Sinusitis - Airway Wellness

Sinusitis

Sinusitis is the most frequently reported disease in America - more than 35 million Americans suffer from one form of this disease.

Sinusitis Facts

The impact of sinusitis is immense. Yearly, Americans:

lose more than73 million days of work and school,
spend more than $5 billion,
visit their physicians more than 12 millions times and
receive over 13 million antibiotic prescriptions - due to sinusitis.

Technically, sinusitis is the inflammation of the sinus cavities usually due to a bacterial infection. Most cases of sinusitis are associated with a prior respiratory viral infection - cold or a respiratory allergy - or both.

Symptoms

Facial pain - may be specific to the involved sinuses
Headache
Nasal discharge - may be yellow or green and could have a foul odor.
Nasal congestion - stuffy nose
Post nasal drip - may result in a sore throat and/or cough.
Loss of smell
Fatigue - tire easily

The sinuses are air filled hollow, bony cavities located behind the cheeks, eyes and forehead. The exact function of the sinus cavities is not entirely understood however, they warm air inspired nasal air, provide resonance to the voice and provide some mechanical protection to the lungs.

Sinusitis can produce localized pain that may indicate the sinuses that are infected:

Forehead pain (either continuously or when touched) may indicate involvement of the frontal sinuses.
Infection in the maxillary sinuses can cause the upper jaw and teeth to ache and the cheeks to become tender to the touch.
Ethmoid involvement (near the tear ducts) often causes smiling of the eyelids, pain between the eyes, loss of smell and a stuffy nose.
Although less frequently affected, sphenoid infection can cause ear aches, neck pain, and deep aching at the top of the head.

Sinusitis rarely exist without the presence of nasal inflammation (rhinitis) as well. The combined condition - rhinosinusits is the more correct term for the disease. The causes of rhinosinusitis vary but all result in swelling of the mucous membranes lining the nasal and sinus passageways. As the swelling block the narrow openings from the nose into the sinuses, the sinuses are unable to drain and mucous and debris from the lining of the sinuses build up, all of which establish an ideal breeding ground for bacteria leading to an infection. Allergies to inhaled environmental particles, viral infections (colds and flu) and other diseases are important factors leading to sinusitis. The net result is that inflammation, regardless of the cause, leads to blockade of normal sinus drainage which then leads to a bacterial infection. There is increasing evidence that in long standing chronic sinusitis the bone underlying the mucous membrane becomes inflamed and maybe come infected leading to a continuous source of recurrent infection.

Diagnosis

Acute sinusitis is diagnosed based upon the presence and duration of symptoms, examination of the nose and sinuses and history. Labatory testing and x-raysare usually not necessary for an initial bout of sinusitis. However, if sinusitis persists with therapy or recurs shortly after a course of treatment further diagnostics including computerized tomography of the sinuses (CT scan) andallergy testing may be indicated.

Sinusitis is classified based upon the duration of symptoms:
Acute - symptoms have been persistent and have lasted less than 8 weeks in adults and less than 12 weeks in children.
Sub-acute -symptoms have improved but have persisted for less than 12 weeks.
Chronic -symptoms have persisted continuously for more than 12 weeks.

» Patients who do not respond to appropriate second line agents (Ceftin, Augmentin, Cipro, Cefzil,etc.) should be referred to a sinus specialist for further evaluation and treatment.

Treatment

Acute sinusitis is treated with oral antibiotics, decongestants, mucolytic agents (loosens and liquifies sinus mucus) and often steroid nasal sprays (to reduce inflammation).

First Line Oral Antibiotics - Amoxicillin, Bactrim/Septra, Augmentin
Decongestants - Sudafed (often in combination with mucolytic)
Mucolytics - Guaifenesin (Humabid, Mucobid,etc.)
Steroid Sprays - Vancenase, Flonase, etc.

Most patients with acute sinusitis will adequately respond to a single 14 day course of antibiotic therapy. A major cause of relapse is patient non-compliance- the patient discontinues the medication early as they begin to feel better only to allow the bacteria to regrow with a vengeance. Patients who do not improve after a trial of first line antibiotics may require anextended course of a second line agent (Ceftin, Augmentin, Cipro, Cefzil,etc.) for 21 days or longer. Patients who do not respond to appropriate second line agents should be referred to a sinus specialist for further evaluation and treatment.

Chronic Sinusitis

Chronic sinusitis patients usually must be treated with an appropriate oral antibiotic for a minimum of 4 to 6 weeks to optimize a response. There are oral antibiotics that are reserved for suspected chronic infections that can be very effective. Again, one should always complete the prescribed medication for the length provided. For a minority of patients, an appropriately selected and dosed oral antibiotic taken for lengthy periods of time may not fully resolve a chronic sinus infection. A CT scan of the sinus will be used to identify physical and/or anatomic changes and help define extent of disease. The physician may perform an in-office endoscopic examination of the sinus utilizing a special lighted scope inserted through the nose. Both diagnostic procedures can tell the physician much about the cause of the disease and guide therapy. Thechronic infection is treated based upon the specific circumstance of the individual patients sinus anatomy and the identified or most likely bacteria causing the infection. When a patient fails to respond to appropriately selected and utilized oral antibiotics, intravenous (IV) antibiotic therapy provides a useful alternative. The IV route of administration avoids the problems of reduced and / or delayed absorption of oral medication (that first mustpass through the digestive tract) by delivering all of the drug directly into the blood stream. IV delivery allows the administration of larger doses of antibiotics than are possible with oral administration due to the limitation of gastrointestinal side effects (nausea and vomiting). Consequently, IV administrations allows for much higher concentrations of the antibiotics to penetrate into the sinus cavities, mucosa and the underlying sinus bonewhich increases the likelihood of clinical response. IV therapy has proven effective in many patients with CS without the need for surgery. Some patients with CS have significant anatomic problems that must be corrected surgically - resistant or large polyps, outlet obstruction and anatomic variants- to insure long term success. Functional endoscopic sinus surgery (FESS) is a minimally invasive procedure designed to restore natural aeration and drainage of the sinuses. Although not designed to remove deeply set bacteria from surrounding tissue, these procedures may allow medications to have the irintended curative effect. Surgical procedures also repair and, remove anatomical structures that may be a source for continued sinus symptoms. For CS sufferers, IV antibiotic care can complement FESS and other surgical care initiatives improving long term outcomes. Allpatients are evaluated for allergy. More than 50% of CS patients have allergies to a varying degree. Allergies must be controlled long term if CS is not to recur. Additionally, a small subset of CS patients may have more complex immunologic problems that are addressed through our allergist / immunologist affiliates.

For additional information on sinusitis, visit these sites:

» Airway Wellness: Allergies | Asthma | Sinusitis | Sleep Disorders