Sinusitis

Sinusitis, also known as rhinosinusitis, is inflammation of the paranasal sinuses. It can be due
to infection, allergy, orautoimmune problems. Most cases are due to a viral infection and
resolve over the course of 10 days. It is a common condition, with over 24 million cases
annually in the U.S.[1]
Classification
Sinusitis (or rhinosinusitis) is defined as an inflammation of the mucous membrane that lines
the paranasal sinuses and is classified chronologically into several categories: [2]
 Acute rhinosinusitis — a new infection that may last up to four weeks and can be
subdivided symptomatically into severe and non-severe;
 Recurrent acute rhinosinusitis — four or more separate episodes of acute sinusitis that
occur within one year;
 Subacute rhinosinusitis — an infection that lasts between four and 12 weeks, and
represents a transition between acute and chronic infection;
 Chronic rhinosinusitis — when the signs and symptoms last for more than 12 weeks; and
 Acute exacerbation of chronic rhinosinusitis — when the signs and symptoms of chronic
rhinosinusitis exacerbate, but return to baseline after treatment.
All these 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
Acute sinusitis is usually precipitated by an earlier upper respiratory tract infection, generally
of viral origin, mostly caused by rhinoviruses, coronaviruses, andinfluenza viruses, others
caused by adenoviruses, human parainfluenza viruses, human respiratory syncytial
virus, enteroviruses other than rhinoviruses, andmetapneumovirus. If the infection is of
bacterial origin, the most common three causative agents are Streptococcus
pneumoniae, Haemophilus influenzae, andMoraxella catarrhalis.[4] Until recently, Haemophilus
influenzae was the most common bacterial agent to cause sinus infections. However,
introduction of the H. influenza type B (Hib) vaccine has dramatically decreased H.
influenza type B infections and now non-typable H. influenza (NTHI) are predominantly seen in
clinics. Other sinusitis-causing bacterial pathogens include Staphylococcus aureus and
other streptococci species, anaerobic bacteria and, less commonly, gram negativebacteria. Viral
sinusitis typically lasts for 7 to 10 days,[4] whereas bacterial sinusitis is more persistent.
Approximately 0.5% to 2% of viral sinusitis results in subsequent bacterial sinusitis. It is thought
that nasal irritation from nose blowing leads to the secondary bacterial infection.[5]
Acute episodes of sinusitis can also result from fungal invasion. These infections are typically
seen in patients with diabetes or other immune deficiencies (such
asAIDS or transplant patients on immunosuppressive anti-rejection medications) and can be
life-threatening. In type I diabetics, ketoacidosis can be associated with sinusitis due
to mucormycosis.[6]
Chemical irritation can also trigger sinusitis, commonly from cigarette smoke and chlorine
fumes.[7] Rarely, it may be caused by a tooth infection.[4]
Chronic
By definition chronic sinusitis lasts longer than three months and can be caused by many
different diseases that share chronic inflammation of the sinuses as a common symptom.
Symptoms of chronic sinusitis 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' that may worsen when bending over, dizziness, aching teeth, and/or halitosis.[2] Each
of these symptoms has multiple other possible causes, which should be considered and
investigated as well. Often chronic sinusitis can lead to anosmia, a reduced sense of smell.[2] 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 investigated.[citation needed]
Chronic sinusitis cases are subdivided into cases with polyps and cases without polyps. When
polyps are present, the condition is called chronic hyperplastic sinusitis; however, 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).
Chronic rhinosinusitis represents a multifactorial inflammatory disorder, rather than simply a
persistent bacterial infection.[4] The medical management of chronic rhinosinusitis is now
focused upon controlling the inflammation that predisposes patients to obstruction, reducing
the incidence of infections. However, all forms of chronic rhinosinusitis are associated with
impaired sinus drainage and secondary bacterial infections. Most individuals require initial
antibiotics to clear any infection and intermittently afterwards to treat acute exacerbations of
