SINUSITIS: SYMPTOMS, CAUSES, AND TREATMENT

Sinusitis is the inflammation of the paranasal sinuses—air filled cavities present around the nose in the bones of head and face. There are four pairs of sinuses in an individual, which are connected to the nose through narrow channels. Maxillary sinuses are located in maxilla (upper jaw), ethmoid sinuses are located between the eyes, frontal sinuses in the forehead, and sphenoid sinuses behind the nose.

The inflammation of sinuses (sinusitis) is commonly associated with inflammation of the nose (rhinitis), a condition known as rhinosinusitis. The presence of sinusitis without rhinitis is rare and symptoms for both conditions are similar. As a result, sinusitis and rhinosinusitis are often used interchangeably.

Epidemiology

Rhinosinusitis is the most-commonly reported disease in the US. Every year, it affects ~30 million individuals and ~USD 6 billion are spent annually to treat individuals with sinus-related complaints.

Classification

Based on the duration of the disease, Rhinosinusitis is classified into:

• Acute rhinosinusitis: This condition is contagious and lasts for up to 4 weeks.
• Subacute rhinosinusitis: This condition lasts for ~4-8 weeks.
• Chronic rhinosinusitis: This condition is less contagious and is characterized by inflammation. It lasts for more than 8-12 weeks.

 Acute rhinosinusitis can be further sub divided into two types:

• Viral rhinosinusitis (VRS): In case of viral rhinosinusitis, symptoms are present for less than 10 days and do not worsen over time. It is a self-limiting condition.
• Acute bacterial rhinosinusitis (ABRS): In case of acute bacterial rhinosinusitis, symptoms last for more than 10 days and worsen over time. Alternatively, they may show little improvement and then show more adverse symptoms within the 10-day period.
• Recurrent acute rhinosinusitis: In this condition, the individual develops symptoms of acute bacterial rhinosinusitis (ABRS) more than four times in a year. In the period between episodes, the individual does not exhibit any signs or symptoms of infection.

Symptoms

Common symptoms of rhinosinusitis include nasal obstruction, facial pain, or pressure in the region of cheeks, eyes, and forehead. Other symptoms include nasal discharge or postnasal drip (discharge of mucus into the throat) and reduced sense of smell, along with headache, bad breath, fever, cough, tooth pain, and ear pain. In individuals with chronic rhinosinusitis, the nasal discharge is white or light yellow whereas in cases with recurrent acute rhinosinusitis, a thick yellow, green, or brown mucus is observed.

Causes

The exact cause for rhinosinusitis is not known. Factors which can contribute to the disease are:

• Allergy-induced rhinitis: Allergy-induced inflammation of nose (rhinitis) can lead to the development and progression of chronic rhinosinusitis.
• Deficiency of immune cells: Individuals with deficiency in antibody production may develop recurrent episodes of sinus infection.
• Defects in mucociliary clearance: Individuals with impaired mucociliary clearance (e.g., diseases such as cystic fibrosis and primary ciliary dyskinesia) have a higher risk of developing chronic rhinosinusitis.
• Respiratory tract infections: Individuals with viral upper respiratory tract infections can develop chronic rhinosinusitis. This condition is commonly seen in individuals exposed to health care facilities, schools, day care centers, or homes with small children. It is most common among children due to high susceptibility to viral infections.
• Structural abnormalities in the nasal pathway: Structural abnormalities such as deviated nasal septum, choanal atresia, abnormality with middle turbinate, nasal polyps, and tumors can cause chronic rhinosinusitis.
• Systemic diseases: Systemic diseases such as Wegener granulomatosis (autoimmune disease), Churg-Strauss vasculitis (disorder causing inflammation of blood vessels), and sarcoidosis (inflammatory disease with masses of granulomas in different organs) can cause chronic rhinosinusitis.
• Gastroesophageal reflux disease (GERD): Reflux of gastric acid to the throat in individuals with gastroesophageal reflex disease can cause inflammation of sinus opening, causing rhinosinusitis.

