SINUSITIS

Ahmad melhem, ahmad smadi

Anatomy
Paranasal Sinuses

 Lateral View of Sinuses

What are the sinuses?

The sinuses are hollow air-filled sacs lined by mucous membrane. Each sinus has an opening into the nose for the free exchange of air and mucus, and each is joined with the nasal passages by a continuous mucous membrane lining. The ethmoid and maxillary sinuses are present at birth. The frontal sinus develops during the 2nd year and the sphenoid sinus develops during the 3rd year.

 Four pairs of paranasal sinuses

Frontal-above eyes in forehead bone Maxillary-in cheekbones, under eyes Ethmoid-between eyes and nose Sphenoid-in center of skull, behind nose and eyes

 Sinuses have small orifices (ostia) which open into recesses (meati) of the nasal cavities. Meati are covered by turbinates (conchae). Turbinates consist of bony shelves surrounded by erectile soft tissue. There are 3 turbinates and 3 meati in each nasal cavity (superior, middle, and inferior).

Considerations for Pediatrics

At birth, the ethmoid, sphenoid and maxillary sinuses are tiny and cause problems in infants and toddlers. Frontal sinuses develop between 4-7 years of age, causing problems in school aged children and adolescents.

Sinusitis
Inflammation of paranasal sinuses

What is sinusitis?
An inflammatory process or infection involving one or more of the paranasal sinuses. A complication of 5%-10% of URIs in children. Maxillary and ethmoid sinuses are most frequently involved.

pathophysiology
1-sinuses are normally sterile, but their proximity to nasopharyngeal flora allows bacterial and viral inoculation following rhinitis. 2-Diseases that obstruct drainage can result in a reduced ability of the paranasal sinuses to function normally. The sinus ostia become occluded, leading to mucosal congestion. 3-The mucociliary transport system becomes impaired, leading to stagnation of secretions and epithelial damage, followed by decreased oxygen tension and subsequent bacterial growth.

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Anything that causes a swelling in the nosean infection, an allergic reaction, or an inflammatory reaction to a chemical to which you may get exposed--can affect your sinuses/ also abrupt pressure changes (air planes, diving) or dental extractions or infections. This result in a-Inflammation and edema of mucous membranes lining the sinuses cause obstruction. b-This provides for an opportunistic bacterial invasion. C-Postnasal drainage causes obstruction of nasal passages and an inflamed throat. D-If the sinus orifices are blocked by swollen mucosal lining, the pus cannot enter the nose and builds up pressure inside the sinus cavities.

E-Air trapped within a blocked sinus, along with pus or other secretions may cause pressure on the sinus wall that can cause the intense pain of a sinus attack. Similarly, when air is prevented from entering a paranasal sinus by a swollen membrane at the opening, a vacuum can be created that also causes pain

classification
Acute, which last up to 4 weeks Subacute, which last 4 to 12 weeks Chronic, which last more than 12 weeks and can continue for months or even years Recurrent, with several acute attacks within a year

Predisposing Factors
Allergies, nasal deformities, cystic fibrosis, nasal polyps, and HIV infection. Cold weather High pollen counts Day care attendance Smoking in the home Reinfection from siblings

1- ACUTE SINUSITIS
A- Most cases of acute sinusitis start with a common cold (acute rhinitis), which is caused by a virus. Colds can inflame your sinuses (damage to cells) and cause symptoms of sinusitis. Both the cold and the sinus inflammation usually go away without treatment within 2 weeks. However, In about 0.5-2% of cases, viral sinusitis can progress to acute bacterial sinusitis The most common culprits in acute viral rhinosinusitis are rhinovirus, influenza virus, and parainfluenza virus. The inflammation caused by the cold results in swelling of the mucous membranes (linings) of your sinuses, trapping air and mucus behind the narrowed sinus openings. When mucus stays inside your sinuses and is unable to drain into your nose, it can become the source of nutrients for bacteria, which then can multiply.

