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Chronic Sinusitis

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  CHRONIC SINUSITIS I.Definition Chronic sinusitis  is a long-term ongoing or recurring inflammation of the air-filled spaces that arelocated within the bones in and around the nose. These spaces are called  paranasal sinuses , andwhen they get infected, they become inflamed. This results in swelling of the  mucus membranes  thatline the sinuses, which causes pain and pressure in and around the eyes and cheekbones.Chronic sinusitis differs from acute sinusitis in thatchronic sinusitis occurs for more than a couple of months or continues to recur while acute sinusitis is short-lived and does not recur. Both chronic sinusitisand acute sinusitis can result from a viral infection,bacterial infection, or rarely, a fungal infection of the sinuses. isk factors for the development of chronic sinusitis include having nasalpolyps, nasal tumors, deviated nasal septum , asthma, and allergies. Common causes of chronic sinusitis include! Nasal polyps or tumors.  These tissue growths may block the nasal passages or sinuses. Allergic reactions.   llergic triggers include fungal infection of the sinuses. eviated nasal septum.   crooked septum # the wall between the nostrils # may restrict or block sinuspassages. Trauma to the !ace.   fractured or broken facial bone may cause obstruction of the sinus passages. Other medical conditions.  The complications of cystic fibrosis, gastroesophageal reflu$, or %I& andother immune system diseases may result in nasal blockage. Respiratory tract in!ections.  Infections in your respiratory tract # most commonly, colds # can inflameand thicken your sinus membranes, blocking mucus drainage and creating conditions ripe for growth of bacteria. These infections can be viral, bacterial or fungal in nature. Allergies such as hay !ever.  Inflammation that occurs with allergies may block your sinuses. Immune system cells.  'ith certain health conditions, immune cells called eosinophils can cause sinusinflammation.II.(athophysiologyThe most common cause of acute sinusitis is an upper respiratory tract infection)*TI+ of viral srcin. Theviral infection may lead to inflammation of the sinuses that usually resolves without treatment in less than days. If symptoms worsen after  to / days or persist for longer than 0 days and are more severethan normally e$perienced with a viral infection, a secondary bacterial infection is diagnosed. Theinflammation may predispose to the development of acute sinusitis by causing sinus ostial blockage.  lthough inflammation in any of the sinuses can lead to blockade of the sinus ostia, the most commonlyinvolved sinuses in both acute and chronic sinusitis are the ma$illary and the anterior ethmoidsinuses.  1  The anterior ethmoid, frontal, and ma$illary sinuses drain into the middle meatus, creating ananatomic area known as the 2ostiomeatal comple$3.The nasal mucosa responds to the virus by producing mucus and recruiting mediators of inflammation,such as white blood cells, to the lining of the nose, which cause congestion and swelling of the nasalpassages. The resultant sinus cavity hypo$ia and mucus retention cause the cilia#that move mucus anddebris from the nose#to function less efficiently, creating an environment for bacterial growth.If the acute sinusitis does not resolve, chronic sinusitis may develop from mucus retention, hypo$ia, andblockade of the ostia. This promotes mucosal hyperplasia, continued recruitment of inflammatoryinfiltrates, and the potential development of nasal polyps. %owever, other factors may predispose tosinusitis. 'hen bacterial growth occurs in acute sinusitis, the most common organisms include 4treptococcuspneumoniae, %aemophilus influen5ae, and 6ora$ella catarrhalis.  7  In chronic sinusitis, these organisms,  plus 4taphylococcus aureus, coagulase-negative 4taphylococcus species, and anaerobic bacteria, arethe most likely involved organisms. 8rganisms isolated from patients with chronic sinusitis increasinglyare showing antibiotic resistance. In fact, penicillin resistance rates for 4. pneumoniae are as high as 9in parts of the *nited 4tates.  0  These resistant organisms commonly occur in patients who have receivedtwo or more recent courses of antibiotics. Conditions That redispose to Sinusitis   llergic rhinitis:onallergic rhinitis  natomic factors! ã 4eptal deviation ã (arado$ical middleturbinate ã ;thmoid bullahypertrophy ã Choanal atresia ã   denoid hypertrophy%ormonal conditions )e.g., progesterone-inducedcongestion of pregnancy, rhinitis of hypothyroidism+<astroesophageal reflu$(rimary immune deficiency! ã 4elective Ig deficiency ã Common variable Immune deficiency  c=uired Immune deficiency ã %uman immunodeficiency virus ã Transplantation ã ChemotherapyCystic fibrosis(rimary ciliarydyskinesia>artagener?ssyndromeIII.Clinical 6anifestationsChronic sinusitis symptoms include!  Drainage of a thick, yellow or greenish discharge from the nose or down the back of the throat  :asal obstruction or congestion, causing difficulty breathing through your nose  (ain, tenderness and swelling around your eyes, cheeks, nose or forehead    ching in your upper @aw and teeth  educed sense of smell and taste  Cough, which may be worse at night8ther signs and symptoms can include!  ;ar pain  4ore throat  Bad breath )halitosis+  Aatigue or irritability  :ausea  I&.Diagnostic ssessment Aindings  Nasal endoscopy.   thin, fle$ible tube )endoscope+ with a fiber-optic light inserted through your nose allows your doctor to visually inspect the inside of your sinuses.  Imaging studies.  Images taken using computeri5ed tomography )CT+ or magnetic resonanceimaging )6I+ can show details of your sinuses and nasal area. These may identify a deepinflammation or physical obstruction that?s difficult to detect using an endoscope.  Nasal and sinus cultures.  