Acute Sinusitis, Causes, Symptoms, Treatment

Acute Sinusitis/Sinusitis is inflammation of the sinus or nasal passage. Chronic sinusitis is chronic inflammation of the sinus or nasal passages occurring for more than 12 weeks at a time. Recurrent sinusitis is defined as greater than four episodes of sinusitis within a one-year period. The evaluation and management of acute and chronic sinusitis are similar. Chronic sinusitis may present as 1) chronic sinusitis without nasal polyps 2) chronic sinusitis with nasal polyps and 3) allergic fungal rhinosinusitis. [rx][rx]

Rhinitis is the inflammation of the nasal mucosa. It can be defined as symptoms of nasal irritation, sneezing, rhinorrhoea and nasal blockage lasting for at least 1 h a day on most days. The term “sinusitis” refers to inflammation of the mucosa of the paranasal sinuses, regardless of the cause. As the understanding of the pathophysiology of the nasal mucosa has evolved, the differentiation between rhinitis and sinusitis has become less apparent.

Pathophysiology

Pathogenesis of rhinosinusitis is as a result of dysfunction of sinus ostia (narrowing), the ciliary apparatus, and viscous sinus secretions. Viral upper respiratory infection or allergens result in mucosal edema to lead to narrowing of the sinus ostia causing direct mechanical obstruction. When there is an obstruction of the sinus ostium, there is a transient increase in pressure within the sinus cavity. As air is depleted in this close space, the pressure in the sinus becomes negative relative to atmospheric air pressure. This negative pressure possibly allows nasal bacteria into sinuses during sniffing or nose blowing. When the sinus ostium is obstructed, secretion of mucous by mucosa continues, resulting in fluid accumulation in the sinus. During viral colds other inflammation of nasal ostia and mucosal membranes, both the structure and the function of the mucociliary apparatus are impaired. The quality and characteristics of sinus secretions also determine the pathogenesis of sinusitis. Cilia can beat only in a fluid. The mucous blanket in the respiratory tract is made up of two layers. The sol phase is a thin, low-viscosity layer that surrounds the shaft of the cilia and allows the cilia to beat freely. The gel phase is a more viscous layer and rides on the sol phase. Alterations in the mucous layer, which occur in the presence of inflammatory debris, as in infected sinus, may further impair ciliary movement. Similarly, mucociliary dysfunction may occur due to frequent irrigation of the nasal cavity.

Sinusitis Types

By Severity

• Acute rhinosinusitis – Sudden onset, lasting less than 4 weeks with complete resolution. Causesd by Haemophilus influenzae, Streptococcus pneumoniae (rarely: anaerobes, Gram negative bacteria, Staphylococcus aureus, Moraxella catarrhalis, Streptococcus pyogenes)
• Subacute rhinosinusitis – A continuum of acute rhinosinusitis but less than 12 weeks. Four or more full episodes of acute sinusitis that occur within one year. Caused by Anaerobes, Gram-negative bacteria, S aureus (rarely, fungal). An infection that lasts between four and 12 weeks, and represents a transition between acute and chronic infection
• Recurrent acute rhinosinusitis – Four or more episodes of acute, lasting at least 7 days each, in any 1-year period.
• Chronic rhinosinusitis – Signs of symptoms persist 12 weeks or longer.
• Acute exacerbation of chronic sinusitis – When the signs and symptoms of chronic sinusitis exacerbate, but return to baseline after treatment

By Location

There are four paired paranasal sinuses, the frontal, ethmoidal, maxillary, and sphenoidal sinuses. The ethmoidal sinuses are further subdivided into anterior and posterior ethmoid sinuses, the division of which is defined as the basal lamella of the middle nasal concha. In addition to the severity of disease, discussed below, sinusitis can be classified by the sinus cavity which it affects:

• Maxillary – can cause pain or pressure in the maxillary (cheek) area (e.g., toothache,^[rx] or headache) (J01.0/J32.0)
• Frontal – can cause pain or pressure in the frontal sinus cavity (located above the eyes), headache, particularly in the forehead (J01.1/J32.1)
• Ethmoidal – can cause pain or pressure pain between/behind the eyes, the sides of the upper part of the nose (the medial canthi), and headaches (J01.2/J32.2)^[rx]
• Sphenoidal – can cause pain or pressure behind the eyes, but is often felt in the top of the head, over the mastoid processes, or the back of the head.^[rx]

Sinusitis Causes

• Abnormality of the osteomeatal complex, Septal deviation, Concha bullosa, Hypertrophic middle turbinates
• smoker (a second-hand smoker has a higher risk of CRS with current and past exposure)
• asthma, especially in the presence of CRS with nasal polyps (CRSwNP)
• allergies, chronic bronchitis and emphysema
• Viral infection
• Allergic and non-allergic rhinitis
• Cigarette smoking
• Diabetes mellitus
• Swimming, diving, high altitude climbing
• Dental infections and procedures
• Cystic fibrosis
• Neoplasia
• Mechanical ventilation
• Use of nasal tubes, such as nasogastric feeding tubes
• Samter’s triad (aspirin sensitivity, rhinitis, asthma)
• Sarcoidosis
• Wegener’s granulomatosis
• Immune deficiency
• Sinus surgery
• Immotile cilia syndrome
• Anatomical variations
• ARS
• chronic rhinitis
• gastroesophageal reflux disease
• sleep apnoea
• adenotonsillitis

