Introduction
The paranasal sinuses are aerated cavities in the bones of the face that develop as outpouches of the nasal cavity and communicate with this cavity throughout life. (1) The maxillary and ethmoid sinuses are fully developed at birth, but the frontal sinus develops after age 2 and the sphenoid sinus after age 7. The nose and sinuses are lined with ciliated pseudocolumnar epithelium that includes mucous producing goblet cells. Small tubular openings called the sinus ostia connect the sinus cavities and facilitate drainage of the sinuses into the nasal cavity through the activity of ciliated cells. (2) The mucous blanket is carried toward the sinus openings (ostia) at a speed of up to 1cm/minute by the beating of cilia. (3) The mucous blanket changes two to three times an hour, and under normal circumstances does not accumulate in the sinus cavities. It is frequently the delay in the mucociliary transport time or obstruction of the ostia that may lead to sinusitis. The paranasal sinuses are frequently involved in the common cold. Computed tomographic study of patients with the common cold reveals that over 85 percent have a self-limited paranasal sinusitis that resolves without treatment. (4) Actually, rhinosinusitis is a more accurate term for what is commonly called sinusitis, since, as already described, the mucous membranes of the sinuses and the nose are contiguous.
The sinusitis that occurs with the most frequency involves the maxillary sinuses, followed by ethmoid sinusitis, then frontal and sphenoid sinusitis. The most common precursor to sinusitis is a viral upper respiratory tract infection; however, the frequency of which a clinically evident complication of acute bacterial sinusitis occurs, is very small, (only about 0.5% of viral upper respiratory infections). The development of sinusitis occurs most frequently from obstruction of the ostia due to mucosal edema. Viral infections also increase the amount of mucous, which may cause damage to ciliated cells and prolong transport time.
Acute sinusitis can be classified into various categories on the basis of several characteristics including its occurrence in the community or hospital setting; the immune status of the patient; its infectious or noninfectious cause; and its viral, bacterial, or fungal cause. (5) For example, in a non-hospitalized patient with normal immunity, sinusitis may be viral, bacterial, a combination of both viral and bacterial, or non-invasive fungal. It may also be allergic or non-allergic. In a hospitalized patient, nosocomial sinusitis is usually bacterial or fungal. Non-infectious causes include allergic or toxic sinusitis. In the immunocompromised patient, sinusitis may have a viral, or bacterial origin, and sometimes may be caused by an invasive fungal pathogen.
The paranasal sinuses, although directly connected to the nasal passages, which are colonized with bacteria, are themselves sterile under normal conditions. Sterility is maintained in the sinus by mechanisms that are not fully understood but are believed to include mucociliary clearance, the immune system, and possibly antibacterial concentrations of nitric oxide gas in the sinus cavity. (6)
The bacteriology of acute community-acquired maxillary sinusitis has been well defined by studies using direct sinus puncture and aspiration. (7) Streptococcus pneumoniae has been shown to cause about one-third of cases, while Haemophilus influenzae (not type b) causes one-fourth of cases. Moraxella catarrhalis, is also an important pathogen, especially in children and causing about 20 percent of pediatric sinusitis. Gram-negative bacilli play a role in approximately 9 percent of adult cases, and anaerobes are found in 6 percent. Anaerobes may be particularly important in patients with dental infections. In about one-fifth of adult cases, the presence of rhinoviruses as well as parainfluenza and influenza viruses are found alone or with bacteria.
Numerous studies have cited nosocomial sinusitis as being primarily associated with Staph aureus, Pseudomonas aeruginosa, Serratia marcescens, Klebsiella pneumonia, Enterobacter sp. and Proteus mirabilis. Moreover, many of these infections are polymicrobic. (8) , (9)
Fungal sinusitis may be classified as either invasive or noninvasive. Noninvasive disease is generally chronic and occurs in immunocompetent hosts. It has two forms that are analogous to the noninvasive pulmonary diseases of aspergilloma and allergic bronchopulmonary aspergillosis. (10) Typically a fungus ball (aspergilloma) is present inside the sinus cavity without invading the surrounding mucosa. Symptoms are usually unilateral, and most often a maxillary sinus is affected. The second form is seen mainly in patients with asthma and nasal polyposis. It is described as allergic fungal sinusitis and is characterized by extremely thick mucous that is found, upon histopathologic examination, to contain esosinophils and rare fungal hyphae. As with the fungus ball, there is no evidence of tissue invasion.