Most healthy people harbor bacteria, such as Streptococcus pneumoniae and Haemophilus influenzae, in their noses and throats. Usually, these bacteria cause no problems. But when sniff or blow your nose when you have a cold, these actions create pressure changes that can send typically harmless bacteria inside the sinuses. If your sinuses then stop draining properly, bacteria can begin to multiply in your sinuses, causing acute sinusitis.

B- People who have allergies or other chronic problems that affect the nose are also prone to episodes of acute sinusitis. Chronic nasal problems cause the nasal membranes to swell and the sinus passages to become blocked. The normally harmless bacteria in your nose and throat again lead to acute sinusitis. C- In general, people who have reduced immune function, such as those with primary immune deficiencys or HIV infection, or abnormalities in mucus secretion or mucus movement, such as those with cystic fibrosis, are more likely to suffer from sinusitis D- mechanical obstruction as seen secondary to foreign bodies, intranasal cocaine use E- Fungal infections very rarely cause acute sinusitis because the human body has a natural resistance to fungi. However, in people whose immune systems are not functioning properly, fungi can cause acute sinusitis.

BACTERIAL SINUSITIS
70% of bacterial sinusitis is caused by: Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Other causative organisms are: Staphylococcus aureus Streptococcus pyogenes, Gram-negative bacilli Respiratory viruses

Signs
Sinusitis has 4 main signs -Mucopurulent rhinorrhea -Nasal congestion -Facial pain, pressure, or fullness -Decreased sense of smell

Subjective Symptoms of Sinusitis

History of URI or allergic rhinitis History of pressure change Pressure, pain, or tenderness over sinuses Increased pain in the morning, subsiding in the afternoon Malaise Low-grade temperature Persistent nasal discharge, often purulent Postnasal drip : thick nasal secretions that are yellow, green, or blood-tinged drain in the back of the throat and are difficult to clear Cough, worsens at night Mouthing breathing, snoring History of previous episodes of sinusitis Sore throat, bad breath Headache

Signs and symptoms of acute sinusitis Ethmoid sinusitis (behind the eyes)
Nasal congestion with discharge or postnasal drip (mucus drips down the throat behind the nose) loss of smell, and tenderness when you touch the sides of your nose

Pain or pressure around the inner corner of the eye or down one side of the nose
Headache in the temple or surrounding the eye Pain or pressure symptoms worse when coughing, straining, or lying on the back and better when the head is upright

Maxillary sinusitis (behind the cheek bones)

Pain across the cheekbone, under or around the eye, or around the upper teeth Pain or pressure on one side or both Tender, red, or swollen cheekbone Pain and pressure symptoms worse with the head upright and better by reclining Nasal discharge or postnasal drip Fever common

 Frontal sinusitis (behind forehead, one or both sides)

Severe headaches in the forehead Fever common Pain worse when reclining and better with the head upright Nasal discharge or postnasal drip

 Sphenoid sinusitis (behind the eyes)

Deep headache with pain behind and on top of the head, across the forehead, and behind the eye Fever common Pain worse when lying on the back or bending forward Double vision or vision disturbances if pressure extends into the brain Nasal discharge or postnasal drip

2- CHRONIC SINUSITIS
A-In chronic sinusitis, the membranes of both the paranasal sinuses and the nose are thickened because they are constantly inflamed. Most experts now use the term chronic rhinosinusitis to describe this condition. B-nasal polyps. (Polyps are grape-size growths of the sinus membranes that protrude into the sinuses or into the nasal passages,more commonly seen in patients with aspirin sensitivity and asthma , results from a localized allergic hyperresponsivity to bacterial endotoxins Polyps make it even more difficult for the sinuses to drain and for air to pass through the nose

D- An allergic reaction to certain fungi may be responsible for some cases of chronic rhinosinusitis; this condition is called allergic fungal sinusitis. However, at least half of all people with chronic rhinosinusitis do not have allergies/ or exaggerated immune response to fungi E- Acute bacterial sinusitis that does not completely resolve can progress to chronic sinusitis, the infecting organisms vary, and a higher incidence of anaerobic organisms is seen (eg, Bacteroides, Peptostreptococcus, and Fusobacterium species

