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RHINO-SINUSITIS: DISEASE DIAGNOSIS & MANGEMENT
Written by Jasbir Singh Bhandari
RHINO-SINUSITIS: DISEASE DIAGNOSIS & MANGEMENT

Abstract: Sinusitis is one of the most commonly encountered diseases by an E.N.T. surgeon, which though today not a life threatening disorder, needs proper diagnosis and management so that the patient can be relived of the frustrating problem.
Definition: sinusitis is defined as any inflammation of the mucosal lining of the sinuses. Most common inflammation of the Para nasal sinuses and the nose is common cold.

Facts about sinusitis

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1. It is the most common health problem in U.S. and effects more then 31 million people yearly.
2. Acute sinusitis is rarely limited to one sinus only and mainly involves osteomeatal complex.
3. Theses days emphasis is mainly laid on early recognition of predisposing factors in the development of sinusitis.

Anatomy and function of Sinuses

Sinus There are four sinuses namely the frontal, ethmoid, maxillary and sphenoid in an adult. Maxillary and ethmoid sinuses are present at birth while sphenoid and frontal sinuses appear at 2nd or 3rd year of life. Complete development generally occurs by 18th year of life.
A simple description follows:

Frontal Sinus:

  • Varies greatly in size and shape
  • Nasofrontal duct drains into the fronto-ethmoidal recess located in middle meatus.
  • 10% of the adults may demonstrate a rudimentary or non-pnumatised frontal sinus.

Ethmoid Sinus:

  • Most developed sinus at birth.
  • Anterior and middle ethmoid sinus cells drain into middle meatus while posterior cells drain into superior meatus.
  • Ostia are approximately 1-2 mm in diameter.
  • Sinuses are separated from the orbit by very thin plate of bone, the lamina papyracia, therefore the infection can rapidly penetrate this thin plate of bone leading rapidly to complications.

  • Maxillary Sinus:

    • Generally present at birth.
    • When fully developed they are pyramidal in shape.
    • Ostium drains into middle meatus.
    • Average diameter is 2.5 mm.
    • Frequently one or more accessory ostia are located in the anterior middle meatus.

  • Sphenoid Sinus:

    • Starts to develop at second or third year of life and fully pneumatised at 17th or 18th year of life.
    • Drain into spheno-ethmoid recess.

  • Function of Sinuses:

    1. Dampening of sudden increased intranasal pressure.
    2. Voice resonance.
    3. Possible participation in olfaction.
    4. Humidification of inspired air.
    5. Reducing the weight of skull.

    Ostiomeatal complex

    Sinus This is the main anatomic area where mucosal swelling and obstruction cause significant disturbance in physiology of the sinuses which can lead to significant disease and resultant symptoms.
    When the mucosa of the paranasal sinus become swollen and inflamed by any mechanism, two opposing mucosal layers often come into direct contact. Messerkliger (1978) noted that the touching of the mucosal surfaces disrupt the mucociliary clearance. Anatomically, these areas of direct mucosal contact are most likely to occur in the narrow channels of ethmoid infundibulum and ethmoidal cell system. Subsequently, any event that occludes the anterior ethmoidal cells may result in mucosal inflammation sufficient to occlude the maxillary or frontal sinus or may allow spread of infection to the maxillary or the frontal sinuses from the ethmoid infundibulum. This specific relationship between the anterior ethmoidal cells and ethmoid infundibulum complex in the ultimate pathogenesis of frontal and maxillary sinus disease led Norman to describe the area known as the osteomeatal complex. (Norman H.: Proceeding VIII International congress of Oto-rhino-laryngology, 1965). Evidence now clearly exist that severe sinus disease in the maxillary and frontal sinus can undergo resolution when normal ventilation and mucociliary clearance are restored to anterior ethmoidal cells. (Proetz AW, 1953).

    Pathophysiology of Sinusitis

    Pathophysiology of sinusitis is related to three factors:
    1. Patency of Ostia
    2. Function of cilia
    3. Quality of nasal secretions
    Alteration of any of these alone or in combination leads to change in physiology and thus sinusitis.

