Sinusitis

Introduction

Sinusitis is a common problem caused by acute or chronic inflammation of the paranasal sinuses. The paranasal sinuses are aerated cavities in the bones of the face that develop from the nasal cavity and maintain communication with it. The main sinuses are the maxillary, the frontal, the ethmoid, and the sphenoid sinuses. Maxillary sinusitis is the most common type of sinusitis. The ethmoid, frontal and sphenoid sinuses are affected less frequently.





Cause and Pathogenesis

Sinusitis is caused by a variety of bacteria such as streptococci, staphylococci, pneumococci and Haemophilus influenzae viruses such as the influenza and the parainfluenza virus and less commonly by fungi such as aspergillus. Sinusitis often begins after an acute respiratory infection, which very often could be viral. Less commonly it may occur after a tooth extraction or other dental procedures, or after diving or swimming in contaminated water. Sometimes sudden changes in the climate, especially the sudden movement into cold climes, can also trigger an attack. Patients with AIDS, and other immunocompromized patients are more prone to attacks of fungal sinusitis. An attack begins with the inflammation of the nasal mucous membrane. This causes an obstruction of the opening of the sinus leading eventually to secretions accumulating in the sinus with associated pain and swelling. The secretions get infected exacerbating the situation.





Symptoms and Signs

Patients with sinusitis usually present with malaise, mild fever and headache, and nasal discharge. The area of the face over the inflamed sinus may even appear swollen in some cases. Maxillary sinusitis may cause pain in the maxillary area of the face, toothache, and frontal headache. Frontal sinusitis causes frontal pain and headache. Ethmoid sinusitis causes pain behind the eyes and frontal headache. Sphenoid sinusitis causes pain in the occipital region. The risks of sinusitis is that it can become chronic or lead to complications such as orbital cellulitis, meningitis and brain abscess, which can even be fatal.





Investigations and Diagnosis


An X-ray of the para nasal sinuses is often the first test done. Haziness or opacities in the region of the infected sinus is often seen. Sometimes a CT Scan may be required for confirmation. The discharge from the sinus is sent for culture and the organism isolated, and appropriate antibiotics may be given. Sometimes transillumination of the involved sinus may be helpful. The affected sinus produces a dark shadow as opposed to a normal sinus, which produces a light shadow. Tests to check for the presence of infection and ESR may be done to gather supportive evidence. Fungal scrapings and smears may be taken from the discharge and fungal cultures have to be done if a fungal aetiology is suspected.





Treatment and Prognosis


The treatment may be either medical or surgical. The initial treatment involves administration of appropriate antibiotics along with an analgesic and an anti-histaminic. Steam inhalation and nasal spray could also provide relief and may be used to relieve the congestion. Avoiding nasal irritants and allergens may help. Irrigation and drainage of the affected sinus is sometimes done.
Surgical treatment involves puncturing the sinus and making a window in it to facilitate easy drainage. Other procedures include the Caldwell-Luc procedure for chronic maxillary sinusitis and ethmoidectomy for ethmoid or sphenoid sinusitis. The prognosis is often quite good and depends upon the sinuses involved and the duration of the infection. Most patients who have acute sinusitis of a short duration generally recover with appropriate early therapy. However chronic sinusitis can be quite a problem and even after drainage patients may be symptomatic. Some patients may require radical surgical techniques for cure.

Prevention


While there are no vaccines to prevent sinusitis and it is impossible to predict who will develop it except in a small number of patients who have an anatomic defect in their nose, early diagnosis and treatment is the only practical solution.