Invasive fungal sinusitis may be life threatening, whether in the immunocompetent or immunocompromised host. Clinical presentation, however, differs in the two populations. In immunocompromised individuals, invasive fungal sinusitis has an acute presentation that generally includes facial pain, headache, and fever; there may also be signs of orbital cellulitis and altered mental status. Black eschars overlying necrotic tissue may be seen in the nasal passages, and should be biopsied emergently. (11) Immunocompetent patients generally have a slowly progressive disease that may be misdiagnosed as optic neuritis or orbital pseudotumor until sinus disease is recognized.
The nasal passages and nasopharynx are colonized with the same bacterial species that cause acute community acquired bacterial sinusitis (ACABS), and, undoubtedly, the bacteria in these areas serve as the reservoir for this infection. (12) Typical clinical presentation includes nasal congestion, purulent nasal discharge, facial pain that usually increases when a patient stoops forward, and, often fevers. Besides the common cold, allergic and vasomotor rhinitis are frequent antecedents. Nasal polyps or a deviated septum seem to predispose patients to sinusitis due to obstruction of drainage. Nasotracheal or nasogastric intubation can result in obstruction of the ostia and is a major risk factor for nosocomial sinusitis in intensive care units. (13) Other potential factors include deep sea diving or airplane travel, mucous abnormalities such as in cystic fibrosis, and chemical irritants including cigarette smoke. They may occur less frequently as a medication side effect, and 5 to 10 percent of maxillary sinusitis cases are caused by dental infections. The presence of tumors or foreign bodies, or trauma may also be responsible for obstruction of the ostia.
While the type of bacteria causing sinusitis has not changed over that last several decades, their susceptibility to treatment by antimicrobials has changed. Increasing number of infections caused by Staph. Aureus are penicillin resistant, and those caused by H. influenzae and M. catarrhalis are frequently beta-lactam resistant. The most recent development of resistance appears to be the emergence of resistant strains of Strep. Pneumoniae.
Sinusitis may also be classified as acute, recurrent acute, subacute or chronic. Acute rhinosinusitis has a relatively rapid onset, is most frequently of viral origin, is normally of four weeks or less duration, and symptoms resolve completely. Acute bacterial rhinosinusitis is suggested by symptoms including purulent drainage that worsens after five days or persists beyond 10 days, and/or symptoms that are out of proportion to those typically associated with a viral upper respiratory process. (14) While the occurrence of four or more episodes within a 12 month period used to be considered chronic disease, it has now been placed under the classification of recurrent acute infection. Each episode is of 7 days or greater duration, and symptoms resolve completely between episodes. Subacute rhinosinusitis is basically a low grade continuum of acute infection of more than four weeks’ duration. Chronic rhinosinusitis is distinguished by symptoms that persist for 12 weeks or more. (15)
No single clinical finding is predictive of acute sinusitis. Three symptoms (maxillary toothache, poor response to decongestants, and colored nasal discharge) and two signs (purulent nasal secretions and abnormal transillumination) are the best clinical predictors of acute sinusitis. (16) When four or more of the signs and symptoms are present, the likelihood of sinusitis is high; when fewer than two of the above signs and symptoms are present, acute sinusitis can be ruled out. (17) , (18) In between these values, the diagnosis is often unclear and sinus radiography is helpful. Sinus puncture with aspiration remains the gold standard for diagnosis, however this procedure is invasive, and impractical for most cases.
