-IBIS-1.5.0-
tx
eyes/ears/nose/throat
sinusitis
diagnoses

definition and etiology

definition: An inflammation or infection in the paranasal sinuses.

etiology: The most common inciting agent of sinusitis is a viral URI, although bacteria, fungi, and allergic reactions may also be responsible. Any factor that creates edema of the nasal tissues resulting in obstruction and the lack of proper drainage of the area will often lead to sinus infection. As the obstruction continues, oxygen is resorbed back into the blood vessels, causing a painful relative negative pressure that draws transudate from the mucous membranes. The transudate is an excellent medium for bacteria, especially streptococcus, pneumococcus, Hemophilus influenza, and staphylococcus, which are the bacteria most implicated in acute sinusitis. The bacterial overgrowth leads to an influx of serum and leukocytes to fight the infection, setting up a painful positive pressure.

Chronic sinusitis is often associated with an allergic individual, and dental infections account for 25% of chronic maxillary sinusitis. Swimming and diving, and injury to the area (especially fractures to the ethmoid or frontal sinuses) are other precipitating factors.

With chronic sinusitis that seems to go away after an antibiotic then returns, consider candidiasis (Easley) or focal infection (Matsumoto).

signs and symptoms

• Tenderness to palpation, swelling, redness, and opaque transillumination of involved sinuses.
• Fever, chills: suggest expansion of the infection beyond the sinuses.
• Nasal congestion and serous or mucopurulent discharge (usually yellow or green, and can often excoriate the nasal tissues).
• Malaise.
• Headache and/or dizziness that changes with position and is worse lying down or bending over.
• History of URI, dental problem, nasal allergy, or injury to the area.
• Nasal mucosa is erythematous and edemic, and the exudate may be seen in the turbinates corresponding to the infected sinus(es).

chronic sinusitis: May present as acute sinusitis or may be relatively asymptomatic presenting with only mild postnasal discharge, recurrent headaches, musty odor, or a nonproductive cough. X-rays may reveal a thickening of the mucous membranes, though cultures of the nose and nasal discharge uncover no pathogenic organisms.

specific areas of infection:
• Frontal: Pain over the forehead, above the eyebrows.
• Maxillary: Pain around cheekbones, toothache, and frontal headache.
• Ethmoid: "Splitting" frontal headaches, pain behind and between the eyes.
• Sphenoid: usually less clearly defined, but often manifests as tenderness and pain around the vertex of the skull, the mastoid areas, and the occiput.

lab findings:
• X-rays clearly show the sites of involvement and to what degree: the radiograph will pick up the swollen mucous membrane or the exudate. X-rays of the apices of the teeth are mandatory to rule out a periapical abscess when there is chronic maxillary sinusitis.
• cultures not reliable

course and prognosis

Complications if treatment is not effective or the cause is not treated:
• Osteomyelitis of the frontal bone: rare complication of frontal sinusitis.
• Bacterial meningitis: usually involves the frontal tissues and osteomyelitis and can lead to a brain abscess.
• Bronchiectasis
• Nasal polyps: may develop in individuals with chronic symptoms, especially in allergic patients.

With proper treatment, all the above complications are very rare. The patients likely to have the most trouble with their sinuses are those with allergies, chronic viral fatigue, or immunosuppression. Otherwise, most patients respond to treatment and resolve the acute infection. If the cause is not removed, however, recurrent attacks are extremely likely.

differential diagnosis

acute sinusitis
:
• dental abscess
• response to exposure to airborne irritant
• immunosuppressive disease or Chronic Viral Fatigue Syndrome.

chronic sinusitis:
• allergies
• exposure to irritating gases/dusts/ tobacco smoke
• Kartagener's syndrome; immunosuppressive disease or CVFS.

tumors: Rule out a tumor especially in an individual complaining of repeated attacks of acute sinusitis, or chronic symptoms notably including recurrent epistaxis while no pathogenic organism can be found.
• osteoma (benign)
• carcinoma of the maxilla
• sarcoma
• Burkitt's lymphoma
• myeloma
• adenocarcinoma
• melanoma of the nasal cavity


footnotes