Acute and Chronic Sinusitis - A Practical Guide for Diagnosis and Treatment docx

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Acute and Chronic Sinusitis
A Practical Guide for
Diagnosis and Treatment
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Presentation Facts
• File size: approximately 2013 KB
• Number of slides: 81
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Acknowledgments
This is a presentation of the
American Academy of Family Physicians
supported by an educational grant from
Aventis Pharmaceuticals
The AAFP gratefully acknowledges
Harold H. Hedges, III, M.D.
and
Susan M. Pollart, M.D.
for developing the content for the AAFP
and

Harold H. Hedges, III, M.D. for providing the
photo images included in this slide presentation.
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Acknowledgments
Harold H. Hedges, III, M.D.
Private Practice
Little Rock Family Practice Clinic
Little Rock, Arkansas
and
Susan P. Pollart, M.D.
Associate Professor of Family Medicine
University of Virginia Health System
Charlottesville, Virginia
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Upon Completion of This Presentation
You Should be Able To
• Be knowledgeable of the causes of and risk factors associated
with sinusitis
• Differentiate acute from chronic sinusitis
• Evaluate patients by history, physical exam, appropriate
laboratory and imaging studies, and when indicated screen
patients for allergy
• Prescribe appropriate medication regimens for acute and
chronic sinusitis
• Know of the relationships between upper airway
(rhinosinusitis) and lower airway disease (asthma)
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Rhinosinusitis May be Better Term Because
• Allergic or nonallergic rhinitis nearly always precedes sinusitis
• Sinusitis without rhinitis is rare
• Nasal discharge and congestion are prominent symptoms of
sinusitis
• Nasal mucosa and sinus mucosa are similar and are contiguous
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Scope of Sinusitis
• Affects 30-35 million persons/year
• 25 million office visits/year
• Direct annual cost $2.4 billion and increasing
• Added surgical costs: $1 billion
• Third most common diagnosis for which antibiotics are
prescribed
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Normal Sinus
• Sinus health depends on:
– Mucous secretion of normal viscosity, volume, and
composition,
– normal mucociliary flow to prevent mucous stasis and
subsequent infection;
– and open sinus ostia to allow adequate drainage and aeration.
• Senior BA, Kennedy DW. Management of sinusitis in the
asthmatic patient AAAI J,1996;77:6-19.
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Development of Sinuses
• Maxillary and ethmoid sinuses present at birth

• Frontal sinus developed by age 5 or 6
• Sphenoid sinus last to develop, 8-10
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Physiologic Importance of Sinuses
• Provide mucus to upper airways
– Lubrication
– Vehicle for trapping viruses, bacteria, foreign material for
removal
• Give characteristics to voice
• Lessen skull weight
• Involved with olfaction
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Sinusitis
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4 paranasal sinuses, each lined with pseudostratified
ciliated columnar epithelium and goblet cells
– Frontal
– Maxillary
– Ethmoid
– Sphenoid
Infectious or noninfectious inflammation of 1 or more sinuses
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Normal Water’s and Towne’ s Views
of the Sinuses
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Lateral View Showing Normal

Sphenoid Sinus
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Ostiomeatal Complex
• Ostiomeatal complex is that area under the middle meatus
(airspace) into which the anterior ethmoid, frontal and
maxillary sinuses drain
• Posterior ethmoids drain into the upper meatus
• Ostiomeatal complex is the functional relationship between
the space and the ostia that drain into it
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Viral Rhinosinusitis
• Most upper respiratory infections are viral
• Short lived, last less than 10 days
• Sinus mucosa as well as nasal mucosa is involved
• Most will clear without antibiotics
• Treatment: decongestants, nasal lavage, rest, fluids
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Classification of Bacterial Sinusitis
• Acute bacterial sinusitis- infection lasting 4 weeks,
symptoms resolve completely (children 30 days)
• Subacute bacterial sinusitis
- infection lasting between 4 to
12 weeks, yet resolves completely (children 30-90 days)
• Chronic sinusitis
- symptoms lasting more than 12 weeks
(children >90 days)
• Some guidelines add treatment failure + a positive imaging

study
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Recurrent Acute Bacterial Sinusitis
• Episodes lasting fewer than 4 weeks and separated by
intervals of at least 10 days during which the patient is
totally asymptomatic
• 3 episodes in 6 months or 4/year
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Acute Sinusitis Imposed on
Chronic Sinusitis
• Patients with chronic, low grade symptoms experience
increase in mucous flow, change in viscosity or color, or
secretions
• Treated
• New symptoms resolve but chronic symptoms continue
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Differentiating Sinusitis from Rhinitis
Sinusitis
Nasal congestion
Purulent rhinorrhea
Postnasal drip
Headache
Facial pain
Anosmia
Cough, fever
Rhinitis
Nasal congestion

Rhinorrhea clear
Runny nose
Itching, red eyes
Nasal crease
Seasonal symptoms
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Road to Bacterial Sinus Infections
• Obstruction of the various ostia
• Impairment in ciliary function
• Increased viscosity of secretions
• Impaired immunity
• Mucus accumulates
• Decrease in oxygenation in the sinuses
• Bacterial overgrowth
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X-Ray Image of Sinuses with
Maxillary Sinusitis
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Pathogenesis of Nasal Obstruction
• Viral upper respiratory infections
– Daycare centers
• Allergic and nonallergic stimuli
• Immunodeficiency disorders
– Immunoglobulin deficiency (IgA, IgG)
• Anatomic changes
– Deviated septum, concha bullosa, polyps
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Allergic Stimuli Causing Rhinosinusitis
• Pollens
– Tree, grass, weeds
• House dust mite
• Animal danders
– Cat, dog, mice, gerbil, other animals with fur
• Molds
• Allergic foods and beverages
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Nonallergic Stimuli Causing Rhinosinusitis
• Tobacco smoke
• Perfumes
• Cleaning solutions
• Potpourri
• Burning candles
• Cosmetics
• Car exhaust, diesel fumes
• Hair spray
• Cold air
• Dry air
• Changes in barometric
pressure
• Auto exhaust
• Gas, diesel fuel
• Nonallergic foods
• Nonallergic beverages
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Causes of Ciliary Dysfunction
• Immotile cilia syndrome
• Prolonged exposure to cigarette smoke
• Common cold viruses causing URI
• Increased viscosity of mucus
• Medications
– First generation antihistamines (non sedating do not affect)
– Anticholinergics
– Aspirin
– Anesthetic agents
– Benzodiazepines