Complications of sinusitis have become less frequent in the antibiotic era, however when they occur, may be life threatening. The most common complication of sinusitis is orbital cellulitis. It occurs most frequently as a complication of ethmoid sinusitis, since the ethmoid sinus is separated from the orbit only by a very thin bone known as the lamina papyracea. It may begin as edema of the eyelids and progress to ptosis, proptosis, chemosis, and diminished extraocular movements.
A complication of frontal sinusitis is a subperiosteal abscess known as Pott’s puffy tumor. In this condition, patients present with a tender doughy swelling over the forehead. Headache and fever are usually present as well.
Intracranial complications may also occur, including epidural abscess, subdural empyema, meningitis, cerebral abscess, and dural vein thrombophlebitis. Clinical findings may vary greatly, ranging from subtle personality changes with frontal lobe abscesses to headache, symptoms of elevated intracranial pressure, alterations of consciousness, visual symptoms, focal neurologic deficits, seizures, and ultimately, coma and death. (19)
Statistic
National Center for Health Statistics, CDC.
- Number of noninstitutionalized adults with diagnosed sinusitis: 29.2 million (2002)
- Percent of noninstitutionalized adults with diagnosed sinusitis: 14.2 (2002)
- Number of visits to office-based physicians: 14.1 million (2002)
Signs and Symptoms
The following list does not insure the presence of this health condition. Please see the text and your healthcare professional for more information.
The signs and symptoms of acute purulent sinusitis depend upon which sinus is involved. Frontal sinusitis produces pain and tenderness over the lower forehead, while maxillary sinusitis produces pain and tenderness over the cheeks. Pain in maxillary sinusitis also may be referred to the teeth. Symptoms of ethmoid sinusitis generally include retro-orbital pain and possibly tenderness over the upper lateral aspect of the nose. Sphenoid sinusitis is uncommon, but may present with frontal, retro-orbital, or facial pain.
Sneezing, nasal discharge, rhinorrhea, nasal obstruction, facial pressure and headache are common. Fever may also occur. Purulence or a colored nasal discharge is generally considered a sign of ACABS, but may also be seen in viral rhinosinusitis. Persistent cough is also frequently associated with sinusitis.
May be dependent upon age of patient and upon acuteness or chronicity of the infection
- Sometimes symptoms are nonspecific and difficult to differentiate from viral URI or allergic rhinitis
- Mucopurulent nasal discharge
- Nasal congestion
- Facial pain (particularly unilateral)
- Maxillary toothache
- Fever
- Persistence of a cough and nasal discharge for more than 10 days following a viral URI
- Poor response to nasal decongestants
- In children
- presence of halitosis in the absence of pharyngitis
- Periorbital swelling with or without pain
- Headaches that respond poorly to analgesics
Treatment Options
Conventional
Many symptoms of sinusitis will resolve without medical therapy within 48 hours. When they persist, the goals of treatment include symptomatic relief, restoring and improving sinus function, preventing intracranial complications, and eradicating the causative pathogen. (20) The first line therapy remains Amoxicillin, at a usual dose of 500mg given three times a day for 10 days. Cure rates remain in the 72-74 percent range. TMP/SMX, is also an excellent option, particularly for penicillin sensitive patients. Second-line antibiotics include amoxicillin-clavulante, loracarbef, azithromycin, clarithromycin, cefuroxime axetil, cefaclor, cefixime, and erythromycin-sulfoxizole. All have similar cure rates; however, do not have any significant advantage over first-line therapy. Many are prescribed due to concerns over rising prevalence of beta-lactamase producing strains of bacteria. However, randomized controlled trials have failed to demonstrate any advantage for such antibiotics over amoxicillin, suggesting that beta-lactamase producing strains may not be as clinically significant as feared. (21)
Decongestants are often used as adjunct therapy in the treatment of sinusitis, although there are no placebo-controlled studies published that establish their effectiveness. Nasal spray decongestants, such as phenylephrine hydrochloride (0.5%) or oxymetazoline hydrochloride (0.05%) may facilitate drainage. (22) Oral decongestants (pseudoephedrine and phenylpropanolamine) have been used to improve nasal patency by increasing the functional diameter of the maxillary ostium.Irrigation of the nasal passages using a saline solution in a squeeze spray bottle may also provide symptomatic relief.
