Professional Documents
Culture Documents
SINUSITIS
By SIYAD.A.R M.Pharm
Crescent college of
pharmaceutical
sciences,Kannur,kerala
HYGEIA JOURNAL FOR
DRUGS AND
MEDICINES
www.hygeiajournal.com
ISSN 0975 6221
Vol.2,no.1 ,2010
SINUSITIS
Siyad A R
--------------------------------------------------------------------------------------------
S
inusitis is the fifth common diagnosis for which an antibiotic is prescribed and about $ 2 billion is spent
annually on medications to treat nasal and sinus problems. Diagnosing and treating sinusitis is therefore being
very important. Acute bacterial sinusitis usually occurs following an upper respiratory infection that result in
the obstruction of the osteomeatal complex, impaired mucociliary clearance and production of secretions. (L J
Fagnan. et al., 1998)
Acute sinusitis is a common illness in primary care diagnosis of acute bacterial sinusitis is usually based
.Studies have demonstrated the difficulty of making on physical findings, no one sign or symptom is
the differential diagnosis of acute purulent sinusitis either sensitive or specific for sinusitis. The
based on clinical evaluations alone. This leads to a predictive power can be significantly improved when
significant overuse of antibiotics, which in turn may all signs and symptoms is either sensitive or specific
contribute to increase bacterial resistance. (Morten for sinusitis. (Martin Desrosiers. et al., 2002)
Lindback. et al., 2002)
There is solid evidence that a positive association
Sinus disease is inherently associated with viral upper between nasal allergy and acute or chronic sinusitis
respiratory tract infections and occurs in 90% of in both adult and children. (Shin- Wen Huang. et al.,
individuals with common cold. Although the 2006
Acute sinusitis frequently follows upper respiratory Sinusitis is a prevalent and important cause of
tract infections. Sinusitis or an inflammation of one morbidity in adults. In the US alone, people with the
or more of the para nasal sinuses, affects sinus disorders spend more than $ 2 billion annually
approximately 16% of US adults, resulting in nearly
on over the counter medications and make 16 million
$ 5.8 billion in annual healthcare costs. (Lauria
Barclay et al., 2005) physician visits each year in pursuit of symptomatic
relief. (J W William Jr. et al., 2007)
Chronic para nasal sinusitis is generally a mild
disease. How ever it is important to realize that it Acute rhinosinusitis is one of the most common
afflicts a significant percentage of the population and reasons for the prescribing antibiotics in primary
causes considerable long term morbidity. (Patrick. care. However it is not clear whether antibiotics
W. Doyle. et al., 1991) improve the out come for patients with clinically
diagnosed acute rhinosinusitis. (Heiner. C. Bucher. et
Acute sinusitis in children is often associated with al., 2003)
two main predisposing factors: viral colds and
allergies. (Mary. E. Temple et al., 2000)
Contact:+ 91
INTRODUCTION
This includes posterior ethmoidal sinuses which open MUCOUS MEMBRANE OF PARA NASAL
in the superior meatus, and the sphenoid sinus which SINUSES
open in spheno-ethmoidal recess.
Paranasal sinuses are lined by mucous membrane
MAXILLARY SINUS (ANTRUM OF which is continuous with that of the nasal cavity
HIGHMORE) through the ostia of sinuses. It is thinner and less
vascular compared to that of the nasal cavity.
It is the largest of paranasal sinuses and occupies the Histologically it is ciliated columnar epithelium with
body of maxilla. goblet cells which secrete mucus. Cilia are more
marked near the ostia of sinuses and help in drainage
It is pyramidal in shape with base towards lateral wall
of mucus into the nasal cavity.
of nose and apex directed laterally into the zygomatic
process. On an average, maxillary sinus has a
capacity of 15 ml in an adult.
Paranasal sinuses develop as outpouchings from the It is not clear why nature provided paranasal sinuses.
mucous membrane of lateral wall of nose. At birth Probable functions of paranasal sinuses are:
only the maxillary and ethmoidal sinuses are present
and are large enough to be clinically significant. Air–conditioning of the inspired air
by providing large surface area over
Growth of sinuses continues during childhood and which the air is humidified and
early adult life. Radiologically maxillary sinuses can warmed.
be identified at 4-5 months, ethmoid at 1 year, To provide resonance to voice.
frontals at 6 years and sphenoids at 4 years. To act as thermal insulators to protect
the delicate structures in the orbit and
LYMPHATIC DRAINAGE the cranium from variations of
intranasal temperature.
The lymphatics of maxillary, ethmoid, frontal and
To lighten the skull bones.
sphenoid sinuses form a capillary network in their
SINUSITIS 1,2
lining mucosa and collect with lymphatics of nasal
cavity. Then they drain into lateral retropharyngeal Sinusitis is the inflammatory condition of the mucous
and/or jugulodigastric nodes. membrane lining of the sinuses. It may be of two
types.
