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Sinusitis
 

Definition & Epidemiology

Sinusitis is a clinical condition characterized by mucosal inflammation of the paranasal sinuses. Acute sinusitis is a rapid-onset bacterial infection that has been present for < 1 month and most commonly affects the maxillary sinus. Subacute sinusitis, with symptoms present between 1 and 3 months, usually develops when an acute episode of bacterial sinusitis has not been adequately treated. Chronic sinusitis has been present for at least 3 months and is often associated with persistent mucosal changes.

Sinus disease is frequently encountered in general practice, and it has been estimated that 0.5% of viral upper respiratory tract infection result in acute sinusitis. Chronic sinusitis is also a very common condition and affects 31 to 35 million Americans.

The most frequent underlying cause is obstruction of the ostiomeatal complex (the area in the nose where the paranasal sinuses drain to) due to allergic rhinitis.

In general, any one with recurrent disease (2 or more episodes of sinusitis for 2 or more years) should be evaluated for an underlying problem, which may predispose to recurring infections. The commonest underlying causes of sinusitis are shown below:

Conditions that predispose to chronic sinusitis:

Allergic rhinitis (50 to 60% of cases)

Non-allergic rhinitis (vasomotor) (20-30%)

Anatomic abnormality, including septal deviation (20-30%)

Aspirin sensitivity (5%)

Common variable immunoglobulin deficiency

IgG subclass deficiency

IgA deficiency

Rare causes

Cystic fibrosis

Ciliary dyskinesia

Acquired immunodeficiency syndrome

Bronchiectasis

Rhinitis medicamentosa (prolonged use of nasal decongestants, to which the nose becomes readily addicted)

Cocaine abuse

Wegner’s granulomatosis

Relationship between Asthma and Sinusitis

The causal relationship between asthma and sinusitis and/or rhinitis is controversial. What is clear is that these two conditions frequently co-exist. Consider the following observations:

80% of patients with asthma have rhinitis symptoms, while 5-15% of patients with perennial rhinitis will also have asthma.

Many patients with allergic rhinitis without a history of clinical asthma will nonetheless show abnormal lung function tests

Approximately 40 to 60% of asthmatic patients will show radiographic evidence of sinusitis.

Whether the relation with recurrent sinusitis is causal or merely an epiphenomenon of an infectious or immune-mediated disease affecting the entire respiratory tract is still a matter of debate.

Although the aetiology may be murky, there are several empirical studies that suggest that treatment of sinusitis or rhinitis may also improve asthma symptoms.

The following characteristics identify those patients in whom sinusitis may play a role in the pathogenesis of asthma:

Sinusitis preceding the development of asthma symptoms

Non-atopic patients (which implies that a fundamental change has occurred in the sinus tissue and airway)

Aspirin sensitivity

Corticosteroid dependency suggests that the underlying sinus disease may be a trigger for asthma

Patients with asthma who are refractory to appropriate therapy

When a child with asthma becomes symptomatic while taking medication that was formerly effective

When a patient receives a short-term course of steroid therapy for an acute episode of asthma and is still symptomatic after several days of treatment

The signs and symptoms of sinusitis

Acute sinusitis

Persistent cold (> 7 days)

Mucopurulent nasal discharge

Cough

Fever

Headache

Facial pain

Chronic sinusitis

Persistent nasal obstruction

Purulent nasal and post nasal drip/discharge

Hyposmia, anosmia (loss of smell)

Headache

Throat clearing

Facial pain

Fatigue / malaise

Bad breath (fetor oris)

Diagnostic tests for sinusitis

Careful history

Examination of the anterior aspect of the nose with an otoscope and the posterior 2/3 of the nose with flexible rhinoscopy

CT scan of the sinuses (if patient fails to respond to initial treatment)

Skin Prick Tests to exclude Allergic Rhinitis (present in 50-75% of chronic sinusitis) as possible predisposing cause

Immunologic assessment (to exclude an underlying immune deficiency) only when patient has recurrent disease or there is bronchitis, IgG and IgA levels. If patient low in IgG immunize with Pneumovax and obtain pre- and post-immunization IgG titre to determine if patients are capable of rising new IgG2 antibody levels.

An approach to the treatment of chronic sinusitis

Hydration (6-8 glasses of water per day)

Antibiotics 21 days or longer (until the patient is well plus 7 days). Choices: Synermox (Augmentin), Ciproxin

Topical long acting decongestants, twice daily for 7-14 days

Nasal douche using saline and applied through an ear bulb syringe

Topical nasal steroids:

3 sprays twice daily, for 2 weeks

2 sprays twice daily, for 2 weeks

1-2 sprays 1-2 times per day until sinusitis resolves

Aim away from the nasal septum and towards the eye to reduce the risk of septal perforation

About 60-80% of patients will improve and have long-lasting remissions.

Allergen immunotherapy can be used in appropriate patients to try and reduce recurrent disease.

If the patient does not improve or the sinusitis continues to recur after initial improvement, several options:

Prophylactic antibiotics

Oral steroids

ENT consultation

Surgery for recurrent sinusitis

Surgery is usually reserved for those patients who have failed medical treatment for 6 months. The surgical procedure (depends on the findings on CT scan) currently recommended is endoscopic widening of the maxillary and ethmoid ostia. Prior to surgery and immediately after the procedure, patients use topical steroids and extensive lavages to reduce post-operative inflammation and reduce the likelihood of recurrence.

Useful link – JCAAI : Sinusitis
http://www.jcaai.org/Param/Sinusitis/Default.htm

 

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