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Chronic Sinusitis

Alternate Names

  • chronic rhinosinusitis
  • chronic frontal sinusitis
  • Sinuses
  • Inflammation of the ethmoid sinuses

Definition

Chronic sinusitis is the presence of constant nasal and sinus symptoms for three months or longer.

What is going on in the body?

There are four pairs of sinuses.
  • The frontal sinuses are in the forehead bone.
  • The maxillary sinuses are below the eyes.
  • The ethmoid sinuses are located between the eyes.
  • The sphenoid sinuses lie between the back parts of the eye sockets.
The ethmoid sinus is a matchbox-sized area filled with 7 to 10 interconnected bubbles made of very thin-walled bone. These bony bubbles are lined with a mucous membrane similar to that found in the nose. Each bubble has its own opening to drain into the nasal, or nose, cavity. The front part of the ethmoid is the most crucial of all the sinuses because the forehead and maxillary sinuses must drain through it into the nose. The back part of the ethmoid drains through a separate opening.
The sinuses are normally air-filled. The lining of the sinuses are covered with microscopic fingers known as cilia that direct the mucus to the drainage openings.
The function of the sinuses is not clearly understood. In the average healthy person, the lining of the sinuses and nose makes about 1 to 1 1/2 pints of mucus each day. One of the functions of the sinuses is to moisten, cleanse and warm the air as it goes through the nose before it enters the lungs. The healthy nose is a wonderful filter removing eighty percent (80%) of all tiny particles as they are breathed in. Since the sinuses are air-filled, another function is thought to be making the skull lighter in weight
Chronic sinus disease affects thirteen percent (13%) of the US population. or about 30-40 million people, according to the National Center for Health Statistics. In cases of chronic sinus disease, the natural drainage pathways of the sinuses do not always work properly.
  • The mucous glands produce thicker secretions that stay in the cavities, increasing bacterial overgrowth and thickening the lining.
  • Less air can pass through, causing nasal stuffiness.
  • The microscopic "fingers" do not work effectively.
  • Chronic inflammation causes face pain over the sinuses affected.
  • Partial or complete blockage of the sinus openings from structure problems in the sinuses themselves can cause chronic sinusitis.
Conditions in the environment like dry air, pollutants, dust and dirt can damage the microscopic "fingers" so that mucus is not cleared, and bacteria overgrow.

Risks

What are the causes and risks of the condition?

People with chronic sinusitis, regardless of the cause, are more likely to develop episodes of acute sinusitis, as well.

Prevention

What can be done to prevent the condition?

Persons who have allergic diseases need to avoid their trigger allergens and use aggressive treatment to limit the damage to the nasal lining and the sinuses.
For environmentally caused disease, avoiding exposure to cold air, keeping the air humidified and minimizing exposure to pollutants all help. Aggressive treatment of symptoms will help minimize damage.
For people with structural problems of the nose and sinuses, here are some ways to reduce chronic irritation:
  • avoiding triggers, such as cold air or allergens
  • use frequent saline nasal spray or rinses
  • humidifiers (to keep room humidity at about 40% relative humidity)
  • increased oral fluids
  • oral decongestant medicines such as pseudoephedrine and phenylephrine as needed
  • prescription steroid nasal sprays are the mainstay in prevent recurrent sinus troubles. Commonly prescribed nasal steroids include
    • beclomethasoneq (i.e., Beconase),
    • fluticasone (i.e., Flonase),
    • flunisolide (i.e., Nasarel),
    • triamcinolone (i.e., Nasacort),
    • mometasone (i.e., Nasonex) or
    • budesonide (i.e., Rhinocort)

Diagnosed

How is the condition diagnosed?

The most important part of diagnosis is the history of the illness. The healthcare provider will pay particular attention to symptoms, environmental reactions and responses to medications. Since other diseases can act like chronic sinusitis, a complete medical history is crucial. Physical exam using a nasal endoscope not only can assist in diagnosing chronic sinusitis, but can also be used to follow the medical management of this disorder.
Computed tomography, or CT scan, of the sinuses is the standard means of X-ray diagnosis. However, often a positive response to treatment can establish the diagnosis without the need for a CT scan.
In some patients, CT scan is needed to assess the extent of the disease or to identify any structural problems. However, the scans must be interpreted with caution since other conditions can look like chronic sinusitis on CT scan. Also, CT scans may not identify chronic sinusitis when it does exist. Diagnosis and treatment should not be based on X-ray alone, but instead should be based on symptoms.