PHYSIOLOGY OF PARANASAL SINUSES
ACUTE SINUSITIS
VENTILLATION OF SINUSES
CHRONIC SINUSITIS
Ventillation of paranasal sinuses takes place through Acute sinusitis is the acute inflammation of the sinus
their ostia. During inspiration air current causes mucosa. This is having a rapid onset with severe
negative pressure in the nose. This varies from -6mm symptoms and a sharp course. The treatment may be
to -200 mm of H2O depending on the force of either medical or surgical but usually
inspiration. During expiration, positive pressure is pharmacotherapy is the choice of treatment.
created in the nose and this sets up eddies which
Chronic sinusitis is a disorder, i.e. inflammation of
ventilate the sinuses. Thus ventillation of sinuses is
the sinus mucosa for a long time lasting for months
paradoxical: they are emptied of air during
or years. Most important cause of chronic sinusitis is
inspiration and filled with air during expiration.
failure of acute infection to resolve. Initial treatment
of chronic sinusitis is conservative including different
drugs. Most often some form of surgery is required
MUCUS DRAINAGE OF SINUSES either to provide free drainage and ventilation.
natural ostia or not. A closed sinusitis causes more 2. STASIS OF SECRETIONS IN THE NASAL
severe symptoms and is also likely to cause CAVITY
complications. Normal secretions of nose may not drain into the
nasopharynx because of their viscosity (cystic
AETIOLOGY OF SINUSITIS IN GENERAL fibrosis) or obstruction (enlarged adenoids, choanal
atresia) and get infected.
A. EXCITING CAUSES
1. NASAL INFECTIONS 3. PREVIOUS ATTACKS OF SINUSITIS
Sinus mucosa is a continuation of nasal mucosa and Local defenses of sinus mucosa are already damaged.
infections from nose can travel directly by continuity
or by way of submucosal lymphatics. Most common GENERAL
cause of acute sinusitis is viral rhinitis followed by
bacterial invasion. ENVIRONMENT
5. REDNESS AND OEDEMA OF CHEEK Postural test- If no pus is seen in the middle meatus,
Commonly seen in children. The lower eye lid may it is decongested with a pledget of cotton soaked with
become puffy. a vasoconstrictor and patient made to sit with the
affected sinus turned up. Examination after 10-15
minutes may show discharge in the middle meatus.
6. NASAL DISCHARGE
AETIOLOGY MEDICAL
1. Usually follows viral infections of upper This is same as for acute maxillary sinusitis i.e.
respiratory tract followed by later bacterial antimicrobials decongestion of the sinus ostium for
invasion. drainage and analgesics. A combination of
2. Entry of water into the sinus during dividing antihistamine with an oral nasal decongestant
or swimming. (pseudoephedrine or phenylephrine hydrochloride) is
3. External trauma to the sinus. eg. Fractures or useful. Placing a pledget of cotton soaked in
penetrating injuries. vasoconstrictor in the middle meatus once or twice
4. Oedema of middle meatus, secondary to daily helps to relieve ostial oedema and promotes
associated ipsilateral maxillary or ethmoid sinus drainage and ventilation. If patient shows
sinus infection. response to medical treatment and pain is relieved,
Predisposing factors, pathology and treatment is continued for full 10 days or two weeks.
bacteriology are the same as in acute maxillary
sinusitis in general. SURGICAL
1. HEAD ACHE
Usually localized to the occiput or vertex. Pain may
CLINICAL FEATURES also be referred to the mastoid region.
4. SWELLING OF THE MIDDLE TURBINATE Mucocele of the sphenoid sinus or its neoplasms may
clinically stimulate the features of acute infection of
TREATMENT sphenoid sinus and should always be excluded in any
case of isolated sphenoid sinus involvement.
Medical treatment is the same as for acute maxillary
sinusitis. Visual deterioration and exophthalmos
indicate abscess in the posterior orbit and may
require drainage of the ethmoid sinuses into the nose TREATMENT
through an external ethnoidectomy incision.
Treatment is same as for acute infection of other
Complications sinuses.
such as loss of cilia, oedema and polyp formation, Initial treatment of chronic sinusitis is conservative
thus continuing the vicious cycle. including antibiotics, decongestants, antihistaminics
and sinus irrigations. More often some form of
PATHOLOGY surgery is required either to provide free drainage and
ventilation or radical surgery to remove all
In chronic infections, process of destruction and
irreversible diseases so as to provide wide drainage
attempts at healing proceed simultaneously. Sinus
or to obliterate the sinus.Recently endoscopic sinus
mucosa becomes thick and polypoidal (hypertrophic
surgery is replacing radical operations on the sinuses
sinusitis) or undergoes atrophy (atrophic sinusitis).
and provides good drainage and ventilation.
