Acute Sinusitis

Acute Sinusitis

Introduction:

Acute inflammation of sinus mucosa is known as acute sinusitis. It is defined as any infection that persists for 3 weeks or less. Commonly involved sinus by acute sinus infections include the maxillary sinus, followed by ethmoid, frontal and sphenoid.

Incidence is roughly in this order.  Often more than one sinus could be involved.
If all the sinuses are involved then it is known as Pansinusitis.

If the secretions from the sinus cavity drains then it is open type of sinusitis.

If infected secretions don't drain from the sinuses due to the presence of ostial

block is known as closed type of sinusitis. Closed type of sinusitis is known to create more complications. It is also more symptomatic when compared with that of open type.

Aetiology:

1. Infections involving nasal mucosa. The nasal mucosa is continuous with that of sinus mucosa and hence any pathology involving nasal mucosa is also bound to affect the sinus mucosa. Infections involving nasal mucosa could involve sinus mucosa by spread via submucosal lymphatics. Initially viral rhinitis is followed by bacterial rhinitis.

2. Swimming & diving could cause rhinitis and sinusitis because infection could enter the nasal cavity and sinuses through sinus ostia. High content of chlorine in swimming pool water could irritate nasal sinus mucosa predisposing to chemical inflammation which could lead to secondary bacterial colonization.

3. Trauma - Compound fractures / penetrating injuries of sinuses may cause direct infection of sinus mucosa. Barotrauma can also be followed by acute sinusitis

Predisposing factors for acute sinusitis:

Local causes:

1. Obstruction to sinus ventilation and drainage:

Normal sinuses are well ventilated. Normal sinus mucosa is known to secrete small amounts of mucous, which could be pushed out by the ciliary movement of the sinus mucous membrane. These secretions are pushed / propelled into the nasal cavity.

Factors that interferes with these functions are known to cause stasis of secretions

within the sinus cavity predisposing to infection. Causes include:

Nasal packing

Deviated nasal septum

Hypertrophic turbinates

Oedema involving the sinus ostia due to allergy / vasomotor rhinitis

Nasal polypi

Structural abnormality of ethmoid air cells

Benign / malignant neoplasm

2. Stasis of secretions in the nasal cavity:

Secretions of the nose may not drain into the nasopharynx because of the viscosity of the secretions (as in the case of cystic fibrosis) or obstruction (enlarged adenoids, choanal atresia) and gets infected.

3. Previous attacks of sinusitis:

Repeated attacks of infections in the sinus mucosa can be detrimental to the local defences of the sinus mucosa predisposing to repeated infections.

General causes:

1. Environmental causes:

Sinus infection is common in cold and wet climates. Atmospheric pollution, smoke, dust and overcrowding also predisposes to sinus infection.

2. Poor general health of the patient:

Recent attack of exanthematous fever (measles, chicken pox, whooping cough), nutritional deficiency, and systemic disorders like diabetes and immunodeficieny syndrome may predispose to sinus infection.

Organisms involved:

Majority of cases of acute sinusitis begin as viral infection and then it is followed by bacterial infection later. Bacteria often responsible for acute sinusitis include:

Hemophilus influenza

Moraxella catarrhalis

Streptococcus pyogenes

Streptococcus aureus

Klebsiella pneumonae

Anaerobic infections and mixed infections are seen in sinusitis of dental origin.

Pathology:

Acute inflammation of sinus mucosa causes:

Hyperemia

Exudation of fluid

Outpouring of polymorphs

Increased activity of serous and mucinous glands

Infection of the sinus mucosa proceeds depending on the virulance of the infecting organism, resistance of the host and the capability of the sinus mucosa to push out the exudates. Initially the exudate could be serous, later it could become mucopurulent and purulent. Severe infections could cause destruction of nasal mucosa. Failure of natural ostium of the sinus to drain results in empyema of the sinus cavity. This could lead to destruction of bony walls of the sinus leading on to complications.

Fulminating infections of sinus mucosa could be caused by dental infections.

Acute maxillary sinusitis:

This indicates infections and inflammation involving the mucosal lining of the maxillary sinus mucosa of 3 weeks or less in duration.

Aetiology:

1. Commonly viral rhinitis spreads to involve maxillary sinus mucosa. This is usually followed by secondary bacterial infection

2. Diving / swimming in contaminated water

3. Dental infections are important source of maxillary sinuses. Roots of premolar and molar are related to the floor of the sinus and could well be separated by a thin plate of bone or just a mucosal lining only. Periapical dental abscess could burst into the maxillary sinus causing infected material to spill into the maxillary sinus. Oroantral fistula can form following dental extraction which could result in bacterial contamination of maxillary sinus from the oral cavity.

4. Sinus mucosal trauma as a result of compound fractures / penetrating injuries

Clinical features:

This depends on the severity of the inflammatory process, efficiency of ostium in draining secretions. Closed ostium sinusitis commonly leads to complications.

Constitutional symptoms:

Fever

Malaise

Body ache

Constitutional symptoms are usually due to toxemia.

