Acute sinusitis is an acute inflammation of the mucosa of one or all of the para-nasal sinuses. The inflammation may be suppurative or non-suppurative.
It is usually due to a pyogenic secondary invasion of the mucous membrane after the normal defenses of the nose, the muco-ciliary blanket and lysozyme are breached by an acute virus invasion. Acute sinusitis following coryza usually affects initially all the sinuses.
It may also occur after trauma or dental extraction. Following trauma such as fractures of the maxilla and frontal bones acute sinusitis may be limited to one sinus and may or may not be associated with a surrounding osteomyelitis.
The commonly found bacteria in this disease include streptococci, staphylococci and pneumococci. Occasionally in post-traumatic cases anaerobic streptococci are found.
Inflammation of the mucous membrane of the sinuses leads to oedema and swelling, together with accumulation of exudates and pus cells within the cavity of sinus concerned.
This exudate is ejected through the natural ostium of the sinus by ciliary action. The mucosal swelling and pouring out of fibrin and exudates may block the ostium producing the empyema. If the body’s defence is poor the infection may spread in to bone; bacteraemia may devlop in to septicemia or pyemia.
Local thrombophlebitis may lead to meningitis, encephalitis, brain abscess or cavernous sinus thrombosis. The rich blood supply of the area and proximity to the brain and meninges makes the development of intracranial complications a danger.
There is usually a history of coryza followed, after three four days by increasing nasal obstruction and discharge, a deterioration of sense of smell, a sense of discomfort in the face accentuated by bending down and a morning headache.
Acute Ethmoiditis: The ethmoids are the most commonly affected sinuses in acute sinusitis.
The characteristic headache or sensation lies between and behind the eyes.
The swelling of the mucosa may produce a complete loss of sense of smell.
The nasal cavities are intensly congested in the region of middle turbinate and mucopus is seen in the area of ethmoid bulla.
Acute frontal sinusitis: This is less common than maxillary or ethmoid sinusitis.
It is usually unilateral and not infrequently follows swimming or diving when patient has a cold.
Headache over one or the other eye after getting up in the morning, gradually increasing and tending to disappear in the late afternoon.
There is tenderness on pressure over the floor of the sinus.
Little or no swelling of the nasal mucosa may be noticeable, but a trickle of pus may be seen high up at the anterior end of the middle meatus.
Acute sphenoiditis: It usually arises in association with posterior ethmoiditis.
It gives rise to pain which may be severe and is located in the centre of the head. It may some times be referred to the area in front of or slightly above either ear or behind the eyes.
On anterior rhinoscopy purulrnt discharge may be seenhigh up in the back of nose between septum and turbinates. In post-nasal space, pus is seenat the apex of the arch of the posterior choana.
Acute Maxillary sinusitis:
Maxillary sinus is characterized by pain in the face on bending down.
There may also be some swelling of the face, frontal headache or pain in the alveolar region.
On examination mucosa of the middle meatus is red and swollen. After sucking out the discharge which is usually present, tilting the head towards the healthy side may produce further discharge.
Occasionally acute maxillary sinusitis follows dental sepsis or extraction. The last three or fourth teeth in the upper jaw on either side lie in close relationship to the sinus. There may b little or no bone between roots of these teeth and antral mucous membrane. Sepsis or dental extraction may breach this weak barrier. Some times during a difficult extraction, a tooth root may be lost in the lumen of the sinus.
On examination besides history of dental sepsis or dental extraction, there is marked tenderness and swelling over lower part of the cheek.
Patient may also complain of foul smelling discharge from the nose and foul taste in the mouth. Pus is seen in the middle meatus and almost every where in the nose.
The diagnosis is confirmed by following investigations
In acute sinusitis radiology will reveal the mucosal oedema, or presence of fluid. When osteomyelitis is present areas of rarefaction the surrounding bone may be seen.
Culture of the nasal swab
TLC, DLC and ESR
Treatment: The preliminary treatment of acute sinusitis should always be conservative. Most patients will respond satisfactorily with rest in bed n a well ventilated room, steam inhalation, and antibiotics. Improvement is expected within 48 hours and resolution should be complete with in 7-10 days.
Chronic sinusitis is a chronic inflammation of the mucous membrane which has resulted in irreversible and usually degenerative changes. The infection may spread to the bony walls.
The organisms usually found are the staphylococcus albus, staph aureus, the Haempphilus influenzae and diptheroids. During periods of more active infection pneumococci and haemolytic streptococci may also be present.
The following factors predispose to development of chronic sinusitis:
Anatomical: Irregularities of the nasal septum may lead to inadequate aeration of the nasal cavities and inadequate drainage from the sinuses.
Inadequate pneumatization of sinuses: The diffuse inflammations of the upper respiratory tract which play such an important role development of immunity in a child have long been recognized. Attacks of inflammation follow each other in quick succession and interval between the attacks may be short that resolution is incomplete. The process of inflammation and repair go hand in hand and the resulting scar tissue narrows ostium of the sinus and lead to insufficient aeration.
Hypersensitivity: In patients with allergic diathesis, allergic changes may be induced by recurrent bouts of acute infection with resulting bacterial hypersensitivity.
Alcohol and tobacco
Pathology: There are three main categories of chronic sinusitis
Sinusitis associated with simple inflammatory hyperplasia: It begins in early childhood. Recurrent bouts of infection, shorter periods of remission result in thickened mucous membranes. There is sub-epithelial fibrosis, reduction in glandular tissue. At a later stage the periosteum becomes affected and hyperemia extends to bone, leading at first to osteoporosis and sclerosis.
Sinusitis as a part of generalized respiratory allergy: Two types of allergy; generalized allergic diathesis presenting in early childhood. In second type there is no sign or symptom of allergy till eight or nine years of age after which water logging of mucosa leads to increasing nasal stuffiness and discharge. Localized edematous areas, perhaps under the pull of gravity, may develop in to polypi especially in ethmoid region.
Either of the two preceding types with superimposed infection. Allergic subjects are more prone to secondary bacterial invasion than the normal subjects. Some of the inflammatory products may then act as allergens, reducing further allergic changes.
Symptoms and local considerations:
Maxillary sinusitis: There is usually a copious postnasal discharge which may be greenish-yellow. Nasal obstruction is usually the result of swelling of the inferior turbinate mucosa consequent on presence of sepsis. Deep chronic headache over the forehead, anosmia or cacosmia. Secondary symptoms may produce of oedema oeutachean tube orifice, OM, granular phryngitis and chronic laryngitis.