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Sinusitis

What are sinuses?

Sinuses are the air chambers in the bone behind your cheeks, eyebrows and jaw. They make mucus, a fluid that cleans bacteria and other particles out of the air you breathe. Tiny hairs called cilia (say: “sill-ee-ah”) sweep mucus out of your sinuses so it can drain out through your nose.

What is sinusitis?

Sinusitis (say: “sine-you-site-iss”) is the name for a condition in which the lining of your sinuses becomes inflamed.

Causes:

Bacteria are the most common direct cause of acute sinusitis. (Other organisms might be the infecting cause in less common cases.) The ability of bacteria or other organisms to infect the sinuses, however, must first be set up by conditions that create a favorable environment in the sinus cavities. Sinusitis is most often an acute condition, which is self-limiting and treatable. In some cases, however, the inflammation in the sinuses is lasting, or is chronic do begin with. The causes for such chronic sinusitis cases are sometimes unclear.

Upper Respiratory Infections

The typical process leading to acute sinusitis starts with a flu or cold virus. Over 85% of people with colds have inflamed sinuses. These inflammations are typically brief and mild, however, and only between 0.5 - 10% of people with colds develop true sinusitis. Instead, colds and flu set the stage by causing inflammation and congestion in the nasal passages (called rhinitis ), leading to obstruction in the sinuses. This creates a hospitable environment for bacterial growth, which is the direct cause of sinus infection. In fact, rhinitis is the precursor to sinusitis in so many cases that expert groups now refer to most cases of sinusitis as rhinosinusitis.

Rhinosinusitis tends to involve the following sinuses:

    • The maxillary sinuses (behind the cheekbones) are the most common sites.
    • The ethmoid sinuses (between the eyes) are the second most common sites affected by colds.
    • The frontal (behind the forehead) and sphenoid (behind the eyes) sinuses are involved in about a third of
      cold-related cases.

Nearly everyone with colds has inflamed sinuses. These inflammations are typically brief and mild, however, and most people with colds do not develop true sinusitis.

Conditions That Cause Chronic or Recurrent Sinusitis

Chronic or recurrent acute sinusitis typically results from one of the following conditions:

    • Untreated acute sinusitis that results in damage to the mucous membranes
    • Chronic medical disorders that cause inflammation in the airways or persistent thickened stagnant mucus (such       as diabetes, AIDS, other disorders of the immune system, hypothyroidism, cystic fibrosis, Kartagener's syndrome,       and Wegener's granulomatosis)
    • Structural abnormalities
    • Allergic reaction to fungi

Chronic or recurrent acute sinusitis can be a lifelong condition.

Inflammatory Response, Allergies, and Asthma

The absence of bacterial organisms as factor in many cases suggests that some instances of chronic sinusitis may be due to a continuing inflammatory condition. Many of the immune factors observed in people with chronic sinusitis resemble those that appear in allergic rhinitis, suggesting that sinusitis in some individuals is due to an allergic response.

Allergies, asthma, and sinusitis often overlap. Those with allergic rhinitis (so-called hay fever and rose fever) often have symptoms of sinusitis, and true sinusitis can develop as a result of the mucus blockage it causes. A causal association, however, has not been proved, and many experts believe allergies themselves rarely predispose to sinusitis. People with chronic sinusitis may also have an allergic reaction to fungal organisms.

Abnormalities of the Nasal Passage

Abnormalities in the nasal passage can cause blockage and thereby increase the risk for chronic sinusitis. Some abnormalities include:

    • Polyps (small benign growths) in the nasal passage block mucus drainage and restrict airflow. Polyps themselves       may be consequences of previous sinus infections that caused overgrowth of the nasal membrane.
    • Enlarged adenoids can lead to sinusitis.

Adenoids are masses of tissue located high on the posterior wall of the pharynx. They are made up of lymphatic tissue, which trap and destroy pathogens in the air that enter the nasopharynx.

    • Cleft palate
    • Tumors
    • Deviated septum (a common structural abnormality in which the septum, the center section of the nose, is shifted        to one side, usually the left)

Bacteria

The Role of Bacteria. The role of bacteria or other infectious organisms is complicated in chronic sinusitis. They may have a direct, or an indirect, role. In some patients, infectious organisms play no role at all. For example, one study reported the following for patients with chronic sinusitis who had not responded to antibiotics:

    • 30% had no evidence of bacteria in their passageways.
    • 20% had bacteria unrelated to infection.