    1. Patency of ostia:

    The patency of the ostia can be altered by any of the following factors like edema, nasal polyps and other structural factors like prominent concha bullosa, presence of haller’s cells, septal deviation or postoperative synachia.
    Nasal polyp (Atopic or Cystic Fibrosis) / Edema (either allergen or infection induced)
    Ostial Obstruction
    Hypoxia inside sinus cavity
    (Hypoxigenation)
    Accumulation of secretions inside sinus
    (Ideal culture medium for bacteria)
    Sinusitis

    2. Quality of nasal secretions

    Normal cillary environment is composed of double layer of mucous, a superficial viscid gel layer and an underlying serous or sol layer. This mucus is produced by goblet cells interspersed between cillary columnar epithelium and sub mucosal mucous producing cells. Changes In this mucus composition like decreased elasticity or increased viscosity will alter effectiveness of cilia in clearing intranasal / intrasinus mucous which leads to accumulation of fluid and bacteria.
    Mucus composition can be altered by changes in water and electrolyte transport as in severe dehydration or in cystic fibrosis. Other important factors which increase mucus production include airway irritants, polluents, allergens and exposure to cold air. This increased mucous production leads to decreased mucus clearance. This accumulated mucus is good culture medium for bacteria leading to sinusitis.

    3. Altered ciliary clearance:

    Ineffective ciliary clearance is caused by:
    i. Slowed ciliary motility
    ii. Loss of monochronous co-ordination among cilia
    iii. Loss of ciliated cells from nasal epithelium.
    Slowed ciliary motility can be congenital as in case of primary ciliary dyskinesis (Kartagener’s Syndrome) or it can be caused by variety of insults including cold air, viral or bacterial ciliotoxins, cytokines or other mediators of inflammation.
    Normal mucus clearance is dependent upon co-ordinated activity of entire population of the ciliated cells. Any impairment of this monochronous activity leads to impaired mucus clearance. Causes like scars in nasal epithelium prevent effective motion of the mucous blanket across normal epithelium.
    Loss of ciliated cells from the nasal epithelium can be caused by injury by nasal irritants or pollutants, surgery , chronic diseases or viral or bacterial induced cell death and abnormally high intranasal airflow, leading to sinusitis.

    Disruption of ciliary clearance of
    Mucus and bacteria
    +
    Ostial Obstruction -------» Stasis -------» Infection -------» Sinus Disease
    +
    Altered rheological properties of mucous

    Predisposing factors for rhino-sinusitis:

    1. Certain systemic factors which predispose to sinusitis include:
    • Malnutrition
    • Long term steroid therapy
    • Uncontrolled diabetes
    • Blood dyscrasias
    • Chemotherapy
    • States of metabolic depletion
    2. Nosocomial sinusitis is more common in ICU patients due to above reasons while regional causes include obstruction causes by nasotracheal and nasogastric tubes.

    3. Serious immune deficiencies like IgG deficiency is a predisposing factor for sinusitis.

    4. HIV infection can lead to delayed mucociliary transport thus predisposing to sinusitis. Initially pseudomonas is an important pathogen. Latter, those affecting elsewhere, like microsporidium, cytomegalovirus, aspergillus, histoplasma, Cryptococcus and atypical mycobacterium propagate the disease.

    5. Bone marrow transplant can also predispose the patient to sinusitis.

    Local and regional causes of sinusitis

    Local predisposing causes, inspiration of dry, cold air, medications and drugs lead to impairment of mucociliary transport which causes secondary bacterial invasion and thus sinusitis.