 Symptoms of Sinusitis

• Headache due to pressure in partially or completely blocked sinuses. The pain may increase when the person bends down.
• Facial tenderness and/or swelling when facial areas over sinus areas are touched.
• Pressure or pain due to mucus pressing on sinus tissue or inflammation of sinuses.
• Fever due to inflammation of sinus tissues and infection.
• A cloudy, discolored nasal drainage is often seen in bacterial sinus infections.
• Congestion is a feeling of nasal stuffiness, and occurs with both infectious and non-infectious sinusitis.
• Post nasal drip is mucus overproduction from sinusitis that flows to the throat and irritates throat tissue.
• Sore throat is inflammation of throat tissue by post nasal drip.
• Cough is a response to post nasal drip and body’s attempt to clear out throat tissue irritants.
• Tooth pain caused by pressure on surrounding nerves and tissues
• Ear pain caused by pressure on surrounding nerves and tissues
• Eye pain caused by pressure on surrounding nerves and tissues
• Fatigue due to fever, immune response and/or coughing
• Bad breath usually is due to bacterial infections
• Itching/sneezing – In noninfectious sinusitis, other associated allergy symptoms of itching eyes and sneezing may be common, but may include some of the symptoms listed above for infectious sinusitis.
• Nasal drainage usually is clear or whitish-colored in people with noninfectious sinusitis.
• Ulceration can occur with rare fulminant fungal infections with sharply defined edges and a black, necrotic center in the nasal area. Some fungal infections cause dark, black-appearing exudates. This requires immediate medical evaluation.
• Multiple chronic (over one to three months) symptoms usually are a sign of subacute or chronic sinusitis
•  Nasal obstruction or congestion
• Hyposmia (reduced sense of smell)
• Facial pressure, pain, tenderness
• Rhinorrhoea (anterior or postnasal)
• Fever or malaise (acute infection)
• Toothache (upper teeth)

Sinusitis Diagnosis

Chronic sinusitis is diagnosed when at least two of the following four symptoms are present and occur for more than 12 weeks:

• (1) Purulent drainage,
• (2) Facial and/or dental pain,
• (3) Nasal obstruction,
• (4) Hyposmia).

The Infectious Disease Society of America (IDSA) defines sinusitis as two of the following major clinical symptoms: purulent nasal discharge, nasal congestion or obstruction, facial congestion or fullness, facial pain or pressure, hyposmia, anosmia. Alternatively, ISDA defines sinusitis as one of the aforementioned major symptoms plus two or more minor criteria such as a headache, ear pain, pressure, or fullness, halitosis or bad breath, dental pain, cough, or fatigue.

CRS, with or without nasal polyps in adults is defined as:

• inflammation of the nose and the paranasal sinuses characterized by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/posterior nasal drip) ± facial pain/pressure ± reduction or loss of smell for ≥ 12 weeks.

This should be supported by demonstrable disease with endoscopic signs of:

• nasal polyps, and/or mucopurulent discharge primarily from middle meatus and/or edema/mucosal obstruction primarily in middle meatus.

and/or

• computed tomography (CT) changes: mucosal changes within the ostiomeatal complex and/or sinuses.

Treatment of Sinusitis

There is no consensus on an approach to the management of chronic sinusitis. The treatment should focus on modulating triggers, reducing inflammation, and eradicating the infection.[rx][rx]

Trigger Reduction

• Allergy testing can help identify environmental triggers that patients should avoid.

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Medication

• Antibiotics – Use empirically and based on community patterns of resistance. Ten to 14 days of amoxicillin or amoxicillin-clavulanate is first-line treatment.Amoxicillin, cephalosporins and macrolides have been studied extensively.^[rx,rx]. Amoxicillin–clavulanate compared to antibiotics in the cephalosporin class was found to be 41% more effective in reducing clinical failure within 10–25 days after treatment initiation. In some communities, amoxicillin effectiveness is less than 70%. Trimethoprim-sulfamethoxazole well for some, but there is a higher rate of resistance.
• Failure of symptoms – to resolve after 7 days of therapy should prompt one to switch to a broader spectrum agent, such as ten to fourteen days of augmentin, cefuroxime axetil, other second or third-generation cephalosporins, clindamycin alone or along with ciprofloxacin, sulfamethoxazole, a macrolide, or one of the fluoroquinolones.
• Metronidazole – may be added to any one of these agents to increase anaerobic coverage. For chronic sinusitis, antibiotics should cover S. aureus and be effective against the higher incidence of beta-lactamase producing organisms that are common in chronic disease. If the patient is not improving after 5 to 7 days, add metronidazole or clindamycin. Treat for 3 to 6 weeks.
• Analgesics – paracetamol or non-steroidal anti-inflammatory drugs may provide symptomatic relief in both viral and bacterial infections of the upper respiratory passages in RS.
• Mucolytics and antiviral agents –  There is no evidence to support the use of these agents in RS.
• Nasal steroids – should be used with or without nasal saline irrigation. The treatment should last at least eight to 12 weeks with proper usage.
• Nasal saline – irrigation is inferior to nasal steroids. However,  nasal saline irrigation can serve as a useful adjunct. High volume nasal saline irrigation was found to be more effective than low-volume nasal spray techniques.
• Antihistamines – should only be used if an allergic component is suspected.
• Anti-fungal – empiric therapy should not be given.
• Oral steroids – can be used. However, their use is not routinely indicated. Comments regarding their use are given below.  Should oral steroids be used, physicians should engage in shared decision-making with patients.