The bacteria most commonly implicated in sinusitis include:

    • Streptococcus pneumoniae. This bacterium is found in 20 - 45% of adults and children with sinusitis.
    • H. influenzae (a common bacterium associated with many upper respiratory infections). This bacterium colonizes       nearly half of all children by age 2, and causes about 25% of sinusitis cases in this group. Studies have reported       the presence of this bacterium in up to a third of adult sinusitis patients.
    • Moraxella catarrhalis. Over 75% of all children harbor this bacterium, which causes about 25% of sinusitis cases.

Other possible bacterial culprits include:

    • Other streptococcal strains
    • Staphylococcus aureus
    • P. aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter species, and Escherichia coli
    • Fusobacterium nucleatum and Prevotella intermedia)

Fungal Sinusitis

While fungi are an uncommon cause of sinusitis, the incidence of such infections is increasing. At least 5 - 10% of chronic rhinosinusitis patients may actually have allergic fungal sinusitis.

Many patients with chronic sinusitis may be colonized with fungi, but this does not necessarily mean the patient has a fungal infection causing their symptoms. Studies suggest that some people who suffer from chronic sinusitis have an immune and inflammatory response to fungi and may benefit from anti-fungal treatment.

Fungi involved in sinusitis include:

    • Aspergillus is the most common cause of all forms of fungal sinusitis.
    • Other fungi include Curvularia, Bipolaris, Alternaria, Dreschslera, Cryptococcus, Candida, Sporothrix,Exserohilum,        and Mucormycosis.
    • There have been a few reports of fungal sinusitis caused by Metarrhizium anisopliae, which is used in biological        insect control.

There are four categories of fungal sinusitis:

    • Acute or invasive fungal sinusitis. This infection is most likely to affect people with diabetes and compromised       immune systems.
    • Chronic or indolent fungal sinusitis. This form is generally found outside the U.S., most commonly in the Sudan       and northern India.
    • Fungus ball (mycetoma). This fungal sinusitis is noninvasive and occurs usually in one sinus, most often the       maxillary sinus.
    • Allergic fungal sinusitis. This form typically occurs because of an allergy to the fungus Aspergillus (rather than       being caused by the fungus itself). In such cases, a peanut butter-like fungal growth occurs in the sinus cavities       that may cause nasal passage obstruction and the erosion of the bones.

Fungal infections can be very serious, and both chronic and acute fungal sinusitis require immediate treatment. Fungal ball is not invasive and is nearly always treatable.

Fungal infections should be suspected in people with sinusitis who also have diabetes, leukemia, AIDS, or other conditions that impair the immune system. Fungal infections can also occur in patients with healthy immune systems, but they are far less common.

Symptoms:

Symptoms Suggesting a Bacterial Infection

Sinus symptoms are very common during a cold or the flu, but in most cases they are due to the effects of the infecting virus and resolve when the infection does. It is important to differentiate between inflamed sinuses associated with cold or flu virus and sinusitis caused by bacteria.

The signs and symptoms that are associated with the diagnosis of sinusitis include one to two of the following:

    • Nasal congestion and discharge that typically is thick and becomes yellowish to yellow-green
    • Facial pain, pressure, congestion, or fullness (that is also accompanied by other symptoms of sinusitis)
    • Symptoms that continue for 10 days or more after the start of a cold or flu
    • Symptoms worsen after 5 - 7 days, or return after initial improvement in a cold (called double sickening)
    • Reduced or absent sense of smell
    • Fever, although should also be accompanied by other symptoms of sinusitis

Other symptoms of sinusitis that usually occur in adults include one to two of the following:

    • Eyes may be red, bulging, or painful if the sinus infection occurs around the eyes
    • A persistent cough (particularly during the day)
    • Ear pain, pressure, or fullness
    • Halitosis (bad breath)
    • Dental pain
    • Fatigue

However, many studies have shown that symptoms used to diagnose sinusitis often do not predict prognosis or response to antibiotic treatment.

