Article: Sinusitis

Sinusitis is inflammation of the paranasal sinuses from either bacterial, fungal, viral, allergic or autoimmune issues. Newer classifications of sinusitis refer to it as rhinosinusitis, taking into account the thought that inflammation of the sinuses can not occur without some inflammation of the nose as well.

Classification

By location

There are several paired paranasal sinuses, including the frontal, ethmoid, maxillary and sphenoid sinuses. The ethmoid sinuses can also be further broken down into anterior and posterior, the division of which is defined as the basal lamella of the middle turbinate. In addition to the acuity of disease, discussed below, sinusitis can be classified by the sinus cavity which it affects:

• Maxillary sinusitis - can cause pain or pressure in the maxillary (cheek) area (e.g., toothache, headache) (J01.0/J32.0)

• Frontal sinusitis - can cause pain or pressure in the frontal sinus cavity (located behind/above eyes), headache (J01.1/J32.1)

• Ethmoid sinusitis - can cause pain or pressure pain between and/or behind eyes, headache (J01.2/J32.2)

• Sphenoid sinusitis - can cause pain or pressure behind the eyes, but often refers to the vertex of the head(J01.3/J32.3)

Recent theories of the sinusitis indicate that it often occurs as part of a spectrum of diseases that affect the respiratory tract (i.e. - the "one airway" theory) and is often linked to asthma. All forms of sinusitis may either result in, or be a part of, a generalized inflammation of the airway so other airway symptoms such as cough may be associated with it.

Acute vs. chronic

Sinusitis can be acute (going on less than four weeks), subacute (4-12 weeks) or chronic (going on for 12 weeks or more).

All three types of sinusitis have similar symptoms, and are thus often difficult to distinguish.

Acute sinusitis

Acute sinusitis is often brought on by bacteria, most commonly Haemophilus influenzae, Streptococcus pneumonia, Moraxella catarrhalis, and Staphyloccus aureus. Other bacterial pathogens include other streptococci species, anaerobic bacteria, and less commonly, gram negative bacteria.

It is usually precipitated by an earlier upper respiratory tract infection, generally of viral origin. Acute episodes of sinusitis can also result from fungal invasion. These infections are often only seen in patients with diabetes or other immune deficiencies (such as AIDS or transplant patients on anti-rejection medications) and can be life threatening.

Chronic sinusitis

Chronic sinusitis is a complicated spectrum of diseases that share chronic inflammation of the sinuses in common. The causes are multifactorial and may include allergy, environmental factors such as dust or pollution, bacterial infection, and/or fungus (either allergic, infective or reactive).

Symptoms include: Nasal congestion; facial pain; headache; fever; general malaise; thick green or yellow discharge; feeling of facial 'fullness' worsening on bending over; aching teeth.

In a small number of cases, chronic maxillary sinusitis can also be brought on by the spreading of bacteria from a dental infection.

Attempts have been made to provide a more consistent nomenclature for subtypes of chronic sinusitis. A task force for the American Academy of Otolaryngology - Head and Neck Surgery / Foundation along with the Sinus and Allergy Health Partnership broke Chronic Sinusitis into two main divisions, Chronic Sinusitis without polyps and Chronic Sinusitis with polyps (also often referred to as Chronic Hyperplastic Sinusitis. Recent studies which have sought to further determine and characterize a common pathologic progression of disease have resulted in an expansion of proposed subtypes. Many patients have demonstrated the presence of eosinophils in the mucous lining the nose and paranasal sinuses. As such the name Eosinophilic Mucin RhinoSinusitis (EMRS) has come into being. Cases of EMRS may be related to an allergic response, but allergy is often not documentable, resulting in further subcategorization of allergic and non-allergic EMRS.

A more recent, and still debated, development in chronic sinusitis is the role that fungus may play. Fungus can be found in the nasal cavities and sinuses of most patients with sinusitis, but can also be found in healthy people as well. It remains unclear if fungus is a definite factor in the development of chronic sinusitis and if it is, what the difference may be between those who develop the disease and those who do not.

Sinus headache

• Sinus headache a headache caused by pressure within the sinus cavities of the head, usually in connection with infection of the sinuses. Signs and symptoms of sinus headache include pain and tenderness in the sinus area, discharge from the nose, and sometimes swelling of the face. The use of the term headache in this regard can often be misleading, however. Recent studies indicate that 'sinus headache' is often misdiagnosed by the sufferer and may instead be a tension headache or result of a migraine phenomenon. Proper evaluation by a trained professional is still required for final determination.

Diagnosis

Factors which may predispose to developing sinusitis include: allergies; structural problems such as, for example, a deviated septum, small sinus ostia; smoking; nasal polyps; carrying the cystic fibrosis gene (research is still tentative); prior bouts of sinusitis as each instance may result in increased inflammation of the nasal or sinus mucosa and potentially further narrow the openings.

When imaging techniques are required for diagnosis CT scanning is the method of choice. If allergies are suspected, allergy testing may be performed.

Treatment

Therapeutic measures range from the medicinal to the traditional and may include simple anti-inflamatories (aspirin, paracetamol (acetaminophen) or similar), inhaling steam, nasal irrigation or jala neti using a warm saline solution, hot drinks including tea and chicken soup, over-the-counter decongestants, prescription nasal sprays, and getting plenty of rest. If sinusitis doesn't improve within 48 hours, or is causing significant pain, one should see a doctor, who may prescribe antibiotics or nasal steroids. If the recommended doses and duration of antibiotic treatment(s) are ineffective, one should consult a doctor; who may suggest further treatment by a qualified specialist.

For chronic or recurring sinusitis, referral to an otolaryngologist is indicated for more specialist assessment and treatment, which may include nasal surgery.

A relatively recent advance in the treatment of sinusitis is a type of surgery called FESS - functional endoscopic sinus surgery, whereby normal clearance from the sinuses is restored by removing the anatomical and pathological obstructive variations that predispose to sinusitis. This replaces prior open techniques requiring facial or oral incisions and refocuses the technique to the natural openings of the sinuses instead of promoting drainage by gravity the idea upon which the less effective Caldwell-Luc surgery was based.

Another recently developed treatment is balloon sinuplasty. This method, similar to balloon angioplasty used to "unclog" arteries of the heart, utilizes balloons in an attempt to expand the openings of the sinuses in a less invasive manner. Its final role in the treatment of sinus disease is still under debate but appears promising.

Based on the recent theories on the role that fungus may play in the development of chronic sinusitis newer medical therapies include topical nasal applications of antifungal agents. Much of the original research indicating fungus, took place at the Mayo Clinic and they have since patented this treatment option. Additional information can be found at [[1]]. Although there are some licensing battles taking place over these drugs as a result of the patent, they are currently available for other uses and therefore can be compounded by pharmacies or even by the patient.