Infective Rhinosinusitis

15 March 2016 Articles 11967
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Epidemiology

Sinusitis accounts for the 5th most common cause of antibiotic use in the US, affecting over 30 million Americans annually(1). This figure is based on the clinical diagnosis by primary care physicians or specialists in otolaryngology.

Definition

Sinusitis is defined as acute when episodes of infection resolve with medical therapy, leaving no significant mucosal damage. In chronic sinusitis the disease is persistent and may not be alleviated by medical therapy alone (2). Clinically speaking patients with chronic rhinosinusitis would have symptoms for over 12 weeks. The more traditional term sinusitis is slowly being replaced by the term ‘rhinosinusitis’ as inflammation or infection in the nasal cavities almost always involves the sinus mucosa (3). Staging systems for sinusitis have been devised which take into account patient symptoms, radiological criteria and nasal endoscopic findings. Clinically, however, the criteria for diagnosis of chronic rhinosinusitis are by no means set in tablets of stone.

 

Bacteriology

Most cases of acute sinusitis arise as a complication of a viral upper respiratory tract infection (URTI) and the maxillary sinuses are commonly involved (4). Sinusitis develops as a complication in 0.5 to 5% of all URTI’s (5). The commonest microorganisms cultured from maxillary sinus puncture include Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarhalis(6). It is thought that mixed infection is common in chronic sinusitis with the involvment of anaerobic species such as peptostreptococci, corynebacteria, bacteroides and veilonella (7).

Less commonly fungal sinusitis may be seen in the immunocompromised patient. Fungal sinusitis may present as a fungal ball (Aspergillus, Candida) or as invasive disease of the skull base (eg mucor species).

 

Risk Factors and pathophysiology

Allergic rhinitis, whether seasonal or perennial, increases the risk of sinusitis (8)(9). The mechanism here is thought to be obstruction of sinus ostia from nasal inflammation and swelling, resulting in mucus stasis and infection. Mechanical obstruction of the nose due to deviated septum, nasal polyps, tumours or foreign bodies may cause sinus ostia obstruction and infection.

Just over one litre of mucus is produced daily by the nasal passages and forms a blanket, which is propelled against gravity by the delicate ciliated lining. The mucus acts as a dust trap. As air enters the cavities of the nose, turbulence is set up, causing dust particles to stick to this mucus blanket. Mucus is then swallowed and digested by the stomach (10). Nasal cilia beat approximately at 11.5Hz and this remains constant despite advancing age (11). In vitro studies have shown that nasal ciliary beat frequency (CBF) is reduced in the presence of cotinine, the main breakdown product of nicotine (12). Nasal CBF is reduced in the presence of infection and mucociliary activity improves after treatment for sinusitis (13, 14). In conditions such as ciliary dyskinesia where the cilia beat asynchronously accumulation of mucus occurs. In patients with cystic fibrosis the excessively thick mucus secretion cannot be successfully swept by cilia in the normal way. Both these latter conditions predispose to chronic sinusitis.

 

Symptoms and signs

In a multi-centre European study of acute maxillary sinusitis (15) the main symptoms in 569 patients were nasal obstruction, purulent nasal discharge and headache. Facial pain, impaired sense of smell and fever were less common.

In 290 Maltese patients with a clinical diagnosis of sinusitis of over three months’ duration, whose symptoms were resistant to conventional therapy, the primary symptom was headache (48%) followed by nasal obstruction (29%) and post-nasal drip (18%) (16). Other symptoms may include referred pain to the teeth, halitosis and eustachian tube dysfunction with middle ear effusion.

 

Complications

Due to the close proximity of the sinuses to the eyes and frontal lobe, and the thin bone separating the sinuses from these structures, local complications of untreated sinus sepsis include orbital cellulitis and abscess, meningitis, extradural,subdural and intradural abscesses, cavernous sinus thrombosis and cortical thrombosis.

 

Imaging

CT scans of the sinuses are the gold standard for diagnostic imaging (17). Fig 1 shows a normal CT scan of the sinuses with well-aerated sinuses. CT is powerful tool that helps the clinician delineate site and extent of disease, and is essential in defining surgical landmarks. When correlated together with patient symptoms and nasal endoscopic findings, partial or complete thickening of sinus mucosa indicates sinusitis. Fluid levels within the sinuses or opacification of sinuses are frequent findings (Fig 2). However, the correlation of patient symptoms with CT findings is poor (18) (19). This is especially true in patients where pain is the primary symptom. Out of 138 Maltese patients with a clinical diagnosis of chronic rhinosinusitis presenting mainly with facial pain, only 51 (37%) had radiological confirmation of their diagnosis. 37% had rhinitis only with mucosal thickening (Fig 3) and 22% had normal findings (16).

Fig 1 Normal sinus CT

Fig 2 Patient with widespread sinus mucosal thickening and fluid levels

Fig 3. Patient with rhinitis-note mucosal thickening but clear, well-aerated sinuses. Such patients often present with nasal obstruction and facial pain

 

 

Treatment

Traditionally, antibiotic therapy for acute sinusitis consists of amoxicillin, 500mg three times daily for about 10 days or its equivalent. The last years, however, have been characterised by the emergence of resistant strains. Between 75 and 90% of Moraxella catarrhalis and 25-35% of Haemophilus influenzae strains are Beta lactamase producers (20). Almost all strains of Pseudomonas and Staphylococcus aureus are similarly resistant. Newer antibiotics have shown comparable clinical recovery with shorter duration of treatment.