    Regional causes include:

    • Apical dental infections
    • Nasal or midfacial trauma
    • Septal pathology causing mechanical obstruction
    • Choanal Atresia
    • Edema secondary to URTI
    • Barotraumas during air travels or swimming leading to edema of ostia
    • Swimming in contaminated waters
    • Nasal polyps, foreign bodies in nose and packing of nose
    • Nasal tumors
    • Immotile cilia syndrome

    Classification of Sinusitis

    This should be done along five lines:
    1. Clinical presentation : a) Acute
    b) Sub acute
    c) Chronic
    2. Anatomic sites of involvement:
    a) Ethmoid
    b) Frontal
    c) Sphenoid
    d) Maxillary
    3. Responsible organism:
    a) Viral
    b) Bacterial
    c) Fungal
    4. Presence of extra sinus involvement:
    a) Complicated
    b) Uncomplicated
    5. Modifying or aggravating Factors:
    a) Atopy
    b) Immunosupression
    c) Ostio-meatal obstruction
    All five are necessary for evaluating a patient of sinusitis.
    Acute sinusitis lasts for 1- 4 weeks. Treatment is medical, surgical intervention is rarely needed. Drainage may be indicated.
    In sub acute sinusitis, sinus infection lingers on from 4 weeks to 3 months. Inflammation process is still reversible. Medical management is indicated, surgery is rarely needed except for underlying predisposing factor.
    In chronic sinusitis the inflammation persists for longer than 3 months and is the result of untreated or inadequately treated sinusitis. Process is irreversible without surgical intervention.
    Viral Sinusitis mostly follows viral rhinitis. It requires no treatment except in immunocompromised patients, but it may predispose to bacterial sinusitis.
    Fungal sinusitis is divided into two types, invasive and noninvasive. Non-invasive form can occur as fungal mycetoma or allergic fungal sinusitis while invasive fungal sinusitis includes a fulminant sinusitis encountered in immunocompromised hosts.

    Microbiology of sinusitis

    Cultures taken directly from the sinus are more accurate then cultures taken from nose, nasopharynx or the oro-pharynx. Culture materials can be obtained directly from sinus puncture and levage or at the time of surgical exploration. Common organisms found are as follows:

    Acute (Community acquired) Sinusitis:

    • Streptococcus Pnemoniae
    • H.Influenzae
    • Moraxella ( Branhamella) cattarhalis
    • Other streptococci
    • Anaerobes like peptostreptococus, fusobacterium and bacteroids.

    Acute Nosocomial:

    • P.aeruginosa
    • Enteric gram –ve bacilli like E.coli, klebsiella, serratia, proteus and enterobacter etc.
    • S. aureus
    • Candida
    • Streptococci
    • Anaerobes

    Immunocompromised:

    • Usual organisms
    • Pseudomonas
    • Staphylococus aureus
    • Listeria monocytogenes
    • Legionella
    • Cytomegalovirus
    • Fungi like aspergilus, candida, mucor etc.
    • Atypical mycobacteria
    • Microsporidia
    • Cryptococus

    Chronic Sinusitis: (Adults)

    • Anaerobes
    • Alpha streptococci
    • H.infuenzae
    • S. aureus
    • S. pneumoniae
    • M. cattarhalis

    (Children)