chronic rhinosinusitis.
A combination of anaerobic and aerobic bacteria, are detected in conjunction with chronic
sinusitis. Also isolated are Staphylococcus aureus (including methicilin resistant [Link] ) and
coagulase-negative Staphylococci and Gram negative enteric organisms can be isolated.
Attempts have been made to provide a more consistent nomenclature for subtypes of chronic
sinusitis. The presence of eosinophils in the mucous lining of the nose and paranasal sinuses has
been demonstrated for many patients, and this has been termed eosinophilic mucin
rhinosinusitis (EMRS). Cases of EMRS may be related to an allergic response, but allergy is not
often documented, resulting in further subcategorization into allergic and non-allergic EMRS.[8]
A more recent, and still debated, development in chronic sinusitis is the role that fungi play in
this disease. It remains unclear if fungi are a definite factor in the development of chronic
sinusitis and if they are, what the difference may be between those who develop the disease
and those who remain free of symptoms. Trials of antifungal treatments have had mixed
results.
By location
There are several paired paranasal sinuses, including the frontal, ethmoidal, maxillary and
sphenoidal sinuses. The ethmoidal sinuses is further subdivided into anterior and posterior
ethmoid sinuses, the division of which is defined as the basal lamella of the middle turbinate. In
addition to the severity of disease, discussed below, sinusitis can be classified by the sinus
cavity which it affects:
 Maxillary – can cause pain or pressure in the maxillary (cheek) area
(e.g., toothache,[9] or headache) (J01.0/J32.0)
 Frontal – can cause pain or pressure in the frontal sinus cavity (located above
eyes), headache, particularly in the forehead (J01.1/J32.1)
 Ethmoidal – can cause pain or pressure pain between/behind the eyes, the sides of the
upper part of the nose (the medial canthi), and headaches (J01.2/J32.2)[10]
 Sphenoidal – can cause pain or pressure behind the eyes, but often refers to the
skull vertex (top of the head), over the mastoid processes, or the occiput (back of the
head).[10]
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.[11][12] 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[edit]
Headache/facial pain or pressure of a dull, constant, or aching sort over the affected sinuses is
common with both acute and chronic stages of sinusitis. This pain is typically localized to the
involved sinus and may worsen when the affected person bends over or when lying down. Pain
often starts on one side of the head and progresses to both sides.[13] Acute and chronic sinusitis
may be accompanied by thick nasal discharge that is usually green in color and may contain pus
(purulent) and/or blood.[14] Often a localized headache or toothache is present, and it is these
symptoms that distinguish a sinus-related headache from other types of headaches, such as
tension and migraine headaches. Another way to distinguish between toothache and sinusitis is
that the pain in sinusitis usually is worsened by tilting the head forwards and with valsalva
maneuvers.[9]
Infection of the eye socket is possible, which may result in the loss of sight and is accompanied
by 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.[13]
Sinus infections can also cause middle ear problems due to the congestion of the nasal
passages. This can be demonstrated by dizziness, "a pressurized or heavy head", or vibrating
sensations in the head. Post-nasal drip is also a symptom of chronic rhinosinusitis.
Halitosis (bad breath) is often stated to be a symptom of chronic rhinosinusitis, however gold
standard breath analysis techniques have not been applied. Theoretically, there are several
possible mechanisms of both objective and subjective halitosis that may be involved. [9]
A 2004 study suggested that up to 90% of "sinus headaches" are actually migraines.[15][16][verification
needed] The confusion occurs in part because migraine involves activation of the trigeminal nerves,
which innervate both the sinus region and the meninges surrounding the brain. As a result, it is
difficult to accurately determine the site from which the pain originates. People with migraines
do not typically have the thick nasal discharge that is a common symptom of a sinus infection. [17]
Complications[edit]
Stage Description