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Decongestant

• An oral decongestant will help reduce inflammation and secretion from the nasal, sinus, and respiratory tract mucosa thus assisting symptomatic relief. This may also assist in keeping the nasal ostia open and resulting in a reduction of sinus pressure. An oral antihistamine may be helpful if suspected sinusitis is as a result of allergic rhinitis. Oral steroids are not recommended for symptomatic relief.

Topical Intranasal Therapy

• Nasal irrigation with saline is an effective symptomatic relief as a result of viral or allergic rhinosinusitis. It should be stressed that prolonged and frequent nasal irrigation of nasal cavity may alter the mucociliary apparatus to result into increase in symptoms of sinus congestion.
• A topical spray of fluticasone may help reduce inflammation and reduce the flaring up. Another topic spray such as oxymetazoline or phenylephrine nasal may help reducing congestion. Patients should be cautioned of rebound congestion following these decongestant sprays and limit the spray to 3 days.

Nasal Polyps

• Chronic sinusitis with polyps should be treated with topical nasal steroids. If severe or unresponsive to therapy after 12 weeks, a short-course of oral steroids can be considered.
• Leukotriene antagonists can be considered.

Other Emerging Options

Many adjunctive agents have been utilized to control CRS including antimycotics,[rx–rx] anti-IgE,[rx] anti-IL5, antihistamine, aspirin desensitization, bacterial lysates, capsaicin,[rx]complementary and alternative medicine, decongestants, furosemide, immunosuppressants, leukotriene antagonists,nasal irrigation, mucolytic agents,[rx]phototherapy, probiotics, and proton pump inhibitors (PPIs). There was limited evidence on the effect of these options. We will focus this topic only on medications with positive effects.

Surgery

• Functional endoscopic sinus surgery can be considered for patients who fail medical management. In more complicated cases, it can serve as an adjunct to medical management. The goal of this surgery is to relieve obstructions, restore drainage and mucociliary clearance, and to ventilate the sinuses.
• Interventions such as balloon sinuplasty are not recommended for recurrent sinusitis and should be reserved for patients with chronic sinusitis refractory to medical management.

Complications 

• Laryngitis
• Dacryocystitis
• Orbital cellulitis/abscess
• Cavernous sinus thrombosis
• Meningitis, subdural abscess, brain abscess
• Frontal bone osteomyelitis

Orbital

• Preseptal cellulitis
• Orbital cellulitis
• Orbital abscess
• Osteomyelitis
• Subperiosteal orbital abscess

Intracranial

• Subdural empyema
• Epidural empyema
• Meningitis
• Brain abscess
• Cortical thrombophlebitis
• Cavernous/sagittal sinus thrombosis

Prevention

• Bathe your nasal passages daily – Run water gently into the nasal passages to help clear excess mucus and moisten membranes. During the day, use nasal saline spray to moisten nasal passages.
• Drink lots of water – Good hydration helps keep the mucus thin and loose. Have a bottle of water at your desk at work, or put a glass near the kitchen sink to remind you to drink water throughout the day.
• Inhale steam – Linger in a hot shower. Or bring water to a boil, and pour it into a pan; place a towel over your head, and carefully bend over the pan to inhale the steam. To avoid burns, keep your distance at first and move in gradually to a comfortable zone.
• Avoid dry environments – A humidifier in your home (in particular, by your bed) and where you work can help prevent nasal passages from drying out. Keep humidifiers clean and free of bacteria and mold.
• Sleep with your head elevated – Mucus pools in your sinuses at night when your head is down, so have your head propped up with pillows or a wedge during sleep.
• Be nice to your nose – Blow your nose gently, one nostril at a time. Forceful blowing can irritate the nasal passages and propel bacteria-laden mucus back up into your sinuses.
• Avoid antihistamines unless prescribed – Antihistamines make mucus thick and hard to drain. But if your sinusitis is triggered by allergies, your clinician may still want you to take an antihistamine along with other medications.
• Be careful with decongestants – Tablets containing pseudoephedrine act on blood vessels to shrink membranes and keep nasal passages open. Nasal sprays containing phenylephrine or oxymetazoline also work well — and quickly. But using topical nasal decongestants for more than a day or two runs the risk of setting off a spiral of dependency as a result of rebound — increased swelling after the medication wears off.

References