Sinusitis - The NocturnalSaint

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Friday, March 25, 2011

Sinusitis

Sinusitis is inflammation of the paranasal sinuses, which may be due to infection, allergy or autoimmune issues. Most cases are due to a viral infection and resolve over the course of 10 days. It is a common condition with more than 24 million cases occurring in the United States annually

Classification

By duration

Sinusitis can be acute (going on less than four weeks), subacute (4–8 weeks) or chronic (going on for 8 weeks or more).[2] All three types of sinusitis have similar symptoms, and are thus often difficult to distinguish. Acute sinusitis is very common. Roughly ninety percent of adults have had sinusitis at some point in their life

Acute

Acute sinusitis is usually precipitated by an earlier upper respiratory tract infection, generally of viral origin. If the infection is of bacterial origin, the most common three causative agents are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Until recently, Haemophilus influenzae was the most common bacterial agent to cause sinus infections. However, introduction of the H. influenza type B (Hib) vaccine has dramatically decreased H. influenza type B infections and now non-typable H. influenza (NTHI) are predominantly seen in clinics. Other sinusitis-causing bacterial pathogens include Staphylococcus aureus and other streptococci species, anaerobic bacteria and, less commonly, gram negative bacteria. Viral sinusitis typically lasts for 7 to 10 days, whereas bacterial sinusitis is more persistent. Approximately 0.5% to 2% of viral sinusitis results in subsequent bacterial sinusitis. It is thought that nasal irritation from nose blowing leads to the secondary bacterial infection.

Acute episodes of sinusitis can also result from fungal invasion. These infections are typically seen in patients with diabetes or other immune deficiencies (such as AIDS or transplant patients on immunosuppressive anti-rejection medications) and can be life threatening. With type I diabetes, ketoacidosis causes sinusitis by Mucormycosis.

Chemical irritation can also trigger sinusitis, commonly from cigarette smoke and chlorine fumes. Rarely, it may be caused by a tooth infection.

Chronic

Chronic sinusitis, by definition, lasts longer than three months and can be caused by many different diseases that share chronic inflammation of the sinuses as a common symptom. Symptoms of chronic sinusitis may include any combination of the following: nasal congestion, facial pain, headache, night-time coughing, an increase in previously minor or controlled asthma symptoms, general malaise, thick green or yellow discharge, feeling of facial ‘fullness’ or ‘tightness’ that may worsen when bending over, dizziness, aching teeth, and/or halitosis.[citation needed] Each of these symptoms has multiple other possible causes, which should be considered and investigated as well. Unless complications occur, fever is not a feature of chronic sinusitis.[citation needed] Often chronic sinusitis can lead to anosmia, a reduced sense of smell.[citation needed] In a small number of cases, acute or chronic maxillary sinusitis is associated with a dental infection. Vertigo, lightheadedness, and blurred vision are not typical in chronic sinusitis and other causes should be investigated.
Chronic sinusitis cases are subdivided into cases with polyps and cases without polyps. When polyps are present, the condition is called chronic hyperplastic sinusitis; however, the causes are poorly understood and may include allergy, environmental factors such as dust or pollution, bacterial infection, or fungus (either allergic, infective, or reactive). Non-allergic factors, such as vasomotor rhinitis, can also cause chronic sinus problems. Abnormally narrow sinus passages, such as having a deviated septum, can impede drainage from the sinus cavities and be a contributing factor. A combination of anaerobic and aerobic bacteria,[7][8] are detected in conjunction with chronic sinusitis, Staphylococcus aureus (including methicilin resistant S.aureus ) and coagulase-negative Staphylococci. Typically antibiotic treatment provides only a temporary reduction in inflammation, although hyperresponsiveness of the immune system to bacteria has been proposed as a possible cause of sinusitis with polyps (chronic hyperplastic sinusitis).
Attempts have been made to provide a more consistent nomenclature for subtypes of chronic sinusitis. The presence of
eosinophils in the mucous lining of the nose and paranasal sinuses has been demonstrated for many patients, and this has been termed Eosinophilic Mucin RhinoSinusitis (EMRS). Cases of EMRS may be related to an allergic response, but allergy is not often documented, resulting in further subcategorization into allergic and non-allergic EMRS.
A more recent, and still debated, development in chronic sinusitis is the role that fungus plays in this disease. 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 remain symptom free. Trials of antifungal treatments have had mixed results.

By location

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

Recent theories of 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.

Signs and symptoms

Headache

Headache/facial pain or pressure of a dull, constant, or aching sort over the affected sinuses is common with both acute and chronic stages of sinusitis. This pain is typically localized to the involved sinus and may worsen when the affected person bends over or when lying down. Pain often starts on one side of the head and progresses to both sides.

Acute and chronic sinusitis may be accompanied by thick nasal discharge that is usually green in colour and may contain pus (purulent) and/or blood.Often a localized headache or toothache is present, and it is these symptoms that distinguish a sinus-related headache from other types of headaches, such as tension and migraine headaches. Infection of the eye socket is possible, which may result in the loss of sight and is accompanied by fever and severe illness. Another possible complication is the infection of the bones (osteomyelitis) of the forehead and other facial bones – Pott’s puffy tumor.

Sinus infections can also cause inner ear problems due to the congestion of the nasal passages. This can be demonstrated by dizziness, “a pressurized or heavy head”, or vibrating sensations in the head.

Recent studies suggest that up to 90% of “sinus headaches” are actually migraines.The confusion occurs in part because migraine involves activation of the trigeminal nerves, which innervate both the sinus region and the meninges surrounding the brain. As a result, it is difficult to accurately determine the site from which the pain originates. Additionally, nasal congestion can be a common result of migraine headaches, due to the autonomic nerve stimulation that can also cause in tearing (lacrimation) and a runny nose (rhinorrhea). A study found that patients with “sinus headaches” responded to triptan migraine medications, but stated dissatisfaction with their treatment when they are treated with decongestants or antibiotics.

Complications

The close proximity of the brain to the sinuses makes the most dangerous complication of sinusitis, particularly involving the frontal and sphenoid sinuses, infection of the brain by the invasion of anaerobic bacteria through the bones or blood vessels. Abscesses, meningitis, and other life-threatening conditions may result. In extreme cases the patient may experience mild personality changes, headache, altered consciousness, visual problems, and, finally, seizures, coma, and possibly death.

Causes

Factors which may predispose someone to developing sinusitis include: allergies; structural abnormalities, such as a deviated septum, small sinus ostia or a concha bullosa; nasal polyps; carrying the cystic fibrosis gene, though research is still tentative; and prior bouts of sinusitis, because each instance may result in increased inflammation of the nasal or sinus mucosa and potentially further narrow the nasal passageways.
Second hand smoke may also be associated with chronic rhinosinusitis.
Another cause of chronic sinusitus can be from the maxillary sinuses that are situated within the cheekbones. Infections and inflammation are more common here than in any of the other paranasal sinuses. This is because the drainage of mucous secretions from the maxillary sinus to the nasal cavity is not very efficient.
Maxillary sinusitis may also be of dental origin and constitutes a significant percentage, given the intimacy of the relationship between the teeth and the sinus floor. Complementary tests based on conventional radiology techniques and modern are needed. Their indication is based on the clinical context.
Chronic sinusitis can also be caused indirectly through a common but slight abnormality within the auditory or Eustachian tube, which is connected to the sinus cavities and the throat. This tube is usually almost level with the eye sockets but when this sometimes hereditary abnormality is present, it is below this level and sometimes level with vestibule or nasal entrance. This almost always causes some sort of blockage within the sinus cavities ending in infection and usually resulting in chronic sinusitis.

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