stiffness, visual changes, nausea or vomiting occur
Educate patient on potential major side effects of selected medications
For patient education materials favorably reviewed on this topic, contact:
- American College of Allergy, Asthma & Immunology, 85 West Algonquin Road, Suite 550, Arlington Heights, IL 60005, 1-847-427-1200
- Smoots E. American Family Physician 1998; 58(5):1805-6 (see www.aafp.org)

PREVENTION/AVOIDANCE

No documented evidence for prevention measures

POSSIBLE COMPLICATIONS

Brain abscess
Cavernous sinus thrombosis
Meningitis
Osteomyelitis
Orbital cellulitis
Subdural empyema

EXPECTED COURSE AND PROGNOSIS

Alleviation of symptoms within 72 hours with complete resolution within 10 days

ASSOCIATED CONDITIONS

Allergic Rhinitis
Asthma
Bronchitis
Otitis Media
Pharyngitis

AGE-RELATED FACTORS

Pediatric:

Average 6-8 colds per year; more frequent may indicate or place at risk for bacterial sinusitis
Adenoid hypertrophy may complicate chronic sinusitis
Chronic sinusitis indicates a need to search for underlying cause, eg., nasal deformities, or infected and hypertrophied adenoids

Geriatric: More difficult to heal in this age group
Others: N/A

PREGNANCY

TMP-SMX = Category B; during term = Category D; can be used during lactation except for premature infants, those with hyperbilirubinemia and those with G-6-PD deficiency; avoid in children < 2, those with severe asthma or allergies; hemolytic anemia may occur in patients with G-6-PD deficiency
Azithromycin = Category B; clarithromycin = Category C
Penicillins listed as Category B; they are excreted in low concentrations into breast milk and can cause symptoms

OTHER NOTES

N/A

ABBREVIATIONS

CSF = cerebrospinal fluid
TMP-SMX = trimethoprim-sulfamethoxazole
URI = upper respiratory infection

Clinical Investigations

ROLE OF HOMOEOPATHY

Holistic healing that treats the person, not just the disease. Experience gentle, lasting wellness with expert constitutional care.