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Sinusitis

Alternative Names: Rhinosinusitis, Ethmoiditis, Maxillary sinusitis, Frontal sinusitis, Sphenoid sinusitis

Definition: Inflammation of the mucus membranes (linings) of the paxanasal sinuses and nasal cavities.

There are four pairs of sinuses. The frontal sinuses are in the forehead bone and the maxillaries are located below the eyes. Between the eyes lie the ethmoids with the sphenoid sinuses residing behind them and between the back of the orbits (eye sockets). The ethmoid sinus is a matchbox-sized area filled with seven to ten interconnected bubbles made of very thin-walled bone that are lined with a mucus membrane. Each bubble has its own opening to drain into the nasal (nose) cavity. The front part of the ethmoid is the most crucial of all the sinuses because the frontal and maxillary sinuses must initially drain through it into the nose. The sphenoid sinus has its own separate opening in the back of the nasal cavity. Sinuses are normally air-filled, the lining of which are covered with microscopic fingers (cilia) that direct the mucus to the drainage openings.

The function of the sinuses is not clearly understood. In the average healthy person, the fining of the sinuses and nose makes about one to one and a half pints of mucus per day. So, one of the functions of the sinuses is to moisten, cleanse, and warm the air as it goes through the nose before it enters the lungs. The normal nose is a wonderful filter, removing 80% of all inspired tiny particles. Most pollen is usually well filtered from the inspired air. Since the sinuses are air-filled, another function of them may be to lighten the skull’s weight. The sinuses also make nitrous oxide, a gas that may be important in keeping the small airways in the lungs open.

Sinusitis occurs when the lining of the nose and sinuses becomes inflamed. Common causes include pollens, animal dander, and other materials to which a person may be allergic. These allergens set off an inflammatory response releasing histamine and other chemicals. When these substances are released, symptoms occur such as sneezing, itching of the nose, ears, and throat, nasal congestion and drainage. Sinuses can also be affected by upper respiratory viruses that attack the lining and cause inflammation of the nasal tissues which leads to symptoms. Most viral infections resolve spontaneously, but about five out of every thousand are complicated by a bacterial sinusitis. Bacterial forms of sinusitis usually occur when the drainage opening becomes blocked by swelling or narrowing. Then the normal bacteria in the sinus and nasal tracts overgrow and cause an infection. Other less common causes of sinusitis are pollutants in the air, cold air, dry air, aspirin sensitivity, and long-term use of spray nasal decongestants.
 
Symptoms: In acute sinusitis, the symptoms are present for less than three weeks. In subacute sinusitis, the illness has been present between three weeks and three months. In both entities the symptoms are essentially the same although more severe in acute sinusitis.

The symptoms depend on what is causing the sinus inflammation. In acute allergic sinusitis, the main symptoms are sneezing, clear, bilateral watery nasal discharge, tearing, eye itching, nasal congestion, nasal and ear itching, and sometimes coughing. Less frequent are wheezing, eczema, skin rashes, face pain or pressure. On exam, the nasal lining is swollen and varies from intensely red to a pale pink appearance with clear liquid secretion. The eyes may also be red. A viral upper respiratory disorder will be characterized by a variety of symptoms including sore throat lasting for 24-48 hours, laryngitis, nasal stuffiness, fever, chills, sweats, muscle aches, and joint pains. The nasal discharge is usually clear and watery, then becomes thicker and discolored. The color ranges from white to slightly yellow to green-brown. Face pain and cough may occur. The hallmark for uncomplicated viral rhinosinusitis is that it will spontaneously resolve in 10-14 days, occasionally lasting 21 days. Viral sinusitis is common in the fall, winter, and early spring. Exam will show red, swollen nasal tissue, fever, and red throat. Bacterial sinusitis is usually preceded by a viral upper respiratory illness or allergies. Symptoms depend on whether the person is a child or adult. In children, bacterial sinusitis symptoms include green to yellow nasal discharge, fever, facial puffiness and redness, cough that is worse at night, and nasal stuffiness. Young children often do not complain of face pain or headache. Instead, they may be irritable and sleep poorly. Older children may complain of face pain over the infected sinus. If the maxillary sinus is involved, they may suffer from pain in the mid-face, behind the eye, or upper teeth. If the ethmoid sinus is infected, they may complain of pain behind the eyes. The frontal sinus does not develop until age seven. In an adult, the symptoms are discolored nasal drainage, nasal stuffiness, face pain and headache. Acute sphenoid sinusitis is the most difficult to diagnose in that the headache can be in many different locations. The symptoms of bacterial sinusitis follow one of three patterns. The most common is that the illness becomes worse over time instead of getting better. The second pattern is when the symptoms last longer than three weeks, often described as “the cold just won’t go away”. The last pattern is the sudden onset of severe upper respiratory symptoms.

