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Ear, Nose and Throat (ENT), Head and Neck Surgery
Specialist Clinic
Sinusitis  Rhinosinusitis - Acute & Chronic EDUCATION
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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
(source of unlabelled diagram: Netter Atlas of Anatomy)
Nasal bones
Pituitary gland
Naso- pharynx
Inferior turbinate
“Doctor, I have sinus.” What is sinusitis or rhinosinusitis ?  What are the causes? How does it differ from the common cold or flu ? How does it differ from allergic nose or allergic rhinitis ? What are the symptoms? How does acute rhinosinusitis differ from chronic rhinosinusitis ? How common is sinusitis ?
"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
 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
Flu ? Allergy ? Sinusitis © Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
© Vincent Tan ENT
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Talks about SINUSITIS on 21/2/14 (for educational purposes)
D R. V INCENT T AN Consultant Ear, Nose and Throat, Head and Neck Surgeon, MD (UKM), MS ORL-HNS (UKM), DOHNS RCS Edinburgh (UK), MRCS Edinburgh (UK), Postgrad. Allergy (UK), A.M. (Mal), Fellowship in Rhinology (Singapore) Fellowship in Head and Neck Oncology & Surgery (Amsterdam)
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