Acute Sinusitis

Inflammation of the paranasal sinus lining results in a pathological condition termed as sinusitis. Rhinosinusitis is the more favored term to describe the condition owning to the concurrent involvement of nasal mucosa and concomitance of rhinitis. In the United States, approximately 35 million people suffer from rhinosinusitis and result in nearly 16 million office visits annually [1].

Acute Sinusitis is associated with infectious processes. The disorder has an incidence of about 3000 / 100.000.

Presentation

Symptoms of acute sinusitis are as follows:

  • Dense, yellow or greenish exudate from the nose or towards the lower part of throat
  • Labored breathing due to clogging of nasal passage
  • Pain, soreness, inflammation and pressure around forehead, eyes, cheeks and nose 
  • Diminished sense of olfaction and gustation
  • Nocturnal cough 

Other less specific symptoms can include:

  • Head and ear ache
  • Teeth and upper jaw pain
  • Halitosis
  • Exhaustion
  • High temperature

Workup

Diagnosis of acute sinusitis:

  • Physical examination of nose and throat. Tenderness indicate sinusitis.
  • Visual inspection of nasal passages aided by a device to hold the nose open and application of medications to constrict blood vessels for easier observation. Signs of sinusitis include swelling, fluid accumulation, nasal polyps or any other abnormalities. 
  • Nasal endoscopy to visually examine the inside of the sinuses.
  • Computerized tomography (CT) or magnetic resonance imaging (MRI) of sinuses and nasal area are recommended for complicated cases of acute sinusitis to identify and confirm suspected complications.
  • Microbial cultures of nasal and sinus specimens are not recommended.

The American Academy of Pediatrics has published the updated guidelines for the diagnosis and treatment of bacterial acute sinusitis in children and young adults in June 2010 [10]. The updated criteria for acute sinusitis include the presence of upper respiratory tract infection (URI) along with aggravating symptoms like nasal discharge, cough and high temperature after initial improvement. The former recommendations only urged the physicians to look for URI with either nasal drainage and/or daytime cough lasting for more than 10 days or severe acute fever, purulent nasal drainage and other breathing discomforts for 3 or more continuous days.

Management of patients with sinusitis symptoms lasting for more than 10 days now include an additional 3 day observation period before antibiotic treatment. However antibiotic therapy is prescribed for children with severe or worsening symptoms. Amoxicillin (with or without clavulanate) is the drug of choice for treating acute sinusitis. Paranasal CT scanning is recommended for children with suspected cases of orbital or central nervous system complications.

Treatment

Most cases of viral acute sinusitis are self-limiting and self-care techniques are sufficient to ease the discomforts and speed up the recovery. Recommendations to ease symptoms include: 

  • Rinsing the nasal passages with saline nasal spray multiple times per day.
  • Treatment of inflammation with nasal corticosteroid sprays like fluticasone (Flonase), budesonide (Rhinocort Aqua), mometasone (Nasonex), beclomethasone (Beconase AQ) and triamcinolone (Nasacort AQ).
  • Managing the nasal congestions with nasal sprays, prescription medications and over-the-counter (OTC) medications. Available OTC medications include Sudafed (oral decongestants) and Afrins (oxymetazoline based nasal sprays). Utmost care should be exercised while using such medications, because their unrestricted use may lead to severe congestion (rebound congestion).
  • Pain associated with sinusitis can be managed by using OTC pain killers (e.g. aspirin, acetaminophen –Tylenol or ibuprofen - Advil, Motrin IB). Aspirin owning to its Reye syndrome linkage should only be used with caution among pediatric and young adult patients.  It should not be prescribed for patients convalescing from chickenpox and flu-like illnesses.
  • Antibiotic treatment is not required in most of the cases.

Prognosis

Sinusitis can be treated effectively with self-care treatment and medical advice. However frequent episodes of sinusitis warrant medical check-up to rule out presence of nasal polyps and other underlying conditions like allergies. Sinusitis rarely result in mortality but complicated sinusitis, when left untreated, may lead to poor health conditions and in rare cases to death.

