Vincent ENT, Head and Neck Surgery Specialist Clinic - Klang, Shah Alam, Subang, PJ, KL and more...

Last update: 10/1/13

Sinusitis Part 1 - What ? How? Who ? Am I the One ?

This patient education is provided in good faith to help patients and their families learn more about their medical conditions, the options available to them and the possible consequences of their decisions. This information is not intended to be used for diagnosis, or treatment of any specific individual. Please consult with your ENT doctor regarding your particular circumstances.

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(source of unlabelled diagram: Schering-Plough. Addtional artwork and caption added)

(Click for larger image...) Figure A: Front view of the nose -The paranasal sinuses: F =frontal sinus, E = ethmoidal sinus, M = maxillary sinus. ‘Turbinates’ are the 3 shelf-like projection from the sidewall of the nose: ST =superior turbinates, T= middle turbinate, IT= inferior turbinate Figure B: Side view of the nose - F = frontal sinus, E =ethmoidal sinus, S = sphenoid sinus

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B

(source of unlabelled diagram: Netter Atlas of Anatomy)

S

E

F

Brain

Nasal bones

Pituitary gland

Palate

Naso- pharynx

Inferior turbinate

"Doctor, I have sinus." Actually everybody has sinuses. In this context, it is called "paranasal sinuses"-"paranasal" as they are situated around next (“para”) to the nose i.e "nasal" These sinuses are air-filled spaces in the skull that are lined with mucus membranes. They are situated behind the forehead and nasal bones (the frontal sinuses), cheeks (the maxillary sinuses), between the eyes (the ethmoid sinuses) and just behind the ethmoid sinuses in the middle of the head (the sphenoid sinus). Usually, mucus is able to drain out and air is able to circulate. Healthy sinuses are sterile i.e contain no bacteria or other germs. They communicate with the nasal cavity via "ostium". The sinus openings or ostia are the focal point for sinus disease. When the ostium becomes blocked, the sinus cannot drain, too much mucus builds up, bacteria and other germs can grow more easily.and thus signs and symptoms of sinusitis would manifest.

