Sinusitis
Sinusitis: Excerpt from Professional Guide to Diseases (Eighth Edition)
Sinusitis — inflammation of the paranasal sinuses — may be acute, subacute, chronic, allergic, or hyperplastic. Acute sinusitis usually results from the common cold and lingers in subacute form in only about 10% of patients. Chronic sinusitis follows persistent bacterial infection; allergic sinusitis accompanies allergic rhinitis; hyperplastic sinusitis is a combination of purulent acute sinusitis and allergic sinusitis or rhinitis. The prognosis is good for all types.
Causes and incidence
Sinusitis usually results from viral or bacterial infection. The bacteria responsible for acute sinusitis are usually pneumococci, other streptococci, Haemophilus influenzae, and Moraxella catarrhalis. Staphylococci and gram-negative bacteria are more likely to cause sinusitis in chronic cases or in intensive care patients.
Predisposing factors include any condition that interferes with drainage and ventilation of the sinuses, such as chronic nasal edema, deviated septum, viscous mucus, nasal polyps, allergic rhinitis, nasal intubation, or debilitation due to chemotherapy, malnutrition, diabetes, blood dyscrasias, cystic fibrosis, human immunodeficiency virus or other immunodeficiency disorders, or chronic use of steroids. Bacterial invasion commonly occurs as a result of the conditions listed above or after a viral infection. It may also result from swimming in contaminated water.
Other risk factors for developing sinusitis include a history of asthma, overuse of nasal decongestants, presence of a foreign body in the nose, frequent swimming or diving, dental work, pregnancy, changes in altitude (flying or climbing), air pollution and smoke, gastroesophageal reflux disease, and having a deviated nasal septum, nasal bone spur, or polyp.
Each year, more than 30 million adults and children get sinusitis.
PEDIATRIC TIP The incidence of both acute and chronic sinusitis increases in later childhood. Sinusitis may be more prevalent in children who have had tonsils and adenoids removed.
Signs and symptoms
The primary indication of acute sinusitis is nasal congestion, followed by a gradual buildup of pressure in the affected sinus. For 24 to 48 hours after onset, nasal discharge may be present and later may become purulent. Associated symptoms include malaise, sore throat, headache, and low-grade fever of 99° to 99.5° F [37.2° to 37.5° C]).
Characteristic pain depends on the affected sinus: maxillary sinusitis causes pain over the cheeks and upper teeth; ethmoid sinusitis, pain over the eyes; frontal sinusitis, pain over the eyebrows; and sphenoid sinusitis (rare), pain behind the eyes.
Purulent nasal drainage that continues for longer than 3 weeks after an acute infection subsides suggests subacute sinusitis. Other clinical features of the subacute form include nasal congestion, vague facial discomfort, fatigue, and a nonproductive cough.
The effects of chronic sinusitis are similar to those of acute sinusitis, but the chronic form causes continuous mucopurulent discharge.
The effects of allergic sinusitis are the same as those of allergic rhinitis. In both conditions, the prominent symptoms are sneezing, frontal headache, watery nasal discharge, and a stuffy, burning, itchy nose.
In hyperplastic sinusitis, bacterial growth on the diseased tissue causes pronounced tissue edema; thickening of the mucosal lining and the development of mucosal polyps combine to produce chronic stuffiness of the nose, in addition to headaches.
Diagnosis
The following measures are useful:
❑ Antral puncture promotes drainage of purulent material. It may also be used to provide a specimen for culture and sensitivity testing of the infecting organism, but it’s seldom performed.
❑ Nasal examination reveals inflammation and pus.
❑ Sinus X-rays reveal cloudiness in the affected sinus, air and fluid, and any thickening of the mucosal lining.
❑ Transillumination is a simple diagnostic tool that involves shining a light into the patient’s mouth with his lips closed around it. Infected sinuses look dark and normal sinuses transilluminate.
❑ Ultrasound, computed tomography scan, magnetic resonance imaging, and X-rays aid in diagnosing suspected complications.
Treatment
Local decongestants usually are tried before systemic decongestants; steam inhalation may also be helpful. Antibiotics are necessary to combat purulent or persistent infection. Amoxicillin and amoxicillin/ clavulanate potassium are usually the antibiotics of choice. Other possible therapy includes cefixime for responsive infections or if beta-lactamase-producing bacteria are present. Because sinusitis is a deep-seated infection, antibiotics should be given for 10 days to 2 weeks, with the exception of azithromycin, which is given for 5 days. Local applications of heat may help to relieve pain and congestion. In subacute sinusitis, antibiotics and decongestants may be helpful.
Treatment for allergic sinusitis must include treatment for allergic rhinitis — administration of antihistamines, identification of allergens by skin testing, and desensitization by immunotherapy. Severe allergic symptoms may require treatment with corticosteroids and epinephrine.
In both chronic sinusitis and hyperplastic sinusitis, using antihistamines, antibiotics, and a steroid nasal spray may relieve pain and congestion. If subacute infection persists, the sinuses may be irrigated. If irrigation fails to relieve symptoms, endoscopic sinus surgery may be required to obtain a histologic diagnosis, remove polyps, and provide adequate ventilation of the infected sinuses. Partial or total resection of the middle turbinate as well as more radical procedures, such as total sphenoethmoidectomy, may be performed.
Special considerations
❑ Enforce bed rest, and encourage the patient to drink plenty of fluids to promote drainage. Don’t elevate the head of the bed more than 30 degrees.
❑ To relieve pain and promote drainage, apply warm compresses continuously, or four times daily for 2-hour intervals. Also, give analgesics and antihistamines as needed.
❑ Watch for and report complications, such as vomiting, chills, fever, edema of the forehead or eyelids, blurred or double vision, and personality changes.
❑ If surgery is necessary, tell the patient what to expect postoperatively: nasal packing will be in place for 12 to 24 hours following surgery; he’ll have to breathe through his mouth and won’t be able to blow his nose. After surgery, monitor for excessive drainage or bleeding and watch for complications.
❑ To prevent edema and promote drainage, place the patient in semi-Fowler’s position. To relieve edema and pain and to minimize bleeding, apply ice compresses or a rubber glove filled with ice chips over the nose, and iced saline gauze over the eyes. Continue these measures for 24 hours.
❑ Frequently change the mustache dressing or drip pad, and record the consistency, amount, and color of drainage (expect scant, bright red, and clotty drainage).
❑ Because the patient will be breathing through his mouth, provide meticulous mouth care.
❑ Tell the patient that even after the packing is removed, nose blowing may cause bleeding and swelling. If the patient is a smoker, instruct him not to smoke for at least 2 or 3 days after surgery.
❑ Tell the patient to finish the prescribed antibiotics, even if his symptoms disappear.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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