Acute sinusitis clears spontaneously without the help of antibiotic treatment in around 40% of the cases. Spontaneous cure rate is about 98% for sinusitis induced by viral infections. Antibiotic treatment of acute sinusitis is very effective with only a less than 5% relapse rate. Re-examination of the patients is necessary when they are unresponsive to the treatment post- 48 hours and when the symptoms worsen. Rhinosinusitis may result in serious conditions like meningitis, cavernous sinus thrombophlebitis, brain abscess and orbital cellulitis or abscess when left untreated. Allergic rhinitis cases deserve assertive treatment to manage nasal symptoms and clogging of sinus outflow tracts due to mucosal edema to prevent the incidence of secondary sinusitis. Surgical removal of adenoids is recommended when it is chronically infected to prevent further infection and associated complications.

Etiology

Sinusitis is a pathological condition in which mucous membranes of nose, sinuses and the upper respiratory tract become swelled up. Mucus that is discharged normally gets clogged under such conditions resulting in facial pain and other associated discomforts. The clogged sinuses provide the moist environment for bacteria to colonize the sinuses. Infected sinuses become pus filled causing drainage of dense, yellow or greenish discharge along with the development of other symptoms.

The microbial causative agents of sinusitis include viruses, bacteria and fungi. In the majority of cases acute sinusitis is induced by the common cold viruses. Bacterial infections are accountable for sinusitis that last for more than seven days. Sinus anomalies and impaired immune system are the major risk factors for contracting fungal infection induced sinusitis.

Health conditions associated with increased risk of sinusitis are as follows:

  • Allergic conditions. Allergy induced swelling up of mucosal lining e.g. hay fever.
  • Presence of nasal polyps or tumors. The physical block due to the presence of growth in nasal channels or sinuses lead to clogging and subsequent infections.
  • Tooth infections 
  • Deviated nasal septum that obstruct or block sinuses. 
  • Other medical conditions: Cystic fibrosis, immune dysfunctions or gastroesophageal reflux disease (GERD) that result in sinus clogging. 

Epidemiology

In the United Kingdom, about 3 in 1000 people suffer from acute sinusitis and about 1 in 1000 from chronic sinusitis annually. Incidence of sinusitis is often reported to follow a seasonal pattern. Incidence of sinusitis peaks in winter and rhinoviral infections in fall and spring. Coronaviral infection which induces sinusitis is reported frequently during the month of December and continues till the end of March.

In the United States, the conditions are more severe and about 1 in every 7 people suffers from acute sinusitis, with about 30 million diagnoses every year. Incidence is acute sinusitis is reported frequently from early autumn to early spring. Rhinosinusitis is responsible for approximately 35 million infections and 16 million medical consultations annually.

As per the data of National Ambulatory Medical Care Survey (NAMCS), about 14% of adult population have rhinosinusitis every year, and it stood at fifth position in diagnosis for which antibiotic therapy is advised and also accounts for about 0.4% of outpatient diagnosis [2]. Americans have spent around $3.39 billion for rhinosinusitis treatment in 1996 [3] and in case of children the money spend for acute sinusitis treatment averages $1.77 billion annually. An average child is prone to develop at least 6-8 upper respiratory tract infections (URI) annually. Approximately 6-13% of viral induced URI in children results in opportunistic bacterial infection and acute sinusitis [4] [5]. Women are reported to develop infective sinusitis more frequently (20.3%) than men (11.5%) owning to their close contact with children.

Sex distribution
Age distribution

Pathophysiology

Human skull possess many air-filled spaces termed as sinuses positioned behind the forehead, cheeks, nasal bones and eyes. Healthy sinuses are germ free with ample air circulation. Under the normal physiological conditions, mucus drainage into the nasal cavity is aided by the ciliary action. The unidirectional flow of mucus secretions towards the ostia helps in preventing the contamination and infections within the sinuses of healthy individuals.

Pathophysiological conditions which lead to sinusitis [6] [7] include: 

  • Retention of mucus with subsequent microbial infection.
  • Contamination of the sterile sinuses by the bacteria colonized in nasopharynx. Bacterial contamination occur when mucociliary clearance of microbes fail leading to the introduction of bacteria into the sinus.

Even though the healthy sinuses are considered as sterile, research studies have proved the presence of bacterial colonies in healthy sinuses. The healthy sinuses of patients undergoing septal deviation corrective surgery were found to harbor aerobic and anaerobic bacterial flora [8]. A study focusing on the presence of aerobic bacteria in healthy sinuses of surgical maxilla repositioning patients revealed the presence of Staphylococcus sp. and alpha-hemolytic streptococci in the maxillary sinus [9]. Bacteria were isolated from 20% of maxillary sinuses patients on whom the surgeries were carried out.