I Preseptal cellulitis

II Orbital cellulitis

III Subperiosteal abscess

IV Orbital abscess

V Cavernous sinus septic thrombosis

The close proximity of the brain to the sinuses makes the most dangerous complication of
sinusitis, particularly involving the frontal and sphenoid sinuses, infection of the brain by the
invasion of anaerobic bacteria through the bones or blood vessels. Abscesses, meningitis and
other life-threatening conditions may result. In extreme cases the patient may experience mild
personality changes, headache, altered consciousness, visual problems, seizures, coma and
possibly death.[13]
Sinus infection can spread through anastomosing veins or by direct extension to close
structures. Orbital complications were categorized by Chandler et al.[18] into five stages
according to their severity (see table). Contiguous spread to the orbit may result in periorbital
cellulitis, subperiosteal abscess, orbital cellulitis, and abscess. Orbital cellulitis can complicate
acute ethmoiditis if anterior and posterior ethmoidal veins thrombophlebitis enables the
spread of the infection to the lateral or orbital side of the ethmoid labyrinth. Sinusitis may
extend to the central nervous system, where it may cause cavernous sinus thrombosis,
retrograde meningitis, and epidural, subdural, and brain abscesses.[19] Orbital symptoms
frequently precede intracranial spread of the infection . Other complications include
sinobronchitis, maxillary osteomyelitis, and frontal bone osteomyelitis.[20][21][22][23] Osteomyelitis of
the frontal bone often originates from a spreading thrombo-phlebitis. A periostitis of the frontal
sinus causes an osteitis and a periostitis of the outer membrane, which produces a tender,
puffy swelling of the forehead.
The diagnosis of these complication can be assisted by noting local tenderness and dull pain,
and can be confirmed by CT and nuclear isotope scanning. The most common microbial causes
are anaerobic bacteria and S. aureus. Treatment includes performing surgical drainage and
administration of antimicrobial therapy. Surgical debridement is rarely required after an
extended course of parenteral antimicrobial therapy.[24] Antibiotics should be administered for
at least 6 weeks. Continuous monitoring of patients for possible intracranial complication is
advised.
Causes
Both smoking and second hand smoke are associated with chronic rhinosinusitis.[25]
Maxillary sinusitis may also be of dental origin ("odontogenic sinusitis"),[26] and constitutes a
significant percentage (about 20% of all cases of maxillary sinusitis),[27]given the close proximity
of the teeth and the sinus floor. The cause of this situation is usually a periapical or periodontal
infection of a maxillary posterior tooth, where the inflammatory exudate has eroded through
the bone superiorly to drain into the maxillary sinus. Once an odontogenic infection involves
the maxillary sinus, it is possible that it may then spread to the orbit or to the ethmoid
sinus.[27] Complementary tests based on conventional radiology techniques and modern
technology may be indicated. Their indication is based on the clinical context.
Chronic sinusitis can also be caused indirectly through a common but slight abnormality within
the auditory or Eustachian tube, which is connected to the sinus cavities and the throat. This
tube is usually almost level with the eye sockets but when this sometimes hereditary
abnormality is present, it is below this level and sometimes level with the vestibule or nasal
entrance.
Pathophysiology
It has been hypothesized that biofilm bacterial infections may account for many cases
of antibiotic-refractory chronic sinusitis.[28][29][30] 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 standardclinical laboratory techniques.[31] Bacteria found
in biofilms have their antibiotic resistance increased up to 1000 times when compared to free-
living bacteria of the same species. A recent study found that biofilms were present on
the mucosa of 75% of patients undergoing surgery for chronic sinusitis.[32]
Diagnosis
Acute
Bacterial and viral acute sinusitis are difficult to distinguish. However, if symptoms last less than
10 days, it is generally considered viral sinusitis. When symptoms last more than 10 days, it is
considered bacterial sinusitis.[33] Imaging by either Xray, CT or MRI is generally not
recommended unless complications develop.[33] Pain caused by sinusitis is sometimes confused
for pain caused by pulpitis (toothache) of the maxillary teeth, and vice versa. Classically, the