Sneezing, sore throat, and muscle aches may be present, but they are rarely caused by sinusitis itself. Muscle aches may be caused by fever, sore throat by post-nasal drip, and sneezing from cold or allergies.

Rare complications of sinusitis can produce additional symptoms, which may be severe or even life threatening.

Symptoms Indicating Medical Emergency

    • Increasing severity of symptoms
    • Swelling and drooping eyelid
    • Loss of eye movement (possible orbital infection, which is in the eye socket)
    • Vision changes
    • Pupil fixed or dilated
    • Symptoms spreading to both sides of face (may indicate blood clot)
    • Development of severe headache, altered vision
    • Mild personality or mental changes (may indicate spread of infection to brain)
    • A soft swelling over the bone (may indicate bone infection)

Symptoms in Children

Children are most likely to develop infection in the ethmoid sinuses, located between the eyes. Children with sinusitis are also less likely to experience facial pain over the affected sinus and headache, which are the primary signs in adults. Symptoms of bacterial sinusitis may be less specific than in adults and include:

    • Persistent nasal discharge (of any type) and day time cough for more than 10 days, or
    • Severe symptoms last for at least 3 - 4 days in a row and include thick, greenish nasal discharge plus a fever of at        least 102° F

Other symptoms in children may include:

    • Irritability
    • Vomiting
    • Gagging on mucus
    • Cough

Chronic Sinusitis

Recurrent acute and chronic sinusitis tend to take the following course:

    • Any of the sinusitis symptoms listed previously may be present
    • Symptoms are more vague and generalized than acute sinusitis
    • Fever may be absent or just low grade
    • Symptoms of sinusitis last 12 weeks or longer
    • Symptoms occur throughout the year, even during nonallergy seasons

Site-Specific Symptoms

Specific symptoms may indicate which sinus is involved.

Frontal sinusitis causes:

    • Pain across the lower forehead.
    • Symptoms are worse when lying on the back

Maxillary sinusitis causes:

    • Pain over the cheeks that may travel to the teeth
    • Hard palate in the mouth sometimes becomes swollen
    • Symptoms are worse when head is upright

Ethmoid sinusitis causes:

    • Pain behind the eyes and sometimes redness and tenderness in the area across the top of the nose
    • Symptoms are worse when coughing, straining, or lying on the back

Sphenoid sinusitis:

    
• Rarely occurs by itself; when it does, the pain may be felt behind the eyes, across the forehead, or in the face
    • Symptoms are worse when lying on the back or bending forward

Other Causes of Sinusitis Symptoms

It is often difficult to tell when a viral infection converts to a bacterial infection. Studies have found that 40 - 85% of patients with the common cold show signs of inflamed sinuses on x-rays or CT scans. A cold, however, unlike sinusitis, typically clears up without treatment within a week. (Only about 0.5 - 2% of adults with viral colds or flus actually develop bacterial infections.)

Allergies. Symptoms of both sinusitis and allergic rhinitis include nasal obstruction and congestion. The conditions often occur together. People with allergies and no sinus infection may have:

    • Thin, clear, and runny nasal discharge
    • Itchy nose, eyes, or throat (do not occur with bacterial sinusitis)
    • Recurrent sneezing
    • Symptoms of allergies appear only during exposure to allergens

Migraine and Other Headaches. Many primary headaches, particularly migraine or cluster, may closely resemble sinus headache. Migraine and sinus headaches may even coexist in many cases. Sinus headaches are usually more generalized than migraines, but it is often difficult to tell them apart, particularly if headache is the only symptom of sinusitis.

Trigeminal Neuralgia. In some cases, headache that persists after successful treatment of chronic sinusitis may be due to neuralgia (nerve-related pain) in the face. This condition requires specific drugs, such as tricyclic antidepressants or carbamazepine. Trials using such drugs may identify patients with neuralgia and help avoid unnecessary invasive treatments for chronic sinusitis.

Risk Factors:

Sinusitis is one of the most common diseases in the United States, affecting about 1 in 7 adults each year. About 31 million Americans are diagnosed with sinusitis each year.