People with cold air sinusitis have sneezing, nasal stuffiness, clear nasal discharge and face pressure caused by exposure to cold air. Dry air sinusitis is most frequently seen in the winter months and presents with nasal stuffiness and frequently a yellow to slightly bloody crusting especially in the front part of the nose. With non-allergic and aspirin sensitivity sinusitis, people have very thick, white or yellow secretions, long-term face pain, loss of smell, headaches and frequently have polyps. ,

Risks: Since most sinusitis is caused by either a virus or bacteria, there is a risk of infecting others.
 
Prevention: For viral sinusitis, avoiding crowded places and infected people can lessen the risk of catching a virus. Influenza vaccination is helpful in preventing infection by the influenza virus. Careful attention to hand washing can prevent spread. Prevention of bacterial sinusitis requires preventing the viral or allergic causes that lead to it.

Allergic sinusitis is diagnosed by the symptoms and what may trigger them. The response to antihistamines and other allergy medications is helpful in confirming the diagnosis. Examining nasal secretions for eosinophils may be helpful. Skin or blood testing for a reaction to allergens may be necessary to identify to what one is allergic. Viral sinusitis is diagnosed by symptoms and examination findings. Some viruses, particularly influenza and respiratory syncytial virus can be cultured from the nose. Bacterial sinusitis can be diagnosed by culturing infected material but most commonly is recognized by the symptom patterns as they unfold.

People with occasional bouts of sinusitis usually have no long-term effects. Those with frequent or prolonged attacks develop loss of smell, increasing nasal secretions, chronic face pain, nasal obstruction, or headaches. The lining of the sinuses thicken and block the sinus openings which can lead to bacterial sinus infections. Lingering inflammation of the nose and sinuses can cause post-nasal drip and cough. Often, oral steroids can help. Any cause of chronic inflammation can lead to polyp formation but non-allergic and aspirin sensitivity rhinitis are the most likely to be complicated by polyps.

Bacterial sinus infections can cause major problems. Acute ethmoiditis can spread into the eye socket and create orbital cellulitis or abscess. A CT scan is necessary for these suspected conditions. Orbital cellulitis is treated with antibiotics. Orbital abscess is a true medical emergency since it can lead to blindness if not treated. It requires surgical drainage and intravenous antibiotics. Acute frontal sinusitis must be followed very carefully. If it does not respond to oral antibiotics, then intravenous antibiotics and possibly surgical drainage are necessary since it can lead to epidural or brain abscess, or meningitis. Some health care providers consider sphenoid sinusitis a medical emergency since it can be associated with meningitis, brain abscess and infections around the optic nerve. One group of people deserve special mention. For some reason, adolescent males with acute frontal and sphenoid sinusitis have a higher rate of infections within the brain. They need very careful observation and early aggressive treatment if they are not responding to oral antibiotics.

Treatment of viral sinusitis consists of medication to reduce the fever and aches, oral or topical decongestants to improve breathing, and salt water rinses and increased fluid intake to help clear the nasal secretions. With bacterial sinusitis, symptoms may resolve using the same measures employed for viral sinusitis in that 60% will resolve without antibiotics. If not, then antibiotics like amoxicillin or sulfa are used. Rarely, if these antibiotics fail to help, then cultures of the nasal secretions may be helpful. Treatment for cold air rhinits is avoiding cold air. Topical steroids and anti-secretion medications help reduce the symptoms. Treatment for dry air rhinitis includes salt-water rinses, water based nasal steroids and petroleum based ointments. Treatment for non-allergic and aspirin-sensitive rhinitis is oral or topical steroids. Some newer medications that block the inflammatory response, like Zyflo®, Accolate®, or Singulair® may help.

Side effects depend on the medications used. Very brief use of topical decongestants has very few side effects, but long-term use can create progressive inflammation in the nose. Most cases resolve with symptomatic treatment. Careful monitoring is necessary for those cases of ethmoid, frontal, and sphenoid sinusitis because of the potential spread to adjacent areas and the possible complications.