Sinusitis also called Sinus infection or acute rhinosinusitis is characterized by inflammation of paranasal maxillary sinuses and the nasal cavity that lasts at least 4 weeks. Its distinctive feature is purulent sputum discharge followed by nasal obstruction, facial pain-pressure-fullness, or both.
Sinusitis is the most common respiratory tract disease. In 2012, approximately 12% of the US population was found to be suffering from sinusitis. It is observed that 0.5% of respiratory tract infections are intricate by sinusitis. The incidence rate range of acute sinusitis was found to be 15 to 40 episodes per 1000 patients in a year2. Incidence rates are seen to be 1.9-fold higher in females than males. The ages of commonly affected adults range between 45-74 years3.
- Infections due to Viruses
- Infections due to bacteria
- Rhinitis that can be either allergic or non-allergic
- Variations in Anatomy of sinuses
- Diabetes mellitus
- Swimming, diving, high altitude climbing
- Dental Infections
- Age: Immune system of the elderly population is weaker than the younger population hence the chances of upper respiratory tract infections are more5.
- Air Pollutants or Smoke: Air pollution or smoke can cause damage to cilia that leads to mucous movement out of the sinuses and responsible for sinusitis5.
- Change in Atmospheric Pressure: Changes in Atmospheric pressure due to any cause can lead to blockage in sinus5.
- Swimming: The swimming pool water contains chlorine that can damage the lining of the nose leading to sinusitis5.
- Asthma: Asthma or other allergies can increase the inflammation of the sinuses and hence is the major cause of sinusitis6.
- Dental Infections: Most dental infections or infections due to dental disease with or without symptoms like periodontal infections can lead to cases of sinusitis7.
Sign & Symptoms4
- Obstruction or congestion of nose
- Sense of smell is decreased
- Facial pressure, pain and tenderness
- Anterior or postnasal rhinorrhea
- Acute infection causing fever and malaise
- Upper toothache
Severity of Sinusitis4
- Acute: Lasting< 4 weeks
- Sub-acute: Lasting 4-12 weeks
- Chronic: Lasting > 12 weeks
- Chronic exacerbation: Worsening of chronic sinusitis even after treatment.
When the sinus ostium of the maxillary sinus is blocked due to various causes there is the retention of mucous in the sinus that leads to various signs and symptoms of sinusitis. Mostly bacteria and viruses are responsible for the trigger of the mechanism but most of the cases are the result of dental node infection4.
Sinuses are small pockets that are present behind the forehead, nose, cheekbones, and eyes and responsible for producing mucus that prevents germs from entering the body. Viruses and bacteria increase mucus production which blocks the sinus opening16.
The sinuses are small air pockets located behind forehead, nose, cheekbones, and in between the eyes. The sinuses produce mucus, which may be a thin and flowing liquid that protects the body by trapping and moving germs away. When mucus becomes viscous or thick hence bacteria and viruses reside in the sinus cavity causing a bacterial or viral infection. It is seen that most sinus infections are viral and lasts 2-3 weeks without treatment16.
Figure 1: Pathophysiology of sinusitis8
Laboratory investigations prescribed in chronic cases are as follows
- Sinus radiography9
- CT scan and magnetic resonance imaging10
- Sinus puncture4
- Computed tomography4
The following medication should be taken for sinusitis infection as prescribes by the doctor. The medication should not be taken without physician advice.
- Amoxicillin-clavulanate is the antibiotic mostly prescribed for sinusitis treatment in adults.
- Duration of therapy: 5-7 days and if it is little or no relief in symptoms therapy is extended to 7-10 days.
- Dose: 90mg/kg/day.
- Antibiotic therapy is recommended in patients who are immunocompromised, hospitalized or have suppurative complications.
Antibiotics in Penicillin Resistant Patients11
- A tetracycline that is Doxycycline 100 mg BD
- Fluoroquinolones: Levofloxacin 500 mg daily or Moxifloxacin 400 mg daily
Treatment in case of antibiotic Therapy Failure11, 12
- If there is a minute worsening in the disease there doesn’t need to be treatment failure the patient might take up to 14 days to fully recover.
- If the patient is detected with acute bacterial rhinosinusitis after 7 days of treatment then the complications are determined and alternate therapy is started.
- If the condition of the patient who was treated by observation only worsens then the antibiotics are started.
In case of severe nasal congestion that lasts up to 5 days topical decongestants like Oxymetazoline and Xylometazoline are recommended but should be used cautiously in high BP patients.
Analgesics11, 12, 13
For relieving the pain in sinusitis non-steroidal anti-inflammatory drugs are prescribed that is Paracetamol 500mg TDS or Diclofenac sodium 50 mg TDS.
There is no requirement for antihistamines but are prescribed in immunocompromised or allergic patients.
Intra nasal corticosteroid spray13
Adjuvant therapy of intranasal corticosteroid spray is included with antibiotics for 10 days for nasal blockages like Fluticasone or mometasone twice daily.
Inhalation of hot water steam is recommended to patients to relieve nasal blockage as it moistens the mucosa and improves ciliary action leading to improved drainage with symptomatic relief. Inhaled steam also softens the secretions.
Nasal spray and douching with physiologic/hypertonic saline13, 14
Adjunctive therapy of physiologic or hypertonic intranasal saline irrigation is prescribed by doctors in adults. Saline irrigation is proven to improve nasal symptoms as it enhances mucociliary function, decreases mucosal edema, mechanically clear thick or congealed mucus, and decreases inflammatory mediators in the body.
In severe or chronic cases patients should visit ENT specialists like:
- Severe infection
- Orbital edema
- Severe headache
- Visual disturbance
- Altered mental status
- Meningeal signs
- Recalcitrant infection which is not cured by the antibiotic therapy
- Immunocompromised Host
- Comorbidities that leads to treatment failure
- Antibiotic Resistance
- Fungal sinusitis or granulomatous disease
- Nosocomial infection
- Sinus obstruction leading to anatomical abnormalities
- Chronic sinusitis due to multiple recurring bacterial sinusitis
- Chronic sinusitis with or without polyps
Endoscopic sinus surgery restores the sinus ventilation as it removes the soft tissue carefully that obstructs the natural drainage of ostia while restoring mucociliary function. After surgery, mucosal healing requires intranasal steroids, saline douching, and nasal toileting, and due to this formation of intranasal adhesions is blocked.
Surgery in sinusitis is done in the most severe or complicated cases and this takes sinus lavage form to drain pus and decompress the affected sinus. This procedure is done endoscopically or via external trephination which is combined with antibiotic therapy and saline douches and sprays15.
- Flu vaccines should be administered every year.
- Take a balanced diet like green leafy vegetables and fruits.
- Washing hands regularly and properly
- Avoid contact with chemicals, smoke, pollens, allergens, or other irritants.
- Anti-allergic medicines should be administered for allergies as prescribes by the doctor
- Avoid coming in contact with cold and flu patients.
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