Sinusitis

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What is sinusitis?

Sinusitis refers to the inflammation ("itis") of the paranasal (around the nose) sinuses (air space cavities) within our skull. They are called frontal, ethmoidal, maxillary and sphenoidal sinuses (see diagrams). Frontal sinusitis becomes clinically significant only in patients 12 years and older. The sinuses involved among those younger than 12 are usually the ethmoidal and maxillary. Sinusitis is a very common medical condition that can affect most anyone.

What are paranasal sinuses for?

Since the final word has not been said yet, the prevailing theories as to the functions of the paranasal sinuses include: (1) Lightening of the skull; (2) Vocal Resonating Box; (3) Regulation of intranasal pressure; (4) Enhancement of olfaction (sense of smell); and, (5) Airconditioning and hmidification of inhaled air (6) decontaminates mucus and inhaled air.

Why do sinuses get inflamed?

Sinusitis develops as a result of either allergy, bacterial, fungal or viral infection. Bacterial infection is the most common culprit, usually Streptococci, pneumococci, Hemophilus influenzae, or staphylococci. Acute sinusitis is commonly precipitated by an acute viral respiratory tract infection. The chronic form may be aggravated by gram-negative or anaerobic microorganisms. In a some cases, dental infection could cause chronic maxillary sinusitis. The vicious cycle (a triangle of): allergy, infection and obstruction, where one leads to the other in a chain, results in chronicity. H. Influenzae is the commonest cause of sinusitis in patients below age 10.

What are the signs and symptoms of sinusitis?

The patient usually presents with painful sinus areas (frontal: aches between or just above the eyes; maxillary: aches over the cheekbones, toothache; ethmoidal: deeper aches between the eyes; and, sphenoidal: less well localized, aches in the frontal and occipital (behind the head). Frontal headaches may accompany any of them. Congestion and malaise (not feeling well) may be present. Fever and chills, if present, may signal extension of infection beyond the sinuses. The nasal mucosa (inner lining of the nose) is red and swollen, with yellow or green mucus, or purulent (pussy) secretions, may be present.

Is X-ray of the sinuses helpful?

The swollen mucosa and retained exudates in the sinuses affected may appear opaque on X-rays, so X-rays can be of help in this regard. However, CT (Computed Tomography) Scan shows more vivid definition and extent of the inflammation. In chronic maxillary sinusitis, X-rays of the apices of the teeth are done to rule out periapical (dental) abscess.

What is the therapy for sinusitis?

The principles of treatment as outlined by our consultant, Dr. Catalino D. Chan, an EENT specialist in Cebu, include: (1) control of infection or allergy, which ever is determined as the cause; (2) control of pain; (3) relief of congestion; and, (4) improving ventilation drainage of the sinuses, where indicated.

Is steam inhalation helpful?

Steam inhalation and saline (salt water) nasal washes my promote drainage and relief of congestion. Topical vasoconstrictor (for relief of congestion), such as phenylephrine 0.25% spray used for a maximum of 7 days are effective in most cases. Systemic (oral) vasoconstrictors, such as pseudoephedrine, are said to be less effective. Both of these medications should be used only under a physician's supervision because of possible side effects on the heart, etc. The EENT specialists today have more varied options in their armamentarium to treat their patients.

How long is the antibiotic therapy?

Among those acute and chronic patients who need antibiotic treatment, the therapy is given for at least 10 to 12 days. In more resistant chronic cases, the course of antibiotic therapy is 4 to 6 weeks, which usually leads to complete resolution of the infection. The culture-sensitivity tests of the culprit microorganisms serve as a guide to subsequent choice of antibiotics. Those not responding to this therapy may require surgery (maxillary sinusotomy, ethmoidectomy, sphenoid sinusotomy) to improve ventilation, to drain out pussy secretions and remove epithelial debris (junks) and hypetrophic mucus membrane. In cases of chronic frontal sinusitis, osteoplastic obliteration of the frontal sinuses may be indicated, although some of them may improve with the endoscopic procedure mentioned below.

Can sinusitis be fatal?

In almost all cases, uncomplicated sinusitis is never fatal. However, in very rare patients with undiagnosed, or untreated, or poorly controlled diabetes mellitus, or in immunosuppressed patients (those on chemotherapy for cancer) or among those with immunedeficiency (as in AIDs victims, etc.), fulminant and even fatal fungal (caused by fungi) or bacterial sinusitis can develop. A condition called Mucormycosis, a fungal infection, may occur in uncontrolled diabetes. In the confirmed cases of this infection, Amphotericin B, given intravenously, is the treatment.

When is drainage/irrigation done?

About 90% of cases are acute sinusitis which respond very well to conservative medical treatment, which includes control of pain and congestion, and appropriate antibiotic for the infection. For the chronic cases (persistent for 2 months or longer) a procedure called Antral Irrigation is performed through the nose to irrigate the affected sinuses and drain whatever mucus is trapped in there. Some of the subacute cases (3 weeks or so in duration) may also benefit from this irrigation and drainage.

What is Caldwell-Luc procedure?

For the persistent and intractable chronic cases of maxillary sinusitis, a surgical procedure called Caldwell-Luc (also known as Radical Antrum Operation) may be done. The approach is through the area under the upper lip, above the incisor tooth of the affected sinus, and the diseased mucosa of the sinus is curreted and polyps, if present, are removed. Then, a naso-antral window (an opening) is created for ventilation and drainage by gravity. The incision and opening are all under and behind the upper lip area so they are not visible after surgery.

What is the new surgery called FES?

The newly introduced procedure is called Functional Endoscopic Sinus surgery, which is done through the nose, and which uses a fiberoptic scope. The goal of the procedure is the same as that of Caldwell-Luc. However, when polyps are present, the nasal approach of FES is very limited, and hence Caldwell-Luc is still the procedure of choice for the safe removal of the polyps, Dr. Chan pointed out.

©2003Raoul R. Diez, M.A.O.D.