SINUSITIS

Sinusitis refers to an inflammatory condition involving the four paired structures surrounding the nasal cavities. Although most cases of sinusitis involve more than one sinus, the maxillary sinus is most commonly involved; Each sinus is lined with a respiratory epithelium that produces mucus, which is transported out by ciliary action through the sinus ostium and into the nasal cavity. Normally, mucus does not accumulate in the sinuses, which remain sterile despite their adjacency to the bacterium-filled nasal passages. When the sinus ostia are obstructed, however, or when ciliary clearance is impaired or absent, the secretions can be retained, producing the typical signs and symptoms of sinusitis.


Acute Sinusitis

Acute sinusitis—defined as sinusitis of <4 weeks' duration—constitutes the vast majority of sinusitis cases. Most cases are diagnosed in the ambulatory care setting and occur primarily as a consequence of a preceding viral URI. Differentiating acute bacterial and viral sinusitis on clinical grounds is difficult. Therefore, it is perhaps unsurprising that antibiotics are prescribed frequently (in 85–98% of all cases) for this condition. Etiology A number of infectious and noninfectious factors can contribute to acute obstruction.non infectious factors include allergic rhinitis,barotrauma or chemical irrtants.Illnesses such as nasal and sinus tumors (e.g., squamous cell carcinoma) or granulomatous diseases (e.g., Wegener's granulomatosis or rhinoscleroma) can also produce obstruction of the sinus ostia, while conditions leading to altered mucus content (e.g., cystic fibrosis) can cause sinusitis through impaired mucus clearance. viral sinusitis is far more common than bacterial.A number of bacteria may also cause sinusitis. the viruses most commonly isolated—both alone and with bacteria—have been rhinovirus, parainfluenza virus, and influenza virus Clinical Manifestations most of the sinusitis patients presents with symptoms of upper respiratory tract infections. Common presenting symptoms of sinusitis include nasal drainage and congestion, facial pain or pressure, and headache. Thick, purulent or discolored nasal discharge is often thought to indicate bacterial sinusitis but also occurs early in viral infections such as the common cold and is not specific to bacterial infection. Other nonspecific manifestations include cough, sneezing, and fever. Tooth pain, most often involving the upper molars, is associated with bacterial sinusitis, as is halitosis. In acute sinusitis, sinus pain or pressure often localizes to the involved sinus (particularly the maxillary sinus) and can be worse when the patient bends over or is supine Table 31-1 Guidelines for the Diagnosis and Treatment of Acute Sinusitis Age Group Diagnostic Criteria Treatment Recommendationsa Adults Moderate symptoms (e.g., nasal purulence/ congestion or cough) for >7 d or Initial therapy
Severe symptoms of any duration, including unilateral/focal facial swelling or tooth pain Amoxicillin, 500 mg PO tid or 875 mg PO bid, or
TMP-SMX, 1 DS tablet PO bid for 10–14 d
Exposure to antibiotics within 30 d or >30% prevalence of penicillin-resistant S. pneumoniae
Amoxicillin, 1000 mg PO tid, or
Amoxicillin/clavulanate (extended release), 2000 mg PO bid, or
Antipneumococcal fluoroquinolone (e.g., levofloxacin, 500 mg PO qd)
Recent treatment failure
Amoxicillin/clavulanate (extended release), 2000 mg PO bid, or
Amoxicillin, 1500 mg bid, plus clindamycin, 300 mg PO qid, or
Antipneumococcal fluoroquinolone (e.g., levofloxacin, 500 mg PO qd)
Children Moderate symptoms (e.g., nasal purulence/congestion or cough) for >10–14 d or Initial therapy
Severe symptoms of any duration, including fever (>102°F), unilateral/focal facial swelling or pain Amoxicillin, 45–90 mg/kg qd (up to 2 g) PO in divided doses (bid or tid), or
Cefuroxime axetil, 30 mg/kg qd PO in divided doses (bid), or
Cefdinir, 14 mg/kg PO qd
Exposure to antibiotics within 30 d, recent treatment failure, or >30% prevalence of penicillin-resistant S. pneumoniae
Amoxicillin, 90 mg/kg qd (up to 2 g) PO in divided doses (bid), plus clavulanate, 6.4 mg/kg qd PO in divided doses (bid) (extra-strength suspension), or
Cefuroxime axetil, 30 mg/kg qd PO in divided doses (bid), or
Cefdinir, 14 mg/kg PO qd


CHRONIC SINUSITIS

Chronic sinusitis is characterized by symptoms of sinus inflammation lasting >12 weeks. This illness is most commonly associated with either bacteria or fungi, and clinical cure in most cases is very difficult. Many patients have undergone treatment with repeated courses of antibacterial agents and multiple sinus surgeries, increasing their risk of colonization with antibiotic-resistant pathogens and of surgical complications. Patients often suffer significant morbidity, sometimes over many years.

in chronoc sinusitis infection is thought to be due to impairment of mucociliary clearence.Chronic fungal sinusitis is a disease of immunocompetent hosts and is usually noninvasive, although slowly progressive invasive disease is sometimes seen. Noninvasive disease, which is typically associated with hyaline molds such as Aspergillus species and dematiaceous molds such as Curvularia or Bipolaris species, can present as a number of different scenarios

Chronic Sinusitis: Treatment

Treatment of chronic bacterial sinusitis can be challenging and consists primarily of repeated culture-guided courses of antibiotics, sometimes for 3–4 weeks at a time; administration of intranasal glucocorticoids; and mechanical irrigation of the sinus with sterile saline solution. When this management approach fails, sinus surgery may be indicated and sometimes provides significant, albeit short-term, alleviation. Treatment of chronic fungal sinusitis consists of surgical removal of impacted mucus. Recurrence, unfortunately, is common.