Surface epithelium may shows desquamation,
regeneration or metaplasia. Submucosa is infiltrated SURGERY FOR CHRONIC SINUSITIS
with lymphocytes and plasma cells and may show
micro abscesses granulations, fibrosis and polyp CHRONIC MAXILLARY SINUSITIS
formation.
ANTRAL PUNCTURE AND
BACTERIOLOGY IRRIGATION
INTRANASAL ANTROSTOMY
Mixed aerobic and anaerobic organisms are often CALDWELL-LUC OPERATION
present. CHRONIC FRONTAL SINUSITIS
CLINICAL FEATURES INTRA NASAL DRAINAGE
OPERATIONS
They are often vague and similar to those of acute
TREPHINATION FRONTAL SINUS
sinusitis but of lesser severity. Purulent nasal
EXTERNAL
discharge is the commonest compliant. Foul–
FRONTOETHMOIDECTOMY
smelling discharge suggests anaerobic infection.
(HOWARTH’S OR LYNCH
Local pain and headache are often not marked except
OERATIONS)
in acute exacerbations. Some patients complain of
OSTEOPLASTIC FLAP OPERATION
nasal stuffiness and anosmia.
CHRONIC ETHMOID SINUSITIS
DIAGNOSIS
INTANASAL ETHMOIDECTOMY
1. X-ray of involved sinus. It may show EXTERNAL ETHMOIDECTOMY
mucosal thickening or opacity. CHRONIC SPHENOID SINUSITIS
2. X-rays after injection of contrast material
SPHENOIDOTOMY
may show soft tissue charges in sinus
COMPLICATIONS OF SINUSITIS98
mucosa.
3. CT scan is particularly useful in ethmoid So long as infection is confined only to the
and sphenoid sinus infection and has sinus mucosa, it is called sinusitis. Complications are
replaced studies with contrast materials. said to arise when infection spreads into or beyond
4. Aspiration and irrigation the walls of the sinus. They are grouped as under
Finding of pus in the sinus is
confirmatory. 1. ORBITAL COMPLICATIONS
2. OSTEOMYELITIS
TREATMENT 3. INTRA CRANIAL
4. DESCENDING INFECTIONS
It is essential to search for underlying aetiological
5. FOCAL INFECTIONS
factors which obstruct drainage and ventilation. A
ORBITAL COMPLICATIONS
work up for nasal allergy may be required. Culture
and sensitivity of sinus discharge helps in the proper Orbit and its contents are closely related to the
selection of an antibiotic. ethmoid, frontal and maxillary sinuses, but most of
the complications, however, follow infections of
ethmoids as they are separated from the orbit only by FOCAL INFECTIONS
thin lamina of bone-lamina papyracea. Infections
travel from these sinuses either by osteitis or as a The role of sinus infections to act as focus of
thrombophlebitic process of ethmoidal veins. infection is doubtful. A few conditions such as
polyarthritis, tenossynovitis, fibrositis and certain
Orbital complications include skin diseases may respond to elimination of infection
in the sinuses.
1. Inflammatory oedema of lids
2. Subperiosteal abscess MUCOCELE OF PARANASAL SINUSES
3. Orbital cellulites
4. Orbital abscess The sinuses commonly affected by
5. Superior orbital fissure syndrome mucocele in the order of frequency are the frontal,
6. Orbital apex syndrome ethmoidal, maxillary and sphenoidal. There are two
views in the genesis of a mucocele.
----------------------------------------------------------------------------------------------------------------------------------------
Pharmacist can play a major role in the management of the disease. Pharmacist can educate the patients
about the use of monitoring devices, medications, screening for un favorable interactions, identification of the
complications of sinusitis, about the side effects and minimization of it and use of different approaches for the
adherence of the treatment plan. Physicians and pharmacists must join their hands and share their individual
knowledge and experience to act synergistically for providing an effective treatment regimen and improve the quality
of life in patients.
BIBLIOGRAPHY
1. Diseases of the Nose, Throat and Ear. A Hand Book for students and practitioners by I. Simon hall,
fourth edition, Page No.79-125.
2. Scott and Brown’s Otolaryngology, sixth edition volume-4, Rhinology edited by Ian. S. Mackary and
T.R.Boll. Page No: 4.8.1-4.8.49; 4.12.1-4.12.29; 4.13.1- 4.13.11.
