SINUSITIS
 
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SINUSITIS

 

DEFINITION:

An inflammatory disease of the paranasal sinuses causing acute and chronic conditions.

EPIDEMIOLOGY:

  • incidence: ?
  • age of onset:
    • infant - maxillary and ethmoid sinusitis
    • childhood - sphenoid (3-5 years) and frontal (6-10 years) sinusitis

TYPES:

1. Acute Sinusitis

  • presence of symptoms for <30 days
  • maxillary and ethmoid sinuses most commonly involved with occasionally frontal sinus and rarely sphenoid sinus affected
  • etiology primarily infectious:
    • S. pneumoniae, H. flu, Moraxella catarrhalis

2. Chronic Sinusitis

  • presence of symptoms for >30 days
  • due to a prolonged obstruction of the osteomeatal complex
  • etiology both infectious and noninfectious
  • noninfectious causes include:
    • asthma - release of bronchial mucosa mediators
    • rhinitis
      • allergic - release of nasal mucosa mediators
      • nonallergic - release of sinus tissue mediators
  • should always investigate for an underlying etiology

PATHOGENESIS:

  • Obstruction of the osteomeatal complex by local (regional) or systemic factors results in hypoxia to adjacent sinuses which leads to dysfunction of ciliary motility and movement of mucous within the sinuses. The sinuses then act as incubation sites where bacteria in the upper respiratory tract can multiply and invade the mucosa.

1. Local (Regional) Factors

1. Mechanical Obstruction

  • anatomical variants:
    • adenoid hypertrophy, concha bullosa, nasal polyps
  • barotrauma/trauma
  • foreign body
  • nasal septal abnormalities (deviation, mucocele)

2. Inflammatory

  • infectious:
    • viral upper respiratory tract infections (URTI), rhinitis (infectious)
  • noninfectious:
    • asthma, rhinitis (allergic & nonallergic)

2. Systemic Factors

1. Decreased Mucociliary Clearance

  • Ciliary Dyskinesia Syndrome
  • Cystic Fibrosis (asymptomatic panopacification seen)

2. Deficient Immune System

  • immunoglobulin deficiency

CLINICAL FEATURES:

1. Acute Sinusitis

  • presents like a prolonged URTI:
    • day and nighttime cough (chronic cough)
    • purulent nasal discharge for at least 10 days
    • fever (>39 C) for longer than 3 days
    • malodorous breath (in those <5 years)
    • rarely headaches or facial pain (in older children)
    • no other sources of infection (i.e., otitis media)

2. Chronic Sinusitis

  • prolonged rhinorrhea and congestion -> nasal obstruction
  • chronic cough and postnasal drip -> sore throat
  • anorexia, headaches, low grade fever, malaise

3. Complications

  • orbital or periorbital cellulitis or edema (ethmoiditis)
  • cavernous sinus thrombosis; optic neuritis
  • epidural or subdural abscesses; meningitis

INVESTIGATIONS:

1. Imaging Studies

1. Sinus Radiographs

  • indicated for diagnosis of acute sinusitis
  • opacification, air-fluid levels, mucosal thickening (>4 mm) of the maxillary and ethmoid sinuses

2. CT

  • indicated for diagnosis of chronic sinusitis or if history is suggestive but sinus radiographs are negative

3. Lateral Neck X-Ray

  • to rule out enlarged adenoids

2. Nasal Endoscopy

  • indicated for diagnosis of chronic sinusitis
  • can identify obstruction of the osteomeatal complex
  • biopsy may identify histopathologic features similar to those seen in bronchial asthma

3. Microbiology

  • culture of sinus aspirate considered the gold standard
  • pathogens:
    • major - S. pneumoniae, H. flu, Moraxella catarrhalis
    • minor - Bacteroides, Fusobacterium, S. aureus, alpha-hemolytic streptococcus

4. Allergy Testing

1. In Vivo (Skin Testing)

  • to rule out an allergic etiology to post nasal drip
  • if environmental allergies, may predict time of the year to expect the most trouble

MANAGEMENT:

1. Acute Sinusitis

1. Antibiotics

  • Clavulin 50 mg/kg/day for 10-14 days (Treatment of Choice as covers typical microorganisms and anaerobes)
  • Amoxicillin 40 mg/kg/day for 10-14 days or
  • Ceclor 40 mg/kg/day for 10-14 days (if penicillin allergy)
  • beta-lactamase antibiotic for 2-3 weeks (Septra, Pediazole)
  • use for 14 days if the nose continues to run after 7 days of initiating therapy

2. Nasal Decongestants

1. Dristan (0.05% Oxymetazoline HCl)

  • 1 application in each nostril bid x 4-5 days

2. Otrivin (0.05% Xylometrazoline HCl)

  • 1-2 applications in each nostril tid x 4-5 days

3. Intranasal Corticosteroids

  • may help to shrink inflammed mucosa in both acute and chronic sinusitis
  • should be continued for several months to allow complete healing and prevent recurrences
  • may take up to 1 week to see an effect

1. Flonase

  • fluticasone propionate suspension
  • 1 application (50 ug) in each nostril od (one bottle will last 30 days)
  • can increase to bid if no response
  • less than 1% oral bioavailability

2. Beconase

  • beclomethasone dipropionate suspension
  • 2 applications (100 ug) in each nostril bid
  • can increase to qid if no response

3. Rhinocort

  • budesonide powder
  • 2 applications (200 ug) in each nostril od
  • can increase to bid if no response
  • 11% oral bioavailability

3. Follow-up

  • in 1 months time to check the effect of the antibiotic and intranasal corticosteriod therapy

2. Chronic Sinusitis

1. Medical

1. Antibiotics

  • Clavulin 40 mg/kg/day for 3-6 weeks

2. Intranasal Corticosteriods

  • as above

2. Surgery

  • indications: failure of medical management (3 months), anatomical obstruction, complications, intense pain
  • antrostomy of middle nasal meatus and ethmoidectomy
  • may need an adenoidectomy

 

 

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