Sinusitis, also known as a sinus infection or rhinosinusitis, is inflammation of the sinuses resulting in symptoms. Common signs and symptoms include thick nasal mucous, a plugged nose, and pain in the face. Other signs and symptoms may include fever, headaches, poor sense of smell, sore throat, and cough. The cough is often worse at night. Serious complications are rare. It is defined as acute rhinosinusitis (ARS) if it lasts less than 4 weeks, and as chronic rhinosinusitis (CRS) if it lasts for more than 12 weeks.

It can be due to infection, allergies, air pollution, or structural problems in the nose. Most cases are due to a viral infection. Abacterial infection may be present if symptoms last more than ten days or if a person worsens after starting to improve. Recurrent episodes are more likely in people with asthma, cystic fibrosis, and poor immune function. X-rays are not typically needed unless complications are suspected. In chronic cases confirmatory testing is recommended by either direct visualization or computed tomography.

Sinusitis

Sinusitis

Some cases may be prevented by hand washing, avoiding smoking, and immunization. Pain killers such as naproxen, nasal steroids, and nasal irrigation may be used to help with symptoms. Treating ARS with or without an antibiotic is reasonable for uncomplicated bacterial cases. If after a further seven days there is still no improvement antibiotics may either be recommended or changed. In those in whom antibiotics are used, either amoxicillin or amoxicillin/clavulanate is recommended first line. Surgery may occasionally be used in people with chronic disease.

Sinusitis is a common condition. It affects about between 10% and 30% of people each year in the United States and Europe.Women are more often affected than men. Chronic sinusitis affects approximately 12.5% of people. Treatment of sinusitis in the United States results in more than 11 billion USD in costs.

 

Classification

Sinusitis (or rhinosinusitis) is defined as an inflammation of the mucous membrane that lines the paranasal sinuses and is classified chronologically into several categories:

Illustration depicting sinusitis

Illustration depicting sinusitis

  • Acute rhinosinusitis – A new infection that may last up to four weeks and can be subdivided symptomatically into severe and non-severe. Some use definitions up to 12 weeks.
  • Recurrent acute rhinosinusitis – Four or more separate episodes of acute sinusitis that occur within one year
  • Subacute rhinosinusitis – An infection that lasts between four and 12 weeks, and represents a transition between acute and chronic infection
  • Chronic rhinosinusitis – When the signs and symptoms last for more than 12 weeks.
  • Acute exacerbation of chronic rhinosinusitis – When the signs and symptoms of chronic rhinosinusitis exacerbate, but return to baseline after treatment

All these types of sinusitis have similar symptoms, and are thus often difficult to distinguish. Acute sinusitis is very common. Roughly ninety percent of adults have had sinusitis at some point in their life.

Signs and symptoms

Headache/facial pain or pressure of a dull, constant, or aching sort over the affected sinuses is common with both acute and chronic stages of sinusitis. This pain is typically localized to the involved sinus and may worsen when the affected person bends over or when lying down. Pain often starts on one side of the head and progresses to both sides.Acute sinusitis may be accompanied by thick nasal discharge that is usually green in color and may contain pus (purulent) and/or blood. Often a localized headache or toothacheis present, and it is these symptoms that distinguish a sinus-related headache from other types of headaches, such as tension and migraine headaches. Another way to distinguish between toothache and sinusitis is that the pain in sinusitis usually is worsened by tilting the head forwards and with valsalva maneuvers.

Infection of the eye socket is possible, which may result in the loss of sight and is accompanied by fever and severe illness. Another possible complication is the infection of the bones (osteomyelitis) of the forehead and other facial bones – Pott’s puffy tumor.

Sinus infections can also cause middle ear problems due to the congestion of the nasal passages. This can be demonstrated by dizziness, “a pressurized or heavy head”, or vibrating sensations in the head. Post-nasal drip is also a symptom of chronic rhinosinusitis.

Halitosis (bad breath) is often stated to be a symptom of chronic rhinosinusitis; however, gold standard breath analysis techniques have not been applied. Theoretically, there are several possible mechanisms of both objective and subjective halitosis that may be involved.

A 2004 study suggested that up to 90% of “sinus headaches” are actually migraines.[verification needed] The confusion occurs in part because migraine involves activation of thetrigeminal nerves, which innervate both the sinus region and the meninges surrounding the brain. As a result, it is difficult to accurately determine the site from which the pain originates. People with migraines do not typically have the thick nasal discharge that is a common symptom of a sinus infection.

By location

There are several paired paranasal sinuses, including the frontal, ethmoidal, maxillary and sphenoidal sinuses. The ethmoidal sinuses is further subdivided into anterior and posterior ethmoid sinuses, the division of which is defined as the basal lamella of the middle turbinate. In addition to the severity of disease, discussed below, sinusitis can be classified by the sinus cavity which it affects:

  • Maxillary – can cause pain or pressure in the maxillary (cheek) area (e.g., toothache, or headache) (J01.0/J32.0)
  • Frontal – can cause pain or pressure in the frontal sinus cavity (located above eyes), headache, particularly in the forehead (J01.1/J32.1)
  • Ethmoidal – can cause pain or pressure pain between/behind the eyes, the sides of the upper part of the nose (the medial canthi), and headaches (J01.2/J32.2)
  • Sphenoidal – can cause pain or pressure behind the eyes, but often refers to the skull vertex (top of the head), over the mastoid processes, or the back of the head.

Complications

Stage Description
I Preseptal cellulitis
II Orbital cellulitis
III Subperiosteal abscess
IV Orbital abscess
V Cavernous sinus septic thrombosis

The close proximity of the brain to the sinuses makes the most dangerous complication of sinusitis, particularly involving the frontal and sphenoid sinuses, infection of the brain by the invasion of anaerobic bacteria through the bones or blood vessels.Abscesses, meningitis and other life-threatening conditions may result. In extreme cases the patient may experience mild personality changes, headache, altered consciousness, visual problems, seizures, coma and possibly death.

Sinus infection can spread through anastomosing veins or by direct extension to close structures. Orbital complications were categorized by Chandler et al. into five stages according to their severity (see table). Contiguous spread to the orbit may result in periorbital cellulitis, subperiosteal abscess, orbital cellulitis, and abscess. Orbital cellulitis can complicate acute ethmoiditis if anterior and posterior ethmoidal veins thrombophlebitis enables the spread of the infection to the lateral or orbital side of the ethmoid labyrinth. Sinusitis may extend to the central nervous system, where it may cause cavernous sinus thrombosis, retrograde meningitis, and epidural, subdural, and brain abscesses. Orbital symptoms frequently precede intracranial spread of the infection . Other complications include sinobronchitis, maxillary osteomyelitis, and frontal bone osteomyelitis. Osteomyelitis of the frontal bone often originates from a spreading thrombo-phlebitis. A periostitis of the frontal sinus causes an osteitis and a periostitis of the outer membrane, which produces a tender, puffy swelling of the forehead.

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