Management of sinusitis has witnessed fundamental change in the last two decades. Nasal endoscopy and CT scan has revolutionized visualization of nose and sinuses.
Basic understanding- (What is Sinus?)
Human skull contains four pairs of hollow air filled cavities connected to the space between nostril and nasal passage; these are called Sinuses (or Para Nasal Sinuses). Sinuses help insulate the skull, reduce its weight and add resonance to voice.
There is 4 major pair of sinuses–
1.Frontal (in the forehead), 2. Maxillary (behind the cheek bones) 3.Ethmoid (between the eyes), 4. Sphenoid (behind the eyes).
Sinuses are lined by respiratory epithelium with Goblet cells to secretes mucus (forming mucus blanket) and cilia (fine hair like structure) to help trap and propel pollutant and bacteria outward to nose through osteum (opening) of sinuses.
Most of the sinuses drain into a key area (Osteo-Meatal complex). Thus treatment of sinusitis is focused on this area.
Infection of sinuses is called sinusitis–acute or chronic based on the time span.
Sinusitis may be caused by anything that interfere with airflow into the sinuses and mucous drainage out of the sinuses, usually follow a viral infection, allergy, or irritants.
Most common bacteria involved are streptococcus pneumonae, Haemophilus influenzae, and moraxella catarhalis.
Signs and symptoms of sinusitis depend on which sinus is involved–usually present with:
-nasal congestion and discharge or post nasal drip
-headache, or facial pain, or pain under or around the eyes
Treatment of acute sinusitis:-
Maxillary sinus is most commonly involved followed by ethmoid, frontal and sphenoid.
Aims of management are:-
1. To achieve normal healthy sinuses
2. To decrease duration of the symptom
3. To prevent complications
4. To prevent development of acute sinusitis.
Most patients of acute sinusitis can be benefitted without many investigations as diagnosis is mainly clinical. Nasal endoscopy for proper visualization of nose and sinuses is important for appropriate management. Endoscopic assessment of nose guide therapy and at the same time accurate pus-swab can be obtained for bacteriological examination.
Sometimes if symptoms persist for longer duration further investigation may be required like examination of mucocilliary mechanism, allergic and immune status of patient and computerized tomography (CT scan) of sinuses.
Analgesics, antibiotics and decongestants are given to reduce swelling and thus increase clearance and drainage from the sinuses.
Antibiotics–studies have confirmed that acute bacterial sinusitis treated with antibiotics have more rapid resolution of symptoms.
Antibiotics should be effective and should cover wide range of organisms.
In general antibiotics are required for 10 days but in some cases especially recurrent cases up to 2 weeks course may be given.
Usually amoxicillin, ampicillin, co-amoxyclav and cephalosporins are primary drugs of choice. If first line drugs fail then second line treatment is based on culture and sensitivity report of pus aspirated from sinuses by antral lavage.
Nasal decongestant drops–Nasal decongestant or steroid drops or sprays are used to decongest sinus osteum and thus encourage drainage.
Clinicians prefer long acting preparation because of less rebound phenomena. Topical decongestant drops should not be used for long duration as it back fires and person develops “rhinitis medicamentosa.”
Oral decongestant or mucolytics–may be used to reduce mucosal inflammation. In general antihistamines are to be avoided in acute bacterial sinusitis because it will thicken and dry the secretion.
Analgesics–any suitable and safe pain killer medicine acetaminophen or ibugesic are prescribed to relieve pain.
Steam inhalation— plain water or medicated steam with menthol provides relief from symptoms and helps in improving sinus drainage.
Hot fomentation–application of warm cloth, hot water bottle or gel pack to face for 5-10 minutes relieves pain and inflammation to some extent.
Saline irrigation, Nasal wash or “jala neti” –-nose and sinuses should be washed by ¼ tsf salt in 1 cup water using bulb syringe or alternatively commercially available saline nasal sprays can be used.
Avoidance of allergy if any
Use of humidifier
Avoidance of irritants
Baloon Sinuplasty– it’s new nonsurgical technique which is cost effective.
A balon is placed in the affected nasal cavity, inflated for short duratin to open up sinus passageways.
Usually acute sinusitis is treated by medicines. Most cases of acute maxillary sinusitis resolve with effective and proper medical management. Very rarely when medical treatment fails surgical approach is required.
Surgical treatment is reserved for-
Failure of medical management
This is opd procedure under local anaesthesia where medial wall of maxillary sinus is punctured in the region of inferior meatus, sinus is drained and irrigated. Now this technique is rarely employed and endoscopic enlargement of middle meatus is preferred.
Frontal sinuses wash outs-
This is done in general anaesthesia. Small incision is given below eyebrow medially.
Functional Endoscopic sinus surgery-
Recurrent acute bacterial sinusitis or sinusitis of long duration unresponsive to medicine is major indication for endoscopic sinus surgery.
Endoscopic surgery is minimally invasive surgery. It does not require skin incisions and done by endoscope inserted through nose.
CT scanning is must before surgery.
One thing to be remembered-meticulous postoperative cleaning is equally important for success as is the expertise of surgeon.
Treatment plan for acute sinusitis may vary according to experience of treating physician, but it is crucial to understand the importance of “osteomeatal region”.
Effective medical management requires good doctor-patient understanding. Medical professional should take time for patient to educate them on importance of taking antibiotics regularly and in proper doses as advised. Often it is irregular time interval and missed doses which create resistant bacteria leading to failure of medical treatment.
From my article at helium.com- http://www.helium.com/items/1269826-treatment-of-acute-sinusitis