Tag Archives: sinusitis

How to diagnose acute sinusitis? Clinical criteria and investigations

Mostly patients of sinusitis can be benefitted without much investigation as diagnosis is mainly based on clinical criteria in patient who presents with persistent or severe upper respiratory symptoms.

 

Although sinus aspiration is the gold standard for the diagnosis of acute bacterial sinusitis, it is an invasive, time consuming, and potentially painful procedure that should only be performed by a specialist (Oto-rhino-laryngologist).  It is not recommended for the routine diagnosis of bacterial sinusitis.

 

Nasal endoscopy for proper visualization of nose and sinuses is important for appropriate management.

 

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.

  How sinusitis develops?–

 Acute sinusitis usually follows an upper respiratory tract infection.

Upper respiratory infection causes– over production of mucus and– impaires mucocilliary clearance (small hair like structure, cilia helps propel mucus out).

 This compounded with blockage of opening of sinuses (osteomeatal area or key area) by mucosal edema and associated structural deformity of nose (like DNS, spur) leads to stagnation of secretion.

 Blockage of sinus opening also impedes with ventilation of sinus cavity.

 Stagnation and poor ventilation causes growth of bacteria.

  Certain factors predisposes for sinusitis-allergy, structural defects like deviated nasal septum, spur, low immunity like in HIV, defects of ciliary mechanism like cystic fibrosis, kartagenar’s  syndrome, and immotile cilia syndrome.

 Diagnosis of sinusitis:–

 Diagnosis is usually based on proper history and thorough physical examination.

 Nasal endoscopy for proper visualization of nose and sinuses is important for appropriate management.

 Symptoms:-

 Purulent discharge from nose

Pain/pressure sensation over face more on leaning forward.

Headache

Nasal blockage

Changes in taste/smell

Poor response to decongestant

Toothache

Pressure sensation in the ear. 

Be prepared with bombarding with questions, you may feel useless or you may not want to answer especially if you are having sinus headache. But it helps your clinician to reach to the diagnosis.

 Examination of nose:

 Nose is inspected thoroughly with nasal speculum (a small metal instrument), with a good source of light focused inside your nose. Any discharge coming from sinuses opening or any structural deformity is looked for. 

120px-thudichum27s_nasal_speculum_ent_instrument_medical

Previously head mirror and Bulls lamp was used to focus light in to nasal cavity.

head mirrorhead mirror

 

Bulls lamp

Bulls lamp

Some use direct source of light attached to headlight by a cable.

Head light with light source
Head light with light source

 With advancement in technology many E.N.T. Specialist are using nasal endoscope attached to camera and monitor to see the nose and nasopharynx. Endoscopic assessment of nose guide therapy and at the same time accurate pus-swab can be obtained for bacteriological examination.

Clinically tenderness over specific point of sinuses is assessed.

 Laboratory test: 

Not of much value in acute sinusitis.

In cases not responding to treatment it may be done.

 Immune status of patient-HIV/chemotherapy

Allergy testing

Nasal cytology

Sweat chloride test for cystic fibrosis

Cilliary function test

 In refractory cases one should always think possibility of fungal sinusitis.

 Radiology:-– 

X-Rays of sinuses are not helpful in making diagnosis.

 CT scan- CT scan are generally not advised routinely. It is advised by otolaryngologist if surgery is anticipated (to evaluate the extent of sinusitis and guiding during surgery), infection is severe or there is risk of complication.

 MRI– MRI is not as effective as CT scan in evaluating sinusitis and is more costly. But when your ENT specialist is suspecting fungal sinusitis (a topic I will cover in my next blogs), want to differentiate sinusitis from tumor or there is intracranial complications.  

 Determination of causative organism: –

 It requires puncture, aspiration of mucopus and culture, but usually it is not done initially as it is invasive procedure. It is reserved for cases refractory to primary line of management.

  Further studies are required in the field and acute bacterial sinusitis is to be differentiated from viral rhinosinusitis and severe common cold. Further researches are required to develop noninvasive strategies to accurately diagnose acute bacterial sinusitis.

 

 

 

 

 

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Sinus, Acute sinusitis and treatment

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).

sinusitis

 

 

 

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.

Acute sinusitis


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
-fever

 

 

 

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.

 

 

 

Medical management:-

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.

 

 

 

Home care–

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.  

Surgical management-

 

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

Severe pain

Impending complications.

 

Antral lavage-

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