Sinusitis - Causes, Symptoms and Treatments

Inflammation of the paranasal sinuses is a common problem. The most common type, maxillary sinusitis, is followed in frequency by ethmoid, frontal, and sphenoid sinusitis. Sinusitis may be acute, subacute, chronic, allergic, or hyperplastic.

Acute sinusitis usually results from the common cold and lingers in subacute form in only about 10% of patients. Chronic sinusitis follows persistent bacterial infection; allergic sinusitis accompanies allergic rhinitis; hyperplastic sinusitis is a combination of purulent acute sinusitis and allergic sinusitis or rhinitis. The prognosis is good for all types.

Causes of Sinusitis:

Sinusitis may result from viral, bacterial, or fungal infection. The bacteria responsible for acute sinusitis are usually pneumococci, other streptococci, Haemophilus influenzae, and Moraxella calarrhalis. Staphylococci and gram-negative bacteria are more likely to occur in chronic cases or in patients in intensive care.

On rare occasions, fungi can also be an etiologic factor. Aspergillus fumigatus is the fungus most frequently associated with sinus disease.

Predisposing factors include any condition that interferes with drainage and ventilation of the sinuses, such as chronic nasal edema, deviated septum, viscous mucus, nasal polyps, allergic rhinitis, nasal intubation, nasogastric tubes, or debilitation related to chemotherapy; malnutrition, diabetes, blood dyscrasias, chronic use of steroids, or immunodeficiency.

Bacterial invasion commonly occurs from the conditions listed above or after a viral infection. It may also result from swimming in contaminated water.

Signs and symptoms of Sinusitis:

The primary symptom of acute sinusitis is nasal congestion, followed by a gradual buildup or pressure in the affected sinus. For 24 to 48 hours after onset, nasal discharge may be present and later may become purulent. Associated symptoms include malaise, sore throat, headache, low­grade fever (temperature of 99° to 99.5° F [37.2° to 37.5° C]), malodorous breath, painless morning periorbital swelling, and a sense of facial fullness.

Characteristic pain depends on the affected sinus: maxillary sinusitis causes pain over the cheeks and upper teeth; ethmoid sinusitis, pain over the eyes or retroorbital; frontal sinusitis, pain over the eyebrows; and sphenoid sinusitis (rare), pain behind the eyes with radiation to the occiput or to the upper half of the face.

Purulent nasal drainage that continues for longer than 3 weeks after an acute infection subsides suggests subacute sinusitis. Other clinical features of the subacute form include a stuffy nose, vague facial discomfort, fatigue, and a nonproductive cough.

The effects of chronic sinusitis are similar to those of acute sinusitis, but the chronic form causes continuous mucopurulent discharge.

The effects of allergic sinusitis are the same as those of allergic rhinitis. In both conditions, the prominent symptoms are sneezing, frontal headache, watery nasal discharge, and a stuffy, burning, itchy nose.

In hyperplastic sinusitis, bacterial growth on the diseased tissue causes pronounced tissue edema. Thickening of the mucosal lining, as well as the development of mucosal polyps, combine to produce chronic stuffiness of the nose in addition to headaches.

Diagnosis of Sinusitis:

The following measures are useful:

1. Nasal examination reveals inflammation and pus.

2. Four view sinus X-rays reveal cloudiness in the affected sinus, air and fluid, and any thickening of the mucosal lining.

3. Antral puncture promotes drainage of purulent material. It may also be used to provide a specimen for culture and sensitivity testing of the infecting microbe, but is rarely done.

4. Ultrasonography and computed tomography (CT) scan aid in diagnosing suspected complications. CT scans are more sensitive than routine X-rays in detecting sinusitis.

The common cold and allergic or vasomotor rhinitis are the most common causes of sinus symptoms. Other conditions that produce symptoms resembling sinusitis include polyps, tumors, cysts, foreign bodies, and vasculitides such as Wegener's granulomatosis.

Treatment of Sinusitis:

In acute sinusitis, local decongestants usually are tried before systemic decongestants; steam inhalation may also be helpful. Local application of heat may help to relieve pain and congestion.

Antibiotics are necessary to combat purulent or persistent infection. (The patient should be aware that allergic reactions to penicillin can occur.) Amoxicillin, ampicillin, and trimethoprim-sulfamethoxazole are usually the antibiotics or choice; question the patient about any known allergy to penicillin. Sinusitis is a deep-seated infection, so antibiotics should be given for 2 to 3 weeks. Surgery to widen the ostia and drain thick secretions may be necessary in severe acute sinusitis, especially when the disease fails to respond to initial intravenous therapy.

In subacute sinusitis, antibiotics and decongestants may be helpful. Treatment of allergic sinusitis must include treatment of allergic rhinitis - administration of antihistamines, identification of allergens by skin testing, and desensitization by immunotherapy. Severe allergic symptoms may require treatment with corticosteroids and epinephrine.

In both chronic sinusitis and hyper­plastic sinusitis, antihistamines, antibiotics, and a steroid nasal spray may relieve pain and congestion. If irrigation fails to relieve symptoms, one or more sinuses may require surgery.

Special considerations of Sinusitis:

1. Enforce bed rest, and encourage the patient to drink plenty of fluids to promote drainage. Don't elevate the head of the bed more than 30 degrees.

2. To relieve pain and promote drainage, apply warm compresses continuously, or four times daily for 2-hour intervals. In addition, give analgesics and antihistamines as needed.

3. Watch for complications, such as vomiting, chills, fever, edema of the forehead or eyelids, blurred or double vision, and personality changes.

4. If surgery is necessary, tell the patient what to expect postoperatively: A nasal packing will be in place for 12 to 24 hours after surgery; he'll have to breathe through his mouth and he won't be able to blow his nose. After surgery, monitor for excessive drainage or bleeding and watch for complications.

5. To prevent edema and promote drainage, place the patient in semi-Fowler's position. To relieve edema and pain and to minimize bleeding, apply ice compresses or a rubber glove filled with ice chips over the nose and iced saline gauze over the eyes. Continue these measures for 24 hours.

6. Frequently change the mustache dressing or drip pad, and record the consistency, amount, and color of drainage (expect scant, bright red, and clotty drainage).

7. Because the patient will be breathing through his mouth, provide meticulous mouth care.

8. Tell the patient that even after the packing is removed, nose blowing may cause bleeding and swelling. If the patient is a smoker, instruct him not to smoke for at least 2 or 3 days after surgery.

9. Instruct the patient to finish the prescribed antibiotics, even if his symptoms disappear.

10. Vasoconstrictive nose drops and spray are associated with rebound edema if used for more than 5 to 7 days.