Functional endoscopic sinus surgery (FESS) has become the procedure of choice for surgical treatment of chronic rhinosinusitis (21). In recent years FESS has been shown to give much better results compared to previous techniques such as the Caldwell-Luc operation (22). The philosophy of this technique aims at normalizing mucociliary flow from the sinuses by removing obstruction to sinus drainage, especially in the region of the ostio-meatal complex (middle meatus of the nose). Bony passages are enlarged and normal mucosa preserved as much as possible.

 

Outcome and patient quality of life

Undoubtedly, the clinician’s role is to alleviate patient hardship and improve quality of life. Due to the variability of the nature of patient symptoms and the inability to objectively measure the severity of chronic sinusitis the decision to proceed to surgery is based on subjective clinical grounds. Outcome of surgery often does not reflect upon the severity of the condition preoperatively (23). In spite of this, success rates in terms of patient satisfaction are high, ranging between 75 and 95% (24, 25).

 

Conclusion

The clinical analysis of patients with sinus symptoms is a challenge to physicians. If, following adequate treatment with antibiotics and decongestants patients are still symptomatic specialist referral is advised. Imaging in the form of coronal sinus CT is required especially if surgical treatment is envisaged.

 

References

 

  1. Benninger MS, Ferguson BJ, Hadley JA et al. Adult chronic rhinosinusitis: Definitions, diagnosis, epidemiology and pathophysiology. Otlaryngol Head Neck Surg 2003; 129(suppl 3): S1-S32
  2. Lund VJ and Kennedy DW. Quantification for staging sinusitis. Ann Otol Rhinol Laryngol 1995; 104 Suppl 167: 17-21
  3. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otlaryngol Head Neck Surg 1997; 117
  4. Daley DL, Sande M. The Runny nose: Infection of the paranasal sinuses. Infect Dis Clin North Am 1988; 2:131
  5. Giebink GS. Childhood sinusitis: Pathophysiology, diagnosis and treatment. Paediatr Infect Dis J 1994; 13: 55-58
  6. Hamory BH, Sande MA, Snydor A et al. Etiology and antimicrobial therapy of acute maxillary sinusitis. J Infect Dis 1979; 139:197
  7. Bolger WE, Kennedy DW. Changing concepts in chronic sinusitis. Hosp Pract 1992; 27:20
  8. Savolainen S. Allergy in patients with acute maxillary sinusitis, Allergy 1989; 44:116-22
  9. Yariktas M, Doner F and Demirci M. rhinosinusitis amoung patients with perennial or seasonal allergic rhinitis. Asian Pac J Allergy Immunol 2003; 21(2): 75-8
  10. Maltinski G. Nasal disorders and sinusitis. Prim Care Clin Off Pract 1998; 25(3): 663-683
  11. Agius AM, Smallman LA, Pahor AL. Age, smoking and nasal ciliary beat frequency. Clin Otolaryngol 1998; 23(3): 227-230
  12. Agius AM, Wake M, Pahor AL, Smallman LA. The effects of in vitro cotinine on nasal ciliary beat frequency. Clin Otolaryngol 1995, 20:465-469
  13. Asai K, Haruna S, Otori N et al. Saccharin test of maxillary sinus mucociliary function after endoscopic sinus surgery Laryngoscope. 2000; 110 (1):117-22
  14. Guo Y, Majima Y, Hattori M et al. Effects of functional endoscopic sinus surgery on maxillary sinus mucosa. Arch Otolaryngol Head Neck Surg. 1997; 123 (10):1097-100.
  15. Penttila M, Savolainen S, Kiukaanniemi H et al. Bacterial findings in Acute Maxillary Sinusitis-European Study. Acta otolaryngol (Stockh) 1997; Suppl 529: 165-168
  16. Agius AM, Vassallo P Personal Data
  17. Strong EB, Senders CW. Surgery for severe rhinosinusitis. Clin Rev Allergy Immunol 2003: 25(2): 165-76
  18. Bhattacharyya T, Piccirillo J, Wippold FJ. Relationship between patient-based descriptions of sinusitis and paranasal sinus computed tomographic findings. Arch Otolaryngol Head Neck Surg 1997; 123(11): 1189-92
  19. Stewart MG, Johnson RF. Chronic sinusitis: symptoms versus CT scan findings. Curr Opin Otolaryngol Head Neck Surg 2004; 12(1): 27-9
  20. Brook I. Microbiology of common infections in the upper respiratory tract. Prim Care Clin Off Pract 1998; 25(3): 633-648
  21. Lieu JE, Piccirillo JF Methodologic assessment of studies on endoscopic sinus surgery. Arch Otolaryngol Head Neck Surg. 2003; 129(11): 1230-5.
  22. Harkness P, Brown P, Fowler S et al. A national audit of sinus surgery. Results of the Royal College of Surgeons of England comparative audit of ENT surgery. Clin Otolaryngol 1997; 22(2): 147-151
  23. Jones ML, Piccirillo JF, Haiduk A et al. Functional endoscopic sinus surgery: do ratings of appropriateness predict patient outcomes? Am J Rhinol 1998; 12(4): 249-255
  24. Acquadro MA, Salman SD, Joseph MP. Analysis of pain and endoscopic sinus surgery for sinusitis. Ann Otol Rhinol Laryngol 1997; 106(4); 305-309
  25. Senior BA, Kennedy DW, Tanabodee J et al. Long-term results of functional endoscopic sinus surgery. Laryngoscope 1998; 108(2); 151-157

 

 

©Mr. Adrian M Agius MD, FRCS (Ed), M Med Sc(Bham) - ENT Surgeon

Last modified on Thursday, 21 February 2019 10:19