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Acute Sinusitis aetiology, symptoms, medical and surgical treatment

Definition: Acute inflammation of the mucosal lining of the paranasal sinuses lasting no longer than 4 weeks.
Acute rhinitis is a common association so it's better called (Acute rhinosinusitis, ARS).
Viral rhinosinusitis (VRS): ARS of less than 10 days duration.
Acute bacterial rhinosinusitis (ABRS): ARS of more than 10 days duration.

Etiology:

Predisposing factors:

  • Viral infections.
  • Obstructive anatomy; Deviated nasal septum, nasal polyps, allergic rhinitis or osteomas.
  • Disturbed muco-ciliary clearance; Kartagner syndrome, or cystic fibrosis -Immune deficiency (IgA deficiency).
  • Air pollution and overcrowdings.
    acute--sinusitis

Routes of spread:

Nasal:
  • Extension of upper respiratory tract infection.
  • Missed foreign body or nasal pack.
  • Nasogastric tube
Dental:
Dental caries or oro-antral fistula causes maxillary sinusitis.

External trauma:
Facial fractures and penetrating injuries.

Causative organisms:


  • Viral: Rhinovirus, corona virus, influenza and respiratory syncytial virus.
  • Bacterial "acute bacterial rhinosinusitis ABRS":
  • Streptococcus Pneumoniae, Hemophilus influenza, Staph aureus and Maroxilla catarrhalis (children).

Pathogenesis:

ARS usually starts by catarrhal followed by suppurative rhinosinusitis.

Clinical picture: 

Acute rhinosinusitis is mainly a clinical diagnosis. It is most appropriately made on the basis of the medical history, symptoms, and clinical examination.

Symptoms:

  • History of URTI is usually present.
  • Constitutional symptoms: Fever, headache, malaise.
  • Nasal obstruction (unilateral or bilateral).
  • Rhinorrhea (unilateral or bilateral).
  • Facial pain and headache.
  • Hyposmia or anosmia.
Over the affected sinus.
  • Acute maxillary sinusitis: facial pain is felt over the cheek and referred to upper teeth and ear.
  • Acute frontal sinusitis: Facial pain is felt over the forehead. It starts in the morning as the sinus fills up during sleeping and secretions are under tension. Headache gets worse by the mid-day as the air doesn’t adequately replace the coming down pus (Vacuum headache). At the end of the day headache disappears as the sinus becomes well drained and aerated.
  • Acute ethmoiditis: Facial pain is felt over the inner canthus and retro-orbital. It may be referred to the parietal region.
  • Acute sphenoidal sinusitis: Facial pain is felt retro-orbital and referred to the occiput. Increasing by leaning forward. More severe in the morning.

NB: When to suspect ABRS clinically?
  • ARS symptoms last for 10 days or get worse.
  • High grade Fever.
  • Purulent discharge.

Signs:

  • Affected sinus is tender.
  • Congestion and edema of nasal mucosa.
  • Mucopurulent or purulent nasal discharge. Its location varies according to the affected sinus;
  • Pus in the middle meatus (anterior group of sinuses).
  • Pus in the superior meatus (posterior ethmoid).
  • Pus in the spheno-ethmoidal recess (sphenoid sinus).
  • Oral examination shows post-nasal discharge.

Investigations:

Usually not needed in uncomplicated cases as it’s a clinical diagnosis.
1- Radiology: X ray sinus view: opacity or fluid level.
2- CT paranasal sinuses: investigation of choice
3- Culture & sensitivity.

Treatment of Acute Sinusitis:

Medical: 

  • Symptomatic treatment: analgesics, decongestants, antihistamines, saline nasal irrigation, mucolytic, and intranasal corticosteroids.
  • Antibiotics may be considered in patients with symptoms or signs of acute rhinosinusitis that do not improve within seven days or that worsen at any time 
  • Most guidelines recommend amoxicillin as first-line therapy. For patients allergic to penicillin, trimethoprim/sulfamethoxazole or macrolides may be used as an alternative to amoxicillin.

Surgical:

  • Indicated in resistant or complicated sinusitis.
  • The aim of surgery is to drain the sinus and to restore aeration. - Functional endoscopic sinus surgery (FESS) has largely replaced open surgical approaches and become the standard technique for treatment.
Open approaches:
  • Maxillary sinus: Antral puncture and lavage.
  • Frontal sinus: Trephine surgery through the sinus floor.
  • Ethmoids: External ethmoidectomy.
  • Sphenoid sinus: External spheno-ethmoidectomy.

Key points

ARS is an inflammation of the mucosal lining of nose and paranasal sinuses.
ARS is a clinical diagnosis.
acute-sinusitis-summary

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