Head ache:

This is confined to the forehead and could well be confused with that of frontal sinusitis. Frontal sinusitis pain is usually worse early in the morning when the sinus is filled with inflammatory exudate. Headache gets relieved as the day progresses as the collections from the maxillary sinus drains assisted by gravity.

Pain:

This is situated over the upper jaw. It can also be referred to gums / teeth. Patient with maxillary sinusitis usually goes to a dentist as it commonly presents as dental pain.

Tenderness:

Digital pressure over the anterior wall of frontal sinus indicates maxillary sinusitis.

Redness / oedema over cheek:

This is commonly seen in children. It is associated with lower eyelid oedema.

Nasal discharge:

Anterior rhinoscopy / nasal endoscopy would reveal purulent / mucoid discharge from middle meatus. Mucosa of the middle meatus and turbinate could appear reddish and swollen.

Post nasal discharge:

Purulent / mucopurulent discharge could be seen in the post nasal space.

Diagnosis:

Transillumination:

Affected sinus would remain opaque on transillumination.

X-ray paranasal sinuses water's view / CT paranasal sinuses both axial and coronal sections could reveal sinus opacification in these patients.

Treatment:

Medical:

Antibiotics:

Ampicillin

Amoxycillin

Erythromycin

All these drugs are useful.

Nasal decongestant drops:

This will open up the maxillary sinus ostium by decongesting the nasal mucosa. Common topical decongestants used include:

Oxymetazoline

Xylometazoline

Steam inhalation:

Steam inhalation provides moisturizing effect to the nasal mucosa thereby attempting to restore the ciliary function.

Analgesics:

Paracetomol is ideal to alleviate sinusitis induced headache.

Surgery:

Antral puncture and lavage

Functional endoscopic sinus surgery

Complications of maxillary sinusitis include:

Chronic maxillary sinusitis

Frontal sinusitis

Osteitis of maxilla

Orbital cellulitis / abscess

Acute frontal sinusitis:

This is defined as inflammation of mucosal lining of frontal sinus of less than 3 weeks duration.

Aetiology:

1. This commonly follows viral infections of upper respiratory tract. This is followed later by bacterial invasion.

2. Entry of water into sinus during diving or swimming

3. External trauma to sinus due to fractures involving paranasal sinuses

4. Oedema of middle meatus. This could cause secondary infection in maxillary, ethmoidal and frontal sinuses

Clinical features:

Frontal headache:

This is usually severe and localized over the affected sinus. It is classic in one way. Frontal sinusitis cause headache which is worse on getting up early in the morning. It reduces gradually as the day progresses. This is due to the fact that gravity enables drainage of the frontal sinus. Headache is classically present during office hours and hence is also known as office headache.

Tenderness:

Application of digital pressure over the floor of frontal sinus just above the medial canthus causes pain. This feature is due to the inflammation of mucosal lining of frontal sinus.

Upper eyelid oedema:

These patients have swelling of upper eyelid with suffused conjunctiva.

Nasal discharge:

Streak of mucopus is seen high in the middle meatus. Nasal mucosa is oedematous over the middle meatus.

Management:

Medical:

Same as that of maxillary sinusitis

Surgery:

1. Frontal sinus trephination

2. FESS

Complications:

1. Orbital cellulitis

2. Osteomyelitis of frontal bone / fistula formation

3. Meningitis / extradural abscess / frontal lobe abscess

4. Chronic frontal sinusitis

Acute ethmoidal sinusitis:

This is considered as acute inflammation of mucosal lining of ethmoidal sinuses.

The duration is less than 3 weeks.  Ethmoidal sinusitis is also commonly associated

with inflammation of other sinuses also. This is common in infants and young children.

Clinical features:

1. Pain - This is localized over the bridge of the nose, medial and deep to the eye.

Pain is usually aggravated by eyeball movements

2. Eyelid oedema - Both eyelids become puffy and swollen. There is also associated increased lacrimation. Orbital cellulitis could also be seen.

3. Nasal discharge - Anterior rhinoscopy would reveal discharge from middle / superior meatus

4. Swelling of middle turbinate

Management:

Medical:

Same as that of maxillary sinusitis.

Visual deterioration / exophthalmos is an indication for surgery.

Surgery:

Ethmoidectomy

FESS

Complications:

1. Orbital cellulitis / abscess

2. Visual deterioration and blindness due to optic nerve involvement

3. Cavernous sinus thrombosis

4. Extradural abscess, meningitis, or brain abscess

Acute sphenoid sinusitis:

Isolated involvement of sphenoid sinus is rather rare. It could also be a part of pansinusitis. It is also associated with involvement of posterior ethmoidal sinuses.

Clinical features:

1. Headache - Localized to the occiput / vertex. Pain may also be referred to the mastoid region.

2. Post nasal discharge - Can be identified on asking the patient to open the mouth.

CT scan of paranasal sinuses is diagnostic

Management:

Medical management is similar to that of other sinus infections