What is rhinosinusitis (as your doctor would understand it) or sinusitis ? ((OK we'll probably stick to this for discussion sake. Henceforth, 'sinusitis' actually means 'rhinosinusitis'and used interchangably thoughout this discussion) Sinusitis is an infection or inflammatory condition of one or more of the paranasal sinuses Sinusitis can be: • Acute -- symptoms last up to 4 weeks • Sub-acute -- symptoms last 4 - 12 weeks • Chronic -- symptoms last 3 months or longer What are the causes? Anyone can get acute rhinosinusitis, but some are more prone to it. Predisposing factors include: • Viral infection especially children in daycare facilities • Non-Allergic/Allergic Rhinitis - Colds and allergies may cause too much mucus to be made or block the opening of the sinuses Colds/flu and allergies are the main risk factors for developing sinusitis • Nasal anatomic variation - Deviated nasal septum (DNS) , Concha bullosa (enalrged middle turbinate filled with air space), Haller's cells narrowing the sinus ostium • Dental infection -dental root penetrating into the sinus, abscess over dental root • Smoking • Large adenoids • Weakened immune system Immune deficiency or acquired immunodeficiency syndrome eg. Ill patients in Intensive Care Unit (ICU), chemotherapy or other immunosuppressive drugs, HIV infection, AIDS • Swimming/diving • Cilia immotility syndrome, Kartagener syndrome, cystic fibrosis-Small hairs (cilia) in the sinuses, which help move mucus out, do not work properly therefore causing mucus retention • Some other medical conditions eg. Wegener's granulomatosis • Cocaine abuse How does it differ from the common cold or flu ? Viral upper respiratory tract infection (URTI) may be the most common triggering mechanism for sinusitis Approximately 90% of patients with colds would be expected to have viral rhinosinusitis as part of their basic illness. Classical history is : • A young adult, often with history of allergy having gradual onset of URTI symptoms (cough, cold, runny nose with clear discharge from both nostrils). This stage likely indicates acute viral URTI. Viral rhinosinusitis is typically accompanied by clear rather than thick or colored secretions. Symptoms can persist up to 14 days or longer. An acute upper respiratory illness of less than approximately 7 days' duration is most commonly caused by viral illness (viral rhinosinusitis), • However, after 5 to 7 days, instead of the URTI resolving, he/she develops facial pressure/pain, thick nasal discharge, then facial pain that radiates to teeth, headache, with possible fever . This stage likely indicates acute bacterial infection of the sinus. Acute bacterial sinusitis becomes more likely beyond 7 to 10 days. Transition from viral URI to ABRS can occur at any time during the viral URTI. Approximately 0.5%-2% of these cases are complicated by an acute bacterial infection of the sinus. The 2 commonest causative bacteria are Streptococcus pneumoniae and non-typeable Hemophilus influenzae. The following signs and symptoms increases the likelihood of bacterial sinusitis: • purulent secretions by history, • purulent secretions in the nasal cavity by examination, • lack of response to decongestants, maxillary pain, The classic physical finding of facial pain on percussion appears to be of little diagnostic value How does it differ from allergic nose or allergic rhinitis ? Allergy can cause chronic inflammation of the sinus and mucus linings. This inflammation prevents the usual clearance of bacteria from the sinus cavity, increasing the chances of developing secondary bacterial sinusitis. What are the symptoms? Colds/flu and allergies are the main risk factors for developing sinusitis The classic symptoms of acute sinusitis in adults usually follow a cold that does not improve, or one that worsens after 5 - 7 days of symptoms. The signs and symptoms of sinusitis vary depending on the level of severity of the inflammation and which sinuses are involved. Only a few or all of the following symptoms and signs may be present: • Thick, green or yellow coloured mucus from the nose or down the back of the throat • Nasal blockage, congestion or stuffiness • Sensation of pressure that is worse with leaning forward • Headache - pressure-like pain, pain behind the eyes, toothache, or facial tenderness • Loss of sense of smell or taste • Bad breath / bad taste in the mouth • Sore throat, postnasal drip / cough - often worse at night • Fatigue, tiredness • Temperature or shivers (fever) • Facial congestion (a feeling of fullness) and pain • Toothache Symptoms of sinusitis in children include: • Cold or respiratory illness that has been improving and then begins to get worse • High fever, along with a darkened nasal discharge, for at least 3 days • Nasal discharge, with or without a cough, that has been present for more than 10 days and is not improving How does acute rhinosinusitis differ from chronic rhinosinusitis ? • Chronic sinusitis is defined as an inflammatory process of the paranasal sinuses lasting longer than 3 months. • The symptoms are identical to those seen in the acute form of the disease but usually milder. • Acute sinusitis is usually caused by a bacterial infection in the sinuses that results from an upper respiratory tract infection. • Chronic sinusitis refers to long-term swelling and inflammation of the sinuses that more likely to be caused by bacteria or a fungus. • Acute sinusitis is usually painful while chronic sinusitis usually isn't Symptoms of chronic sinusitis are the same as those of acute sinusitis, but tend to be milder and last longer than 12 weeks. Acute sinusitis is usually managed with a non-surgical approach eg. antibiotics, anthihistamine, decongestants However, in CRS, chronic sinusitis symptoms can be difficult to treat even with a long regimen of antibiotics. When antibiotic treatment fails, allergy testing, desensitization, and/or surgery may be recommended as the most effective means for treating chronic sinusitis. Research studies suggest that the vast majority of people who undergo surgery have fewer symptoms and better quality of life. Surgery to clean and drain the sinuses- Functional Endoscopic SInus Surgery (FESS) remains the gold standard of treatment to overcome this problem of CRS, especially in patients whose symptoms fail to go away after 3 months, despite medical treatment, or in patients who have more than two or three episodes of acute sinusitis each year. Other coexistent conditions like a deviated nasal septum or nasal polyps usually require surgery. Most fungal sinus infections require surgery. How common is sinusitis ? Sinusitis is considered to be one of the most common illnesses in the United States. National health statistics in the US show that: • Between 29 million and 31 million adults are diagnosed with sinusitis each year • Chronic sinusitis affects nearly 35 million people in the United States, or 14% of the population

A rough guide differentiating between common cold/influenza/flu, nasal allergy/allergic rhinitis and acute sinusitis

Continue to Sinusitis Part 2 -Diagnosis & Treatment

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MYTHS !!! 1. Everyone who has frequent runny nose has Allergic Rhinitis 2. Rhinitis equals Sinusitis

THE TRUTH : • As part of the same air passages, and lined by the same mucous membrane, the nose and sinuses tend to be affected by the same problems. • Rhinitis is commoner than sinusitis, and can cause almost similar symptoms. • Most cases of sinusitis start off as rhinitis, so we usually get rhinosinusitis rather than pure sinusitis. • Nearly all cases of sinusitis are in fact rhinosinusitis

• It is important to differentiate between Allergic Rhinitis, Common Cold/Flu and sinusitis/rhinosinusitis Colds/flu and allergies are the main risk factors for developing sinusitis • Although most cases resolve completely, sinusitis can, rarely, have serious complications, especially in children • Acute sinusitis - mainstay of treatment : medical or non-surgical methods • Chronic rhinosinusitis - mainstay of treatment : Surgical methods • Early treatment reduces the risk of developing complications

A view through the ostium into the maxillary sinus

The ostium into the maxillary sinus seen from the nasal cavity

The ostium into the sphenoid sinus seen from the nasal cavity

( Mouse over to zoom in)