Young Children and Sinusitis

Before the immune system matures, all infants are susceptible to respiratory infections, with a possible frequency of one cold every 1 - 2 months. Young children are prone to colds and may have 8 - 12 bouts every year. Smaller nasal and sinus passages also make children more vulnerable to upper respiratory tract infections than older children and adults. Ear infections such as otitis media are also associated with sinusitis. Nevertheless, true sinusitis is very rare in children under 9 years of age. Some experts believe it is greatly over-diagnosed in this population.

The Elderly and Sinusitis

The elderly are at specific risk for sinusitis. Their nasal passages tend to dry out with age. In addition, the cartilage supporting the nasal passages weakens, causing airflow changes. They also have diminished cough and gag reflexes and faltering immune systems and are at greater risk for serious respiratory infections than are young and middle-aged adults.

People with Asthma or Allergies

People with asthma or allergies are at higher risk for non-infectious inflammation in the sinuses. The risk for sinusitis is higher in patients with severe asthma. People with a combination of polyps in the nose, asthma, and sensitivity to aspirin (called Samter's, or ASA, triad) are at very high risk for chronic or recurrent acute sinusitis.

Hospitalization

Some hospitalized patients are at higher risk for sinusitis, particularly those with:

    • Head injuries
    • Conditions requiring insertion of tubes through the nose
    • Breathing aided by mechanical ventilators. (Such patients may have a significantly higher risk for maxillary       sinusitis. In fact, treating sinusitis in such patients may significantly reduce the risk for ventilator-associated       pneumonia.)
    • Patients who had a weakened immune system (immunocompromised)

Other Medical Conditions Affecting the Sinuses

A number of medical conditions put people at risk for chronic sinusitis. They include:

    • Diabetes
    • Gastroesophageal reflux disease
    • Nasal polyps or septal deviation
    • AIDS and other disorders of the immune system predispose the patient to sinusitis (fungal infections are       especially risky)
    • Pregnancy -- may cause temporary congestion and symptoms of sinusitis
    • Oral or intravenous steroid treatment
    • Hypothyroidism -- causes congestion that clears up when the condition is treated
    • Cystic fibrosis -- a genetic disorder in which the mucus is very thick and builds up
    • Kartagener's syndrome

Miscellaneous Risk Factors

Dental Problems. Anaerobic bacteria are associated with infections from dental problems or procedures, which precipitate about 10% of cases of maxillary sinusitis.

Changes in Atmospheric Pressure. People who experience changes in atmospheric pressure, such as while flying, climbing to high altitudes, or swimming, risk sinus blockage and therefore an increased chance of developing sinusitis. (Swimming increases the risk for sinusitis for other reasons, as well.)

Cigarette Smoke and Other Air Pollutants. Air pollution from industrial chemicals, cigarette smoke, or other pollutants can damage the cilia responsible for moving mucus through the sinuses. Whether air pollution is an important cause of sinusitis and, if so, which pollutants are critical factors is still not clear. Cigarette smoke, for example, poses a small but increased risk for sinusitis in adults. Second-hand smoke does not appear to have any significant effect on adult sinuses, although it does seem to pose a risk for sinusitis in children.

Treatment:

General Treatment Approaches

The primary objectives for treatment of sinusitis are reduction of swelling, eradication of infection, draining of the sinuses, and ensuring that the sinuses remain open. Fewer than half of patients reporting symptoms of sinusitis need aggressive treatment. Home remedies can be very useful.

Treatment of Acute Sinusitis.

    • Support treatment with only saline nasal irrigation, decongestants, antihistamines, and expectorants are       appropriate for a minimum of 7 - 10 days for patients with mild-to-moderate symptoms, and may be used for       longer.
    • Antibiotics are not helpful for patients with mild-to-moderate symptoms, so they should not be prescribed for at       least the first 7 days.

Treatment of Chronic Sinusitis.