Prevention

Preventive measures to minimize the risk of contracting acute sinusitis include the following:

  • Avoiding URI by distancing from people suffering from common cold. Frequent cleansing of hands with soap and water before eating food and after shaking hands.
  • Annual vaccination against influenza.
  • Careful management of allergies to keep symptoms under check.
  • Quitting cigarette smoking and avoiding exposure to polluted air which can irritate and inflame the mucous membranes.
  • Humidifying the indoor dry air aids in preventing sinusitis. Humidifier used should be cleansed frequently to avoid mold formation.
  • Boosting the immune system by maintaining a healthy diet with vegetables and fruits, which are rich sources of antioxidants. 
  • Reducing stress.

Summary

Sinusitis can be classified into two types based on the duration of the symptoms: 

Acute sinusitis: Symptoms last for less than 4 weeks. Bacteria that colonize the sinuses are the major causative agent.
Chronic sinusitis: Symptoms last for more than 3 months. The causative agent can either be a bacteria or a fungus.

Viral or bacterial infections are responsible for acute sinusitis in the majority of cases. Viruses causing common cold induce an inflammatory response in the host. The resultant acute inflammation of the sinuses, entrapment of air and mucus beyond the narrowed sinus openings results in sinusitis. The associated symptoms and discomfort usually last for about two weeks. Occasionally viral infections may lead to opportunistic bacterial infections caused by Haemophilus influenzae, Streptococcus pneumoniae and Moraxella catarrhalis. These bacteria are the frequent colonizers of nose and throat that cause acute sinusitis.

Acute sinusitis has many clinical and radiological classifications in the literature. However there is no general agreement on a precise definition. People at high risk of developing sinusitis are those who endure:

  • Allergies or other chronic rhinal problems 
  • Reduced immune function e.g. HIV infections 
  • Abnormal mucus secretion or movement, e.g. cystic fibrosis patients who suffer from clogged airways due to thick mucus build up

Patient Information

Acute sinusitis (acute rhinosinusitis) is a condition in which the cavities in skull bone become swollen, mucus filled and clogged. The main symptoms of acute sinusitis include difficulty in breathing, pain around eyes, swollen painful face and headache.

Contracting common cold often result in acute sinusitis. Allergies, fungal and bacterial infections may also lead to acute sinusitis. Most of the time symptoms of acute sinusitis can be managed with self-care treatments. Chronic sinusitis, in which the symptoms last for more than two months or keeps coming back, require immediate medical attention as untreated cases may quickly lead to severe infections and other complications. Symptoms that do not improve or get worse after effective self-care and prolonged fever warrant immediate medical attention.

Risk factors for contracting sinusitis include:

Recommended medications that help to ease the discomforts include use of pain relievers and decongestants to make breathing easy.

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References

  1. Lucas JW, Schiller JS, Benson V. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2001. Vital Health Stat 10. 2004; 218:1-134.
  2. Bishai WR. Issues in the management of bacterial sinusitis. Otolaryngol Head Neck Surg. 2002; 127(6 Suppl): S3-9.
  3. Ray NF, Baraniuk JN, Thamer M, et al. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol. 1999;103(3 Pt 1):408-14.
  4. Fendrick AM, Saint S, Brook I, Jacobs MR, Pelton S, Sethi S. Diagnosis and treatment of upper respiratory tract infections in the primary care setting. Clin Ther. 2001; 23(10):1683-1706.
  5. Wald ER, Guerra N, Byers C. Upper respiratory tract infections in young children: duration of and frequency of complications. Pediatrics. 1991; 87(2):129-33. 
  6. American Academy of Pediatrics - Subcommittee on Management of Sinusitis and Committee on Quality Management. Clinical practice guideline: management of sinusitis. Pediatrics. 2001;108(3):798-808.
  7. Cherry JD, Shapiro NL, Deville JG. Sinusitis. In: Feigin RD, Cherry JD, Demmier GJ, Kaplan SL, eds. Textbook of pediatric infectious disease. 5th ed. Philadelphia, PA: WB Saunders; 2004. 201.
  8. Brook I. Aerobic and anaerobic bacterial flora of normal maxillary sinuses. Laryngoscope. 1981; 91(3):372-376.
  9. Su WY, Liu C, Hung SY, Tsai WF. Bacteriological study in chronic maxillary sinusitis. Laryngoscope. 1983; 93(7):931-934.
  10. Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 Years. Pediatrics. 2013;132(1):e262-280.

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