G-As with acute sinusitis, other causes of chronic rhinosinusitis may be an immune deficiency disorder E-Another group of people who may develop chronic rhinosinusitis are those with significant variations in the anatomical structure inside the nose that lead to blockage of mucus (septal deviation). F-Diseases such as cystic fibrosis, primary ciliary dyskinesia, Wegener granulomatosis, ChurgStrauss vasculitis, and sarcoidosis have also been known to be affiliated with chronic rhinosinusitis

Signs and symptoms of chronic sinusitis Ethmoid sinusitis

- Chronic nasal discharge, obstruction, and low-grade discomfort across the bridge of the nose - Pain worse in the late morning or when wearing glasses
- Chronic sore throat and bad breath - Usually recurs in other sinuses

 Maxillary sinusitis

- Discomfort or pressure below the eye

- Chronic toothache - Pain possibly worse with colds, flu, or allergies

- Increased discomfort throughout the day with increased cough at night

 Frontal sinusitis

- Persistent, low-grade headache in the forehead

- History of trauma or damage to the sinus area Sphenoid sinusitis

- Low-grade general headache common

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However, most people with sinusitis have pain or tenderness in several locations, and their symptoms usually do not clearly point out which sinuses are inflamed. Pain is not as common in chronic rhinosinusitis as it is in acute sinusitis. Also, acute and chronic rhinosinusitis are strongly associated with a stuffy nose, as well as with a general feeling of fullness over the entire face.

DIAGNOSIS
1- physical exams, signs and symptoms 2- imaging study (x-ray,CT, MRI, ULTRASOUND) 3- laboratory tests 4-ENT can directly visualize the nasal passages and the OMC (passage into the sinuses) with a nasopharyngoscope. This is a fiberoptic, flexible tube that is insertable through the nose and enables the doctor to view the passageways and see if the OMC is open and draining right. Anatomical causes of breathing difficulties may also be found, such as a deviated nasal septum, nasal polyps, and enlarged adenoids and tonsils 5- drain the affected sinus to test for organisms ( culture)

History, physical
Sinusitis usually a clinical diagnosis Because your nose can get stuffy when you have a condition like the common cold, you may confuse simple nasal congestion with sinusitis. A cold, however,usually lasts about 7 to 14 days and goes away without treatment. Acute sinusitis often lasts longer and typically causes more symptoms than a cold

Imaging study ( X-ray)

In the past, doctors relied on x-ray films for diagnosis because the symptoms of acute sinusitis are very similar to those of an acute upper respiratory tract infection. In fact, most of the time, a viral infection is required to promote sinusitis. However, these films are not specific and depend on a good technique by the technician. According to one study, sinusitis is not visible on x-ray films about 55% of the time. If symptoms continue beyond 7-10 days and are associated with a simple cold, a diagnosis of sinusitis may be possible.

Imaging study ( CT, MRI, ultrasound A) CT scan may indicate a sinus infection if any of these
conditions is present: 1-Air-fluid levels in 1 or more sinuses 2-Total blockage in 1 or more sinuses

3-Thickening of the inner lining (mucosa) of the sinuses

Mucosal thickening can occur in people without symptoms of sinusitis. Therefore, CT scan findings must be correlated with a person's symptoms and physical examination findings to diagnose a sinus infection.

Laboratory tests
Laboratory tests your healthcare provider may use to assess possible causes of chronic sinusitis include 1- Blood tests to rule out conditions associated with sinusitis, like an immune deficiency disorder 2- A sweat test or a blood test to rule out cystic fibrosis 3- Tests on the material that is inside your sinuses to look for bacterial or fungal infection 4- Biopsy (taking a small sample) of the membranes (linings) of the nose or sinuses to find out the health of the cells lining these cavities