3. Diseases of Ear, Nose and Throat, Second edition by P.L. Dhingra, page No: 188- 202.
4. Hall and Colman’s diseases of the nose, Throat and Ear and Head and Neck, A Hand Book for students
and practitioners, Bernard. H. Colman, Fourteenth edition section-2, Page No: 45-73.
5. Logan Turner’s Diseases of the Nose, Throat and Ear edited by J.F. Birrell. Ninth edition, section-I,
Page No. 1- 106.
6. A text book of head and neck anatomy by K.B.Bertovitz,
J. Moxnam, page no: 242- 271.
7. Pathology of granulomas and neoplasms of the nose and paranasal sinusis by Imrich Triedmann and
Denis. A. Osborn.
8. Boie’s Fundamentals of otolaryngology. Fifth edition. A text book of Ear, nose and Throat diseases.
Asian edition. Page No. 393 – 414.
9. A.G. Likhachex, Diseases of the Ear, Nose and Throat, Page No.: 117 – 173.
10. Hand book of diseases of Nose, Throat and Ear by Dulal. K R. Basu, Page No: 5-7 & 43 -51.
11. A short text Book of diseases of Nose, Throat and Ear for students and practitioners by K.R.
Bhargawa, S.K. Bhargawa and T.M. Shah, Page No.: 149-168, 232 – 244.
12. Neeraj Singh, NH Bhalodiya, Allergic fungal sinusitis (AFS) –Earlier diagnosis and management. The
journal of Laryngology and Otology 2005, November; vol. 119: 875 – 881.
13. Itzhak Brook. Microbiology and antimicrobial management of sinusitis. The journal of laryngology and
otology, 2005 April; vol. 119: 251 – 258.
14. Klossek.J.M.Sinegert.R.Nikolaidis.P, et al. Comparison of the efficacy and safety of moxifloxacin and
trovafloxacin for the treatment of acute bacterial maxillary sinusitis in adults. Journal of laryngology,
2003 January; Vol. 117, Issue. 1; Page.43.
15. Trinh.N, Ngo.H.H, Practice variations in the management of sinusitis. The journal of otolaryngology,
2000 August; Vol. 29. Issue. 4: page. 211.
16. L.J.Fagan. Acute sinusitis : A cost effective approach to diagnosis and treatment. American Family
Physician. 1998 November.
17. Krystal Revai, Laura A Dobbs, Sangeeta Nair et al. Incidence of acute otitis media and sinusitis
complicating upper respiratory tract infections: The effect of age. Pediatrics 2007 June; vol.119.Issue.6;
page E1408.
18. Dinaz.K.Irani, Makarand.V.Damle. Medical management of sinusitis. Cochrane Data Base of
systematic Reviews 2007 Issue 1.
19. Knut Stavem, Edna Rossbery and Pal.G.Larrson. Reliability, validity and responsiveness of a
Norwegian version of the chronic sinusitis survey. Bio Med Central Ear, Nose and Throat Disorders
2006, 6:9; 10- 1186/1472- 6815-6/9.
20. Horacio Ariza, Ramon Rajas, Peter Johnson et al. Eradication of common pathogens at day 2, 3 and 4
of moxifloxcin therapy in patients with acute bacterial sinusitis. Bio Med Central Ear, nose and Throat
Disorders 2006, 6:8; 10.1186/1472-6815/6/8.
21. J.W. William.Jr, C. Aguilar, J. Cornell et al, Antibiotics for acute maxillary sinusitis. Cochrane data
base of systematic Review 2007, Issue 3.
22. Michael Halpern, Jordana Schmier et al., Antimicrobial treatment patterns, resource utilization and
charges associated with acute sinusitis in asthma patients. American Journal of Health System Pharmacy
2000 May; vol. 57: 875- 881.
23. Mary. E. Temple, Milap.C. Mahata, Pharmacotherapy of acute sinusitis in children. American Journal
of Health System Pharmacy 2000 April; Vol. 57, 664-668.
24. Bill Zepf, Antibiotics for Acute Sinusitis. American family Physician 2004 October; 70, 7; ProQuest
Medical Library Page 1367.
25. Jane. M. Garbutt, Marion Goldstein, et al., A randomized placebo-controlled trial of antimicrobial
treatment for children with clinically diagnosed acute sinusitis. Pediatrics 2001 April; Vol. 107 No: 4,
pp. 619-625.
26. Text Book of the Ear, Nose and Throat by Lt. Col. B.S. Tuli and Isha Preet Tuli First Edition, Page No.
186- 197.
27. www.ncbi.nlm.nih.gov/pubmed
28. www.indmed.nic.in
29. www.sciencedirect.com
30. www.embase.com
31. www.emedicine.com
32. www.entjournal.com
33. www.medscape.com
34. www.x-plain.com
35. www.elseiver.com