aboratory tests are generally unnecessary for diagnosing chronicsinusitis. %owever, in cases in which the condition fails to respond to treatment or is progressing,tissue cultures may help pinpoint the cause, such as identifying a bacterial pathogen.  An allergy test.  If your doctor suspects that the condition may be brought on by allergies, anallergy skin test may be recommended. skin test is safe and =uick and can help pinpoint theallergen that?s responsible for your nasal flare-ups.  Radiographic #valuation The two modalities most commonly used include the plain radiograph and CT scan. (lainradiography does not ade=uately represent the individual ethmoid air cells, the e$tent of mucosalthickening in chronic sinusitis, or visuali5ation of the ostiomeatal comple$. 6agnetic resonanceimaging can be considered for evaluation of suspected tumors but is not recommended for acutesinusitis because it does not distinguish air from bone. Aor these reasons, CT scanning of thesinuses is the imaging procedure of choice )Aig. +. In many centers, the cost is similar to that of plain radiographs because of the availability of limited coronal views )usually comprisingappro$imately si$ coronal views of the ma$illary, ethmoid, sphenoid, and frontal sinuses+ that areoptimally sufficient for ruling out sinusitis. 6ore detailed coronal slices are useful for viewing theostiomeatal comple$ and for surgical mapping.  Transillumination   common practice before plain radiographs and CT scans were widely available, it is of limiteduse, with a high rate of error.  Ultrasonography This method has not been proved accurate enough to substitute for a radiographic evaluation.%owever, it may be considered to confirm sinusitis in pregnant women, for whom radiographicstudies may pose a risk.  Nasal Smear  By e$amining the cellular contents of the nasal secretions, one may find polymorphonuclear cellsand bacteria in sinusitis. In a viral infection, these would not be found, and in allergic disease, onewould e$pect eosinophils.  Sinus uncture The most accurate way to determine the causative organism in sinusitis is a sinus puncture. fter anestheti5ation of the puncture site, usually in the canine fossa or inferior meatus, the contents of the ma$illary sinus are aspirated under sterile techni=ues, and bacterial cultures are performed toidentify the organism. Culture specimens obtained from nasal swabs correlate poorly with sinuspathogens found by puncture because of contamination of the swab with normal nasal flora.%owever, because sinus puncture is an invasive procedure, it is not routinely performed. 6orerecently, studies have shown a close correlation between organisms found by sinus puncture andby endoscopically guided aspiration of the sinus cavities through the middle meatus. lthough thisneeds to be done by an otolaryngologist trained in the procedure, it may be necessary for defining the pathogenic organism when standard therapy has failed or in an immunocompromised  patient who is at high risk for se=uelae of untreated sinusitis, such as orbital or central nervoussystem complications.&.ComplicationsChronic sinusitis complications include!  Asthma !lare ups.  Chronic sinusitis can trigger an asthma attack.  $eningitis%  an infection that causes inflammation of the membranes and fluid surrounding your brain and spinal cord.  &ision problems.  If infection spreads to your eye socket, it can cause reduced vision or evenblindness that can be permanent.  Aneurysms or blood clots.  Infection can cause problems in the veins surrounding the sinuses,interfering with blood supply to your brain putting you at risk of a stroke.&I.6edical4urgical 6anagement  Saline nasal spray%  which you spray into your nose several times a day to rinse your nasalpassages.  Nasal corticosteroids.  These nasal sprays help prevent and treat inflammation. ;$amplesinclude fluticasone )Alonase+, budesonide )hinocort =ua+, triamcinolone ):asacort +,mometasone ):asone$+ and beclomethasone )Beconase+.  Oral or in'ected corticosteroids.  These medications are used to relieve inflammation fromsevere sinusitis, especially if you also have nasal polyps. ;$amples include prednisone andmethylprednisolone. 8ral corticosteroids can cause serious side effects when used long term, sothey?re only used to treat severe asthma symptoms.  econgestants.  These medications are available in over-the-counter )8TC+ and prescriptionli=uids, tablets and nasal sprays. ;$amples of 8TC oral decongestants include 4udafed and  ctifed. :asal sprays include phenylephrine ):eo-4ynephrine+ and o$ymeta5oline ) frin+. Thesemedications are generally only taken for a few days at mostE otherwise they can cause the returnof more severe congestion )rebound congestion+.  Over(the(counter pain relievers  such as aspirin, acetaminophen )Tylenol, others+ or ibuprofen) dvil, 6otrin, others+. Because of the risk of eye?s syndrome # a potentially life-threateningillness # never give aspirin to children.  Aspirin desensiti)ation treatment%  if you have reactions to aspirin that cause sinusitis.%owever, this treatment can have serious complications such as intestinal bleeding or severeasthma attacks.  Antibiotics    ntibiotics are sometimes necessary for sinusitis if you have a bacterial infection. %owever,chronic sinusitis is usually caused by something other than bacteria and antibiotics won?t help.  ntibiotics used to treat chronic sinusitis caused by a bacterial infection include amo$icillin) mo$il, Trimo$, others+, do$ycycline )Dory$, 6onodo$, others+ or the combination drugtrimethoprim-sulfametho$a5ole )Bactrim, 4eptra, others+. If the infection doesn?t subside or if thesinusitis comes back, your doctor may try a different antibiotic.  Immunotherapy  If allergies are contributing to your sinusitis, allergy shots )immunotherapy+ that help reduce thebody?s reaction to specific allergens may help treat the condition.

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