1.2 Sinusitis A. Definition Sinusitis is an inflammation of nasal sinuses that can be acute or chronic B.

. Incidence Sinusitis affects 1 out of every 7 adults in the United States, with more than 30 million individuals diagnosed each year. It is estimated that 32 million people a year develop chronic sinusitis. Sinusitis is more common from early fall to early spring Women have more episodes of infective sinusitis than men because they tend to have more close contact with young children. The rate in women is 20.3%, compared with 11.5% in men. C. Etiology Acute sinusitis develops as a result of an upper respiratory tract infection, particularly a viral infection or an exacerbation of allergic rhinitis The cause of chronic sinusitis is not clear Chronic sinusitis is an inflammation of the sinuses that persists for more than 3 weeks in an adult and 2 weeks in a child. D. Pathophysiology

Acute sinusitis is an infection of the paranasal sinuses. It frequently develops as a result of an upper respiratory infection, such as an unresolved viral or bacterial infection, or an exacerbation of allergic rhinitis. Nasal congestion, caused by inflammation, edema, and transudation of fluid, leads to obstruction of the sinus cavities (see Fig. 22-1). This provides an excellent medium for bacterial growth. Bacterial organisms account for more than 60% of the cases of acute sinusitis, namely Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis (Murray & Nadel, 2001). Dental infections also have been associated with acute sinusitis.

Chronic .. A narrowing or obstruction in the ostia of the frontal, maxillary, and anterior ethmoid sinuses usually causes chronic sinusitis, preventing adequate drainage to the nasal passages. This combined area is known as the osteomeatal complex. Blockage that persists for greater than 3 weeks in an adult may occur because of infection,

allergy, or structural abnormalities. This results in stagnant secretions, an ideal medium for infection. The organisms that cause chronic sinusitis are the same as those implicated in acute sinusitis. Immunocompromised patients, however, are at increased risk for developing fungal sinusitis. Aspergillus fumigatus is the most common organism associated with fungal sinusitis. E. Signs and symptoms a. Acute Sinusitis Pressure and pain over affected sinus area nasal obstruction fatigue purulent nasal discharge fever headache ear pain and fullness dental pain cough decreased sense of smell sore throat eyelid edema, b. Chronic sinusitis Cough due to constant dripping of thick discharge backward into the nasopharynx Chronic headache in the periorbital area and facial pain most pronounced on awakening Nasal stuffiness Fatigue impaired mucociliary clearance and ventilation chronic hoarseness decrease in smell and taste fullness in the ears. F. Laboratory and Diagnostic findings a. acute sinusitis Sinus radiographic studies Reveals inflammation of the sinuses Computed tomography scanning of the sinuses is the most effective diagnostic tool. It is also used to rule out other local or systemic disorders, such as tumor, fistula, and allergy.

b.Chronic sinusitis Computed tomography scan of the sinuses or magnetic resonance imaging (if fungal sinusitis is suspected), are performed to rule out other local or systemic disorders, such as tumor, fistula, and allergy. Nasal endoscopy may be indicated to rule out underlying diseases such as tumors and sinus mycetomas (fungus balls). The fungus ball is usually a brown or greenish-black material with the consistency of peanut butter or cottage cheese.

G. Medical Management The goals of treatment of acute sinusitis are to treat the infection, shrink the nasal mucosa, and relieve pain. First-line antibiotics include amoxicillin (Amoxil), trimethoprim/sulfamethoxazole (Bactrim, Septra) AMOXICILLIN (AMOXIL) Derivative of ampicillin and has similar antibacterial spectrum, namely certain gram-positive and gram-negative organisms. More effective against gram-negative organisms (eg, N meningitidis, H influenzae) than penicillin. Interferes with synthesis of cell wall mucopeptides during active multiplication resulting in bactericidal activity against susceptible bacteria NURSING CONSIDERATION Obtaine specimen culture and sensitivity test before giving the first dose Ask patient about allergic reaction to penicillin Instruct patient to take drug with or without food Side effect/Adverse effect: Diarrhea, Anaphylaxis, Nausea, vomiting Second-line antibiotics include cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), and cefprozil (Cefzil) and amoxicillin clavulanate (Augmentin). AMOXICILLIN CLAVULANATE (AUGMENTIN). Treatment of otitis media, sinusitis and infection caused by susceptible organism involving lower respiratory tract . NURSING CONSIDERATION Obtaine specimen for culture and sensitivity test before giving fisrt dose Give drug at leats 1 hour before bacteriostatic antibiotic Instruct patient to take drug with food to prevent G.I upset Side effect/Adverse effect: rash, Diarrhea