    • all above plus beta streptococci

    Symptoms of sinusitis

    Symptoms are related to the location and duration of sinus involvement.
    • Most remarkable and common symptom of acute sinusitis is pain. D/D includes other facial pains.
    • Pain is usually present over the infected sinus, may be localized to frontal, Ethmoid or maxillary sinus region.
    • Patient of maxillary sinusitis complaint of pain in the cheek area which may radiate to frontal region or the teeth and is classically increased by straining and bending down. Patient may also have dental pain.
    • Ethmoid pain presents as pain in the medial portion of the nose or retro-orbital area.
    • In frontal sinusitis, pain is localized over the forehead and the patient complaints of headache which is severe in the morning and subsides towards the noon as infected material gets drained from the sinus.
    • Sphenoid sinusitis presents as vertex or bitemporal headache or pain in occipital area. It may be retro orbital.
    • Along with pain, the patient usually complaints of a mucopurulent greenish yellow discharge either unilateral or bilateral. It is found in middle meatus in case of maxillary, ant. Ethmoidal, middle ethmoidal and frontal sinus involvement. Discharge in case of sphenoid sinusitis is usually in post-nasal space through speno-ethmoidal recess.
    • There may be nasal obstruction due to oedema in the region of middle meatus. There is swelling and hyperemia of nasal mucous membrane leading to obstructive features.
    • Periorbital oedema may be present, when Ethmoid, frontal & maxillary sinuses are involved, because of close proximity of sinuses to eye. Externally there may be slight redness and swelling of cheek spreading to lower eyelid from antrum and upper eyelid from frontal sinus.
    • Along with these symptoms there may be various systemic effects like fever, malaise and lethargy.
    • In chronic sinusitis there usually is a mucopurulent discharge and symptoms of mild nasal obstruction, whereas pain and systemic symptoms are conspicuously absent. The Patient is not febrile and does not complaint of headache and facial pains.
    • Presentation of sinusitis in children is slightly different. Much less likely are the children able to complaint of classic sinus headache. Usual presentation is that of a cold, that has lasted for 7 to 10 days, daytime cough with nocturnal exacerbation, mucopurulent nasal discharge, fetid breath and low grade fever.

    Physical Examination

    Physical findings on nasal examination should carefully be noted.
    • Mucosal edema and erythema may be present
    • Note streaking of mucopurulent discharge & note the area of this discharge, which may help in determining the involved sinus.
    • Note any facial tenderness and its location. Palpate and purcuss the frontal sinus area.( Tenderness to pressure over floor of frontal sinus immediately above the inner canthus & tapping supraorbital ridge may cause severe pain.) Palpate medial orbital region (ethmoids) and anterior face as well as gingivo-buccal sulcus for maxillary sinus.
    • Look for Periorbital oedema & for malodorous breath in children
    • Examine nasopharynx for adenoidal obstruction, tumor, choanal atresia & post nasal purulent discharge.
    • Complete E.N.T. examination ( otitis media)
    • Perform Tran illumination test which is useful in frontal and maxillary sinusitis.

    Investigations

    1. Nasal endoscopy:
    • Physician has the advantage of clinically determining the sinus or sinuses involved and presence of any associated local factor that are important in etiology of sinusitis.
    • Can be performed with rigid or flexible fiber optic endoscopes.
    • Is conducted before and after topical decongestion.
    • Examine septal deformities, see middle meatus, middle and inferior turbinate as well as look for any anatomical variation, polyps tumors etc.
    2. Sinuscopy:
    With culture, biopsy or levage can be accomplished through anterior maxillary puncture under lo cal anesthesia or by insertion of an endoscope through inferior meatal puncture.
    3. Swabs and anteral levage:
    Should be taken from middle meatus or through antrostomy.
    4. Radiology of sinus:
    Plain X-Ray of sinuses is more valuable in accessing acute than chronic inflammatory disease. They may show no abnormality, mucosal thickening, fluid level or total opacity.
    5. CT Scanning:
    This has revolutionized the physician’s ability to evaluate the anatomy and abnormalities of Ostio-meatal complex as well as the extent of sinus involvement. Limitation of CT is high dose of radiation to orbit and lens in particular.
    6. Ultrasound:
    Is helpful in following resolution of acute suppurative sinusitis. Fluid filled sinus shows a back wall echo called double peak 7. Blood tests:
    Full blood counts including TLC, DLC, ESR, Urea, and electrolytes, LFT, FBS, Serum IgG, IgA and IgM may be needed.