Antihistamines should only be used when there is an underlying allergic component. In the absence of an allergic component, they may act to thicken secretions and worsen sinus outflow obstruction. Steroids are of little benefit and may actua
Nutritional Supplementation
Vitamin C
Studies have not directly evaluated the effectiveness of vitamin C in the treatment of sinusitis. However, numerous studies have documented that relatively large doses of vitamin C (above 1,000 mg/day) are effective at reducing the duration of symptoms in the common cold. (23) In the 1940’s, Fred Klenner, M.D. was one of the first physicians to recognize that vitamin C was a powerful anti-viral agent. (24) , (25) Although bacterial sinusitis can be a complication of the common cold, many cases of sinusitis are thought to be viral in nature. Therefore, it is reasonable to suggest that supplemental vitamin C could be therapeutically useful in the treatment of sinusitis.
Herbal Supplementation
This category contains no therapies clinically applicable to this disease state.
Clinical Lab Assessment
Some of the following laboratory testing can provide information necessary for diagnosis and treatment. In addition, the tests listed may also give insight to functional metabolism and functional nutrient status in the body.
CBC
White blood cells
ESR
An elevated ESR is reportedly one of the most reliable indicators of sinusitis. (26)
C-reactive protein (CRP Thyroid Profile)
An elevated C-reactive protein indicates the possibility of an infection with either Streptococcus pyogenes or Streptococcus pneumoniae. (27)
Culture, Bacteria
Bacteriology culture s used to determine if the inflammation is due to a bacterial pathogen. However, is it reported that these cultures are often of questionable value due to contamination of the sample with normally resident flora. (28)
Clinical Notes
Vitamin A: It has been reported that vitamin A reduces morbidity and mortality when it is used in the treatment of viral conditions such as measles, pneumonia, and HIV. (29) Although no studies have evaluated whether or not vitamin A is useful in the treatment of sinusitis, its effectiveness in other viral conditions makes it worthy of consideration, especially in individuals who might have low levels of vitamin A to begin with.
Probiotics (acidophilus and bifidus): A substantial number of cases of sinusitis are now known to have fungal colonization involvement. (30) Hence, providing patients with a program to improve bowel terrain with probiotics will help to reduce the intestinal load of unfavorable bacterial and fungal agents.
Grapefruit seed extract: A nasal douche, or nasal insufflation with a weak (approximately 1%) solution of grapefruit seed extract will deliver anti-fungal activity directly to the sinus cavities.
Quercetin is a nutraceutical agent with significant anti-inflammatory activity. It may help to reduce some of the inflammatory activity in the affected sinus tissues.
References
- Durand M, et al. Infections of the upper respiratory tract, In: Fauci AS, et al. eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:179-181.
- View Abstract: Low DE, Desrosiers M, McSherry J, et al. A Practical Guide for the diagnosis and treatment of acute sinusitis. Can Med Assoc J. Mar1997;156(6 suppl):S1-S14.
- Durand M, et al. Infections of the upper respiratory tract, In: Fauci AS, et al. eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:179-181.
- Simon HB. Approach to the patient with Sinusitis, in: Goroll AH, May LA, Mulley AG, eds. Primary Care Medicine, Office Evaluation and Management of the Adult Patient, 3rd ed. Philadelphia: Lippincott-Raven; 1995:1004-1007.
- Gwaltney JM, et al. In: Mandell Gl, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases, 5th ed. Philadelphia: Churchill-Livingstone Inc: 2000:676-683.
- Gwaltney JM, et al. In: Mandell Gl, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases, 5th ed. Philadelphia: Churchill-Livingstone Inc: 2000:676-683.
- Durand M, et al. Infections of the upper respiratory tract, In: Fauci AS, et al. eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:179-181.