 Newer and more expensive antibiotics with a broader spectrum include macrolides, azithromycin (Zithromax), and clarithromycin (Biaxin). Quinolones such as ciprofloxacin (Cipro), levofloxacin (Levaquin) (used with severe penicillin allergy), and sparfloxacin (Zagam) have also been used. The course of treatment is usually 10 to 14 days. A recent report found little difference in clinical outcomes between first-line and second-line antibiotics; however, costs were greater when newer second-line antibiotics were used. Use of oral and topical decongestant agents may decrease mucosal swelling of nasal polyps, thereby improving drainage of the sinuses. Heated mist and saline irrigation also may be effective for opening blocked passages. Decongestant agents such as pseudoephedrine (Sudafed, Dimetapp) have proven effective because of their vasoconstrictive properties. Topical decongestant agent such as oxymetazoline (Afrin) may be used for up to 72 hours. It is important to administer them with the patients head tilted back to promote maximal dispersion of the medication. Guaifenesin (Robitussin, AntiTuss), a mucolytic agent, may also be effective in reducing nasal congestion. Antihistamines such as diphenhydramine (Benadryl), cetirizine (Zyrtec), and fexofenadine (Allegra) may be used if an allergic component is suspected. If the patient continues to have symptoms after 7 to 10 days, the sinuses may need to be irrigated and hospitalization may be required. H. Surgical Management When standard medical therapy fails, surgery, usually endoscopic, may be indicated to correct structural deformities that obstruct the ostia (openings) of the sinus. Excising and cauterizing nasal polyps, correcting a deviated septum, incising and draining the sinuses, aerating the sinuses, and removing tumors are some of the specific procedures performed. When sinusitis is caused by a fungal infection, surgery is required to excise the fungus ball and necrotic tissue and drain the sinuses. Oral and topical cortico- steroids are usually prescribed. Antimicrobial agents are administered before and after surgery. Some patients with severe chronic sinusitis obtain relief only by moving to a dry climate.
Recurrent or persistent sinusitis and presence of complications may require surgical therapy. Failure to respond to appropriate antibiotic therapy, especially in chronic and persistent sinusitis (eg, cystic fibrosis), is an indication for surgical intervention. Functional endoscopic sinus surgery (FESS) has revolutionized the treatment of sinusitis in recent years. The therapeutic benefits of FESS have helped a large number of patients with chronic sinus disease

Functional Endoscopic Sinus Surgery

Surgical care is used as an adjunct to medical treatment in some cases. Surgical care is usually reserved for cases that are refractory to medical treatment and for patients with anatomic obstruction. Recent studies suggest that preoperative CT findings prior to sinus surgery may be poor predictors of surgical outcomes.[28] The goal in surgical treatment is to reestablish sinus ventilation and to correct mucosal opposition in order to restore the mucociliary clearance system. Surgery strives to restore the functional integrity of the inflamed mucosal lining. Recent advances in endoscopic technology and a better understanding of the importance of the ostiomeatal complex in the pathophysiology of sinusitis have led to the establishment of functional endoscopic sinus surgery (FESS) as the surgical procedure of choice for the treatment of chronic sinusitis.[29] FESS facilitates the removal of disease in key areas, restores adequate aeration and drainage of the sinuses by establishing patency of the ostiomeatal complex, and causes less damage to normal nasal functioning. FESS is successful in restoring sinus health, with complete or at least moderate relief of symptoms in 80-90% of patients. Supportive medical treatment is instituted preoperatively and postoperatively. In children, surgical management is not as well established and should be reserved for complicated cases. Occupational exposure may affect FESS outcomes. Symptoms may persist with workrelated exposure to inhaled agents, and revision surgery may be required. [30] For more information, see the Medscape Reference article Functional Endoscopic Sinus Surgery.

I. Nursing Management 1. The nurse instructs the patient about methods to promote drainage such as inhaling steam (steam bath, hot shower, and facial sauna), increasing fluid intake, and applying local heat (hot wet packs). 2. The nurse also informs the patient about the side effects of nasal sprays and about rebound congestion. a. In the case of rebound congestion, the bodys receptors,which have become dependent on the decongestant sprays to keep the nasal passages open, close and congestion results after the spray is discontinued. 3. The nurse stresses the importance of following the recommended antibiotic regimen, because a consistent blood level of the medication is critical to treat the infection. 4. The nurse teaches the patient the early signs of a sinus infection and recommends preventive measures such as :

a. following healthy practices and avoiding contact with people who have upper respiratory infections 5. The nurse should explain to the patient that fever, severe headache, and nuchal rigidity are signs of potential complications. If fever persists despite antibiotic therapy, the patient should seek additional care.

J. Nursing Diagnosis 1. Ineffective Airway Clearance related to increased secretions. 2. Imbalanced Nutrition: Less than Body Requirements related to decreased appetite secondary to sinus inflammation. 3. Disturbed Sleep Pattern related to clogged nose, nasal inflammation secondary pain. 4. Anxiety related to lack of client knowledge about diseases and medical procedures 5. Risk for infection related to presence of infectious organisms as evidenced by fever or presence of virus or bacteria on laboratory screening K. Nursing Care Plan

L. Citation / References

http://emedicine.medscape.com/article/232670-medication#3 http://emedicine.medscape.com/article/232791-treatment#aw2aab6b6b5

Lippincott's Review Series Medical-Surgical Nursing, 4th Edition Brunner and Suddarth's Textbook of Medical-Surgical Nursing, 11th Edition 2009 Lippincott's Nursing Drug Guide