increased pain when tilting the head forwards separates sinusitis from pulpitis.
Chronic
For sinusitis lasting more than 12 weeks a CT scan is recommended.[33] Nasal endoscopy, and
clinical symptoms are also used to make a positive diagnosis.[4] A tissue sample
for histology and cultures can also be collected and tested.[34] Allergic fungal sinusitis (AFS) is
often seen in people with asthma and nasal polyps. In rare cases, sinusoscopy may be made.
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
Recommended treatments for most cases of sinusitis include rest and drinking enough water to
thin the mucus.[35] Antibiotics are not recommended for most cases.[35]
Breathing low-temperature steam such as from a hot shower, gargling, or nasal irrigation can
relieve symptoms.[35][36] Over the counter medications may be used cautiously as they can lead to
worsening of the symptoms if used improperly.[35] Decongestant nasal sprays containing for
example oxymetazoline may provide relief, but these medications should not be used for more
than the recommended period. Longer use may cause rebound sinusitis.[37]
Antibiotics
The vast majority of cases of sinusitis are caused by viruses and will therefore resolve without
antibiotics.[4] However, if symptoms do not resolve within 10 days,amoxicillin is a reasonable
antibiotic to use first for treatment[4] with amoxicillin/clavulanate being indicated when the
person's symptoms do not improve after 7 days on amoxicillin alone.[33] Antibiotics are
specifically not recommended in those with mild / moderate disease during the first week of
infection due to risk of adverse effects, antibiotic resistance, and cost.[38]
Fluoroquinolones, and a newer macrolide antibiotic such as clarithromycin or a tetracycline
like doxycycline, are used in those who have severe allergies to penicillins.[39] Because of
increasing resistance to amoxicillin the 2012 guideline of the Infectious Diseases Society of
America recommends amoxicillin-clavulanate as the initial treatment of choice for bacterial
sinusitis.[40] The guidelines also recommend against other commonly used antibiotics, including
azithromycin, clarithromycin and trimethoprim/sulfamethoxazole, because of growing drug
resistance.
A short-course (3–7 days) of antibiotics seems to be just as effective as the typical longer-
course (10–14 days) of antibiotics for those with clinically diagnosed acute bacterial sinusitis
without any other severe disease or complicating factors.[41] The IDSA guideline suggest five to
seven days of antibiotics is long enough to treat a bacterial infection without encouraging
resistance. The guidelines still recommend children receive antibiotic treatment for ten days to
two weeks.[40]
Corticosteroids
For unconfirmed acute sinusitis, intranasal corticosteroids have not been found to be better
than a placebo either alone or in combination with antibiotics.[42] For cases confirmed by
radiology or nasal endoscopy, treatment with corticosteroids alone or in combination with
antibiotics is supported.[43] The benefit, however, is small.[44]
There is only limited evidence to support short treatment with oral corticosteroids for chronic
rhinosinusitis with nasal polyps.[45][46]
Surgery
For chronic or recurring sinusitis, referral to an otolaryngologist specialist may be indicated, and
treatment options may include nasal surgery. Surgery should only be considered for those
patients who do not experience sufficient relief from optimal medication.[45][47]
Maxilliary antral washout involves puncturing the sinus and flushing with saline to clear the
mucus. A 1996 study of patients with chronic sinusitis found that washout confers no additional
benefits over antibiotics alone.[48]
A number of surgical approaches can be used to access the sinuses and these have generally
shifted from external/extranasal approaches to intranasal endoscopicones. The benefit
of 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.[49] The use of drug eluting stents such as propel mometasone furoate
implant may help in recovery after surgery.[50]
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. The utility of this treatment for sinus disease
is still under debate but appears promising.[citation needed]
For persistent symptoms and disease in patients who have failed medical and the functional
endoscopic approaches, older techniques can be used to address the inflammation of the
maxillary sinus, such as the Caldwell-Luc radical antrostomy.