    Treatment of Acute rhino-sinusitis

    This is primarily medical and includes analgesics, antibiotics and decongestants which help to reduce mucosal edema, increase ciliary clearance and drainage from the sinus and is thus helpful in resolution of the disease.
    1. Analgesics:
    Pain can be relived by aspirin or codeine preparations. These should be avoided in patients allergic to aspirin. Acetaminophen + NSAIDS is a good alternative.
    2. Antibiotics:
    They are the keystone to the management in acute rhinosinusitis. Amoxicillin is a good first line empiric therapy, covering gram +ve and gram –ve organisms except strains producing beta lactamase. Other acceptable and inexpensive choice for first line therapy includes erythromycin and sulfonamide combination or cephalexin plus sulfonamide.
    In patients with failed previous treatment use synthetic penicillin antibiotic with beta – lactamase inhibitor like amoxicillin plus clavulanate or ampicillin plus sulbactum.
    Other acceptable choices include clarithromycin, second generation cephalosporin’s (cefpodoxime, cefuroxime etc.).
    Quinolones like ciprofloxacin, pefloxacin, levofloxacin, sparfloxacin, ofloxacin, gatifloxacin are also used to treat sinusitis in adults. They are to be avoided in children.
    Parenteral antibiotics should be used in complicated cases like those with orbital and intracranial complications. Penetration of the antibiotic through blood brain barrier should be kept in mind. Ceftrioxone or Ampicillin plus sulbactum are good choices. Antibiotic coverage against anaerobes like metronidazole may also be needed.
    Nosocomial Sinusitis should be treated with parenteral antibiotics on basis of culture and sensitivity. Antibiotic therapy should be continued for a minimum of 7 days extending up to 10 days and even up to 3 weeks and above depending upon condition of patient.
    3. Decongestants:
    They induce vasoconstriction through alpha adrenergic receptors. The aim is to shrink the mucosa and thus improve airway and assist in sinus drainage. While there is symptomatic relief, lowered blood flow reduces speed of resolution. Long acting preparations like oxymetazoline or xylometazoline are preferred as they are more effective and have less rebound effect. They should not be prescribed for more than a few weeks. Systemic decongestants are less effective and may lead to urinary retention, elevated blood pressure, increased ocular pressure, tachycardia and dysrhythmias. They are thus best avoided in patients of hyperthyroidism, BPH, narrow angle glaucoma, hypertension and IHD and also in those who are taking MAO inhibitors.
    4. Humidification:
    May be useful especially at bed time in the form of steam.
    5. Mucolytics and expectorants:
    Such as guaifenesin are helpful in some patients especially those with thick secretions. Treatment of chronic rhino-sinusitis
    Aims in the management of recurrent or chronic sinusitis include:
    • To identify and treat underlying cause.
    • If possible to restore the functional integrity of the inflamed mucosal lining.
    • Restoration of sinus ventilation and correction of mucosal apposition, thus restoring the mucocillary clearance.
    • Anatomical obstruction needs surgical correction.
    • Physiological abnormalities are treated by medical treatment.
    Treatment modalities include antibiotics, Mucolytics, nasal irrigations, corticosteroids, and anti-allergic therapies.
    As there is much higher frequency of anaerobic organisms, metronidazole plus co-amoxyclav or clindamycin are useful.
    If the secretions are thick increased fluid intake, carrot soup or chicken soup are helpful. Potassium iodide, acetylcystine and carbocystine are also helpful. Guaifenesin is most effective.
    Nasal toilet with saline sprays or irrigations and moist heat application to face and steam inhalations are helpful.
    Corticosteroids usually as nasal sprays are useful to reduce oedema.
    Despite the above treatment ch. Sinusitis needs some form of surgery to fully relive the patients of their symptoms. FESS is the most appropriate therapy these days for the patients of chronic sinusitis.

    Conclusion

    Due to continuity of the nasal and sinus mucosa inflammation of one part defiantly affect the other part also, therefore, the term rhinosinusitis should be preferred despite rhinitis and sinusitis. The disease should be properly classified with attention to patho physiology and microbiology. A thorough physical examination and investigation are always rewarding in treating the patient.
    Author:
    Dr. J.S.Bhandari,
    M.S.Shalakya Tantra (E.N.T.)
    A.M.O., A.H.C.Dhamla,
    Distt. Sirmour (H.P.)
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