Pathophysiology

The sinuses are connected to the nose through narrow channels. These channels aid in the drainage of the mucus secreted by sinuses. The mucus entraps foreign bodies, microbes, and allergens present in the air we inhale and filters the air in a process called mucociliary clearance. This entrapped mucus is then swallowed and drained through the throat.

Sometimes, the presence of upper respiratory tract infections, structural abnormalities, reaction to viruses, bacteria, allergies, or other related conditions can affect mucociliary clearance. This can cause swelling (inflammation) of the mucosa (inner skin lining the sinus and nose), impair the mucociliary clearance, and block the sinus opening. The blockage of sinus opening obstructs the drainage of mucus, allowing its accumulation within sinuses. The clogged sinus becomes a breeding ground for microbial growth, leading to sinus infections. ~1.5% of sinus infections are bacterial in origin (e.g., Streptocoocus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis).

Diagnosis:

• History and physical examination: The diagnosis of sinusitis involves collection the patient’s medical history, including evaluation of signs and symptoms, duration of symptoms, severity of symptoms, and response to medications (especially decongestants). This is accompanied by physical examination such as examining the color and consistency of the sputum and erythema (redness) in the nose and throat.
• Imaging: Sinus CT scans (Computed tomography), MRI, or radiographic examination aids in evaluating the extent of the disease and specific location of the obstruction.  These aid in evaluation of tumors, structural abnormalities, or presence of foreign bodies in the nose or sinuses.
• Nasal endoscopy: It is performed using endoscope which is a thin, flexible tube with a tiny camera that aids in better visualization and identification of structural abnormalities or foreign bodies within the nose.
• Transillumination test: In this, a light is placed to focus on the sinuses. In normal conditions, hollow sinuses give a reddish glow. In inflamed and clogged sinuses, the light fails to shine and sinuses appear opaque.
• Allergy testing: Allergy testing is performed to detect the cause of allergies, if any.
• Culture test: Culturing of microbes from the samples collected from nose or throat helps in identification of microorganisms involved.

Treatment

The treatment for rhinosinusitis includes both medical and surgical therapy

• Medical therapy:
  • Antimicrobial therapy: In individuals with acute sinusitis, two weeks of antimicrobial therapy is helpful. Meanwhile, in individuals with chronic sinusitis three weeks of antimicrobial therapy is recommended.
  • Decongestants: They help in reducing the swelling in the sinus, assist in mucus drainage, and help maintain the size of the sinus opening.
  • Steroid therapy: They are anti-inflammatory and assist in the reduction of inflammation, allowing the drainage of the mucus from the clogged sinuses.
  • Antihistamines: They aid in reducing the influx of inflammatory mediators which cause inflammation in the nose and sinuses. They are effective in rhinosinusitis associated with allergic conditions.
  • Saline irrigation: This method involves flushing of the nose using saline (salt water). This aids in mucociliary clearance (draining of mucus embedded with foreign particles), which clears nasal and sinus congestion.
• Surgical therapy:
  • Individuals with persistent symptoms even after medical therapy are advised to undergo surgery to clear the obstruction from the sinus opening.

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Sources:

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• Pearlman, A. N., & Conley, D. B. (2008). Review Of Current Guidelines Related To The Diagnosis And Treatment Of Rhinosinusitis. Current Opinion In Otolaryngology & Head And Neck Surgery, 16(3), 226–230.
• Dykewicz, M. S., & Hamilos, D. L. (2010). Rhinitis And Sinusitis. Journal Of Allergy And Clinical Immunology, 125(2), S103–S115.
• Meltzer, E. O., Hamilos, D. L., Hadley, J. A., Lanza, D. C., Marple, B. F., Nicklas, R. A., … Zinreich, S. J. (2004). Otolaryngology-Head And Neck Surgery. Otolaryngology-Head And Neck Surgery, 131(6_Suppl), 1–62.
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• Dass, K., & Peters, A. T. (2016). Diagnosis and Management of Rhinosinusitis: Highlights from the 2015 Practice Parameter. Current Allergy and Asthma Reports, 16(4).

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