Long Term Effects

What are the long-term effects of the condition?

Long-term effects depend on the underlying causes and the effects of sinus opening obstruction. Left untreated, chronic sinusitis can cause significant problems because the infection erodes the bony walls.
In the frontal sinus, this can lead to pressure on the eyeball and double vision, forehead swelling, or brain abscesses and meningitis. In the ethmoid sinus, an abscess can form around the eye.
In the maxillary sinus, the nasal passages is can become blocked. In the sphenoid sinus, bony erosion can lead to double vision and decreased movement of the eyeball, or brain abscesses and meningitis.

Other Risks

What are the risks to others?

The viruses and bacteria involved in those forms of sinusitis are contagious from person to person. However, if infected, a close contact of a person with sinusitis might develop sinusitis, another respiratory illness, or no symptoms at all.

Treatments

What are the treatments for the condition?

Treatment for chronic sinusitis caused by allergies includes:
  • taking antihistamines, however antihistamines have been shown to worsen sinusitis for many people by thickening the mucous, which makes it harder to drain. However, for people whose symptoms are worsened by allergies, antihistamines may be helpful - such as diphenhydramine (i.e., Benadryl) or chlorpheniramine (i.e., Chlor-Trimeton). Non-sedating antihistamines, such as loratadine (i.e., Claritin) or fexofenadine (i.e., Allegra), are more expensive but have fewer side effects.
  • avoiding triggers, such as cold air or allergens
  • saline nasal spray or rinses
  • warm compresses on the face
  • humidifiers (to keep room humidity at about 40% relative humidity)
  • increased oral fluids
  • pain medicine such as ibuprofen (i.e., Advil, Motrin), aspirin or acetaminophen (i.e., Tylenol)
  • oral decongestant medicines such as pseudoephedrine (i.e., Sudafed) and phenylephrine (i.e., Sudafed-PE)
  • decongestant nasal sprays such as oxymetazoline (i.e., Afrin) or phenylephrine (i.e., Neo-Synephrine). However, these sprays should not be use for more than three to five days
  • prescription non-steroid nasal sprays such as azelastine (i.e., Astelin), cromolyn (i.e., NasalCrom), ipratropium (i.e., Atrovent Nasal) or any number of nasal steroid sprays.
  • prescription steroid nasal sprays such as beclomethasoneq (i.e., Beconase), fluticasone (i.e., Flonase), flunisolide (i.e., Nasarel), triamcinolone (i.e., Nasacort), mometasone (i.e., Nasonex) or budesonide (i.e., Rhinocort)
  • oral corticosteroids such as prednisone
  • undergoing allergy desensitization (i.e., allergy shots)
Treatment for chronic bacterial sinusitis includes appropriate antibiotics such as:
  • amoxicillin/clavulanic acid (i.e., Augmentin),
  • cefpodoxime (i.e., Vantin),
  • cefuroxime (i.e., Ceftin),
  • trimethoprim/sulfamethoxazole (i.e., Bactrim, Septra),
  • azithromycin (i.e., Zithromax, Zmax),
  • clarithromycin (i.e., Biaxin)
  • levofloxacin (i.e., Levaquin)
  • moxifloxacin (i.e., Avelox)
Chronic infection is usually caused in adults by Staphylococcus aureus and anaerobic bacteria - that is, bacteria that cannot live in an environment with oxygen.
In children, the bacteria are the same in both acute and chronic infections. In addition to antibiotics, nasal steroids, saltwater rinses, decongestants, and mucus-thinning agents are helpful.
For people who do not respond to these treatments and who have structural problems, surgery is the next step in management. The goal of surgery is to reestablish the normal routes of drainage and remove all areas of infection.
Newer forms of Endoscopic surgery are far less invasive that older forms and result in excellent results and more rapid recovery.
After surgery:
  • 90% of people report improvement in their headaches.
  • 85% have reduced postnasal drainage.
  • more than 70% recover the sense of smell.

Side Effects

What are the side effects of the treatments?

Side effects depend on the different treatments used. With surgery, complications are infrequent. There is a very rare occurrence of tear duct injury, a disturbance in vision, or leak of spinal fluid.

After Treatment

What happens after treatment for the condition?

With successful medical and surgical treatment, symptoms are usually controllable and infections can be reduced.

Monitor

How is the condition monitored?

Monitoring depends on the symptoms. However, any person with progressively worsening symptoms or eye involvement needs to seek immediate medical care.

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