    • A broad-spectrum antibiotic (one that can eliminate a wide range of bacteria) may be helpful. Some patients benefit       from prolonged therapy.
    • A corticosteroid nasal spray. Some doctors also recommend oral corticosteroids (such as prednisone) for patients       who do not respond to nasal corticosteroids or for those patients who have nasal polyps. Prednisone is also used       for patients who have allergic fungal sinusitis.
    • Saline nasal irrigation is often needed on an ongoing basis.
    • If the condition dramatically improves after 1 - 2 months, antibiotics are stopped. The patient should continue with       both the steroid and saline nasal solutions. If there is no improvement after this time, surgery may be considered.       For some people with chronic sinusitis, however, the condition is not curable, and the goal of treatment is to       improve the quality of life.
    • A thorough diagnostic work-up should be performed to rule out any underlying conditions, including but not limited       to allergies, asthma, any immune problems, gastroesophageal reflux disorder, and structural problems in the       nasal passages. If a primary trigger for chronic sinusitis can be identified, it should be treated or controlled if       possible.

Hydration

Home remedies that open and hydrate sinuses may, indeed, be the only treatment necessary for mild sinusitis that is not accompanied by signs of acute infection.

    • Drinking plenty of fluids and getting lots of rest when needed is still the best bit of advice to ease the discomforts of       the common cold. Water is the best fluid and helps lubricate the mucous membranes. (There is NO evidence that       drinking milk will increase or worsen mucus, although milk is a food and should not serve as fluid replacement.)
    • Chicken soup does, indeed, help congestion and aches. The hot steam from the soup may be its chief advantage,       although laboratory studies have actually reported that ingredients in the soup may have anti-inflammatory effects.       In fact, any hot beverage may have similar soothing effects from steam. Ginger tea, fruit juice, and hot tea with       honey and lemon may all be helpful.
    • Spicy foods that contain hot peppers or horseradish may help clear sinuses.
    • Inhaling steam 2 - 4 times a day is extremely helpful, costs nothing, and requires no expensive equipment. The       patient should sit comfortably and lean over a bowl of boiling hot water (no one should ever inhale steam from       water as it boils) while covering the head and the bowl with a towel so the steam remains under the cloth. The       steam should be inhaled continuously for 10 minutes. A mentholated or other aromatic preparation may be added       to the water. Long, steamy showers, vaporizers, and facial saunas are alternatives.

Nasal Wash

A nasal wash can be helpful for removing mucus from the nose. A saline solution can be purchased at a drug store or made at home. (Mix 1 teaspoon of table salt with a pinch of baking soda in 2 cups of warm water.) Perform the nasal wash several times a day. Researchers have reported that daily irrigation of the nasal passages with a hypertonic saline solution relieves sinusitis symptoms and also reduces antibiotic use and the occurrence of acute exacerbations. Patients in the study had 72% fewer sinus infections, a 69% improvement in breathing, and they reduced medication usage by more than half.

A simple method for administering a nasal wash is:

    • Lean over the sink head down.
    • Pour some solution into the palm of the hand and inhale it through the nose, one nostril at a time.
    • Spit out the remaining solution.
    • Gently blow the nose.

The solution may also be inserted into the nose using a large rubber ear syringe, available at a pharmacy. In this case the process is:

    • Lean over the sink head down.
    • Insert only the tip of the syringe into one nostril.
    • Gently squeeze the bulb several times to wash the nasal passage.
    • Then press the bulb firmly enough so that the solution passes into the mouth.
    • The process should be repeated in the other nostril.

Antibiotic Use in the Treatment of Sinusitis

Overview on Antibiotics and Their Overuse. Sinusitis is the fifth most common diagnosis for antibiotic prescriptions. And, there is much evidence that antibiotics are inappropriately prescribed for many patients:

    • Most acute sinusitis cases clear up on their own.
    • Antibiotics generally help only a very small number of children with persistent nasal discharge for at least 20 days.       Even when antibiotics are helpful, benefits are modest in reducing duration of the infection.
    • The intense and widespread use of antibiotics (not only for sinusitis but also for ear infections and other upper       respiratory tract infections) has led to a serious global problem, which is bacterial resistance to common       antibiotics.

When to Use Antibiotics. Because up to 70% of sinusitis cases resolve on their own, doctors generally wait 7 - 14 days before prescribing antibiotics. However, antibiotics may be prescribed sooner if severe symptoms develop. These symptoms include:

    • Fever greater than 39° C (102.2° F)
    • Facial pain or headache
    • Severe swelling around the eyes

Chronic sinusitis is often the result of damage to the mucous membrane from a past, untreated acute sinus infection. The aerobic and anaerobic bacteria present in chronic sinusitis are often different from those that cause the acute form. The role of antibiotic treatment for chronic sinusitis is controversial. Special types of antibiotics may be used, and treatment may be needed for a longer time.