- View Abstract: Bert F, Lambert-Zechovsky N. Microbiology of nosocomial sinusitis in intensive care unit patients. J Infect. Jul1995;31(1):5-8.
- Maltinski G. EAR, NOSE AND THROAT DISORDERS, Primary Care. Clinics in Office Practice Volume 25, Number 3. Sep1993.
- Durand M, et al. Infections of the upper respiratory tract, In: Fauci AS, et al. eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:179-181.
- Durand M, et al. Infections of the upper respiratory tract, In: Fauci AS, et al. eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:179-181.
- Gwaltney JM, et al. In: Mandell Gl, Bennett JE, Dolin R, eds. Principles and Practice of Infectious Diseases, 5th ed. Philadelphia: Churchill-Livingstone Inc: 2000:676-683.
- Durand M, et al. Infections of the upper respiratory tract, In: Fauci AS, et al. eds. Harrison’s Principles of Internal Medicine, 14th ed. New York: McGraw-Hill; 1998:179-181.
- Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg. Sep1997;117(3 pt):S1-7.
- View Abstract: Osguthorpe JD. Adult rhinosinusitis: Diagnosis and Management. Am Fam Physician. Jan2001;63(1):69-76.
- Richer M, et al. Upper Respiratory Tract Infections. In: DiPiro JT, Talbert RL, Yee GC, et al, eds. Pharmacotherapy, A Pathophysiologic Approach,4th ed. Stamford, CT: Appleton & Lange; 1999:1678-1680.
- View Abstract: Williams JW Jr, Simel DL, Roberts L, Samsa GP. Clinical evaluation for sinusitis: Making the diagnosis by history and physical examination. Ann Intern Med. Nov1992;117:705-710.
- Williams JW Jr, Simel DL. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA. Sep1993;270:1242-1246.
- Simon HB. Approach to the patient with Sinusitis, in: Goroll AH, May LA, Mulley AG, eds. Primary Care Medicine, Office Evaluation and Management of the Adult Patient, 3rd ed. Philadelphia: Lippincott-Raven; 1995:1004-1007.
- View Abstract: Osguthorpe JD. Adult rhinosinusitis: Diagnosis and Management. Am Fam Physician. Jan2001;63(1):69-76.
- Simon HB. Approach to the patient with Sinusitis, in: Goroll AH, May LA, Mulley AG, eds. Primary Care Medicine, Office Evaluation and Management of the Adult Patient, 3rd ed. Philadelphia: Lippincott-Raven; 1995:1004-1007.
- View Abstract: Malow JB, Creticos CM. Nonsurgical treatment of sinusitis. Otolaryngol Clin North Am. Aug1989;22:809-818.
- View Abstract: Douglas RM, Chalker EB, Treacy B. Vitamin C for preventing and treating the common cold. Cochrane Database Syst Rev. 2000;(2):CD000980.
- Klenner F. Virus pneumonia and its treatment with vitamin C. Southern Med Surg. Feb1948.
- Klenner F. Massive doses of vitamin C and the virus diseases. J So Med & Surg. Apr1951;4:113.
- View Abstract: Hansen JG, Schmidt H, Rosborg J, Lund E. Predicting acute maxillary sinusitis in a general practice population. BMJ. Jul1995;311(6999):233-6.
- View Abstract: Savolainen S, Jousimies-Somer H, Karjalainen J, Ylikoski J. Do simple laboratory tests help in etiologic diagnosis in acute maxillary sinusitis? Acta Otolaryngol Suppl. 1997;529:144-7.
- View Abstract: Carroll K, Reimer L. Microbiology and laboratory diagnosis of upper respiratory tract infections. Clin Infect Dis. Sep1996;23(3):442-8.
- View Abstract: Semba RD. Vitamin A and immunity to viral, bacterial and protozoan infections. Proc Nutr Soc. Aug1999;58(3):719-27.
- View Abstract: Vennewald I, Henker M, Klemm E, Seebacher C. Fungal colonization of the paranasal sinuses. Mycoses. 1999;42 (Suppl 2):33-6.