Some patients with chronic sinusitis may need intravenous antibiotic therapy, particularly those with underlying medical disorders that can worsen their condition. This therapy is typically given 2 weeks before surgery and continued for about a month afterwards.

Antibiotic Regimens.

    • The standard first-line antibiotic treatment for acute uncomplicated bacterial sinusitis is a 10 - 14 day course of       amoxicillin. Trimethoprim-sulfamethoxazole is an alternative choice.
    • For more complicated illnesses (chronic illness, chronic sinusitis, symptoms lasting longer than 30 days, children       in day care or younger than 2 years old, smokers, recent antibiotic use, or unresponsiveness to initial antibiotic       course), the doctor may prescribe a different type of antibiotic, such as amoxicillin-clavulanate, cephalosporin, or a       macrolide.
    • If the patient does not respond after 21 - 28 days, the doctor may switch to another broad-spectrum antibiotic, such       as amoxicillin-clavulanate, cefuroxime, or cefpodoxime. Other choices include clarithromycin or azithromycin       (macrolides) or levofloxacin (a fluoroquinolone).

Side Effects of Antibiotics. Most antibiotics have the following side effects (although specific antibiotics may have other side effects or fewer of the standard ones):

    • The most common side effect for nearly all antibiotics is gastrointestinal distress.
    • Antibiotics double the risk for vaginal infections in women. Taking supplements of acidophilus or eating yogurt with       active cultures may help restore healthy bacteria that offset the risk for such infections.
    • Allergic reactions can also occur with all antibiotics but are most common with medications derived from penicillin       or sulfa. These reactions can range from mild skin rashes to rare but severe, even life-threatening, anaphylactic       shock.
    • Certain drugs, including some over-the-counter medications, interact with antibiotics; patients should inform the       doctor of all medications they are taking and of any drug allergies.

Managing Sinusitis in Patients with Allergies

Patients often have various combinations of allergies, sinusitis, and asthma. Treating each condition is important for improving them all. In addition to decongestants, pain relievers, and expectorants, other remedies are available for people who suffer from nonbacterial sinusitis during allergy season.

    • Anti-Inflammatory Drugs. Nasal spray corticosteroids (commonly called steroids) are important for reducing the       inflammatory response in the nasal passages and airways. They are important in the treatment of asthma and are       now considered to be the most effective measure for preventing allergy attacks. Leukotriene-antagonists are also       useful for sinusitis symptoms.
    • Antihistamines. Antihistamine tablets relieve sneezing and itching and can prevent nasal congestion before an       allergy attack. Many brands are available by prescription and over the counter. Because they thicken mucus and       make it harder to drain out from the sinuses, they should not be used for sinusitis.
    • Immunotherapy. Immunotherapy, commonly referred to as allergy shots, may be considered for patients with       severe seasonal allergies that do not respond to treatment. Immunotherapy is the only treatment that affects the       cause of allergies. In one year-long study using immunotherapy, over half of young patients participating       experienced improvement in overall sinusitis symptoms, and nearly all felt better in general. Immunotherapy also       may prevent asthma and the development of new allergies in children. Newer immunotherapeutic approaches       using specially designed antibodies and vaccines are also showing promise.
    • All drug treatments have side effects, some very unpleasant and, rarely, serious. Patients may need to try different      drugs until they find one that relieves symptoms without producing excessively distressing side effects.

Emergency Treatment

Patients who show signs that infection has spread beyond the nasal sinuses into the bone, brain, or other parts of the skull need emergency care. High dose antibiotics are administered intravenously, and emergency surgery is almost always necessary in such cases.

Severe Fungal Sinusitis. Sinusitis caused by severe fungal infections is a medical emergency. Treatment is aggressive surgery, and high-dose antifungal chemotherapy with a drug such as amphotericin B can be life saving. The use of high-pressure oxygen (hyperbaric oxygen) is showing promise as additional therapy for potentially deadly fungal infections.

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