Have you ever wondered why the head always drops when a person sleeps in the sitting position? It is because the head is very heavy. When we are awake, the muscles of the neck are always at work keeping the head in its normal position. Much of the head’s weight is from the bone of the skull which is very dense.
To make the head lighter and bearable for the human neck, some part of the skull bone is made hollow; pretty much in the same way that we have hollow blocks for building. These cavities are known as sinuses. Incidentally, they are all found near the nasal cavity and so are called paranasal sinuses. Each sinus is lined by a thin mucous membrane that secrets a moisturising and lubricating liquid or discharge called mucus often called ‘phlems’. Every sinus has an opening which allows for the out flow of sinus discharges.
What is sinusitis
Sinusitis (or rhinosinusitis) is defined as an inflammation of the mucous membrane that lines the paranasal sinuses. It can be due to infection, allergy, or autoimmune problems. Most cases of sinusitis are due to a viral infection and resolve over the course of 10 days. It is a common condition.
Sinusitis is classified chronologically into several categories;
Acute rhinosinusitis is a new infection that may last up to four weeks and can be subdivided symptomatically into severe and non-severe;
Recurrent acute rhinosinusitis occurs if there are four or more separate episodes of acute sinusitis that occur within one year;
Subacute rhinosinusitis is an infection that lasts between four and 12 weeks, and represents a transition between acute and chronic infection;
Chronic rhinosinusitis occurs when the signs and symptoms last for more than 12 weeks; and
Acute exacerbation of chronic rhinosinusitis occurs when the signs and symptoms of chronic rhinosinusitis exacerbate, but return to baseline after treatment.
All these types of sinusitis have similar symptoms, and are thus often difficult to distinguish. Acute sinusitis is very common. Roughly ninety percent of adults have had sinusitis at some point in their life.
When a person develops a common cold, the virus involved not only infect the respiratory tract mucous membrane but also the membrane lining the sinuses as well. This causes the membrane to secrete more discharge and get swollen. The viruses involved in causing sinusitis include rhinoviruses, coronaviruses, and influenza viruses as well as many others.
The infection may also be caused by a bacteria which is different from a viral sinusitis. If the infection is of bacterial origin, the most common three causative agents are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis.
What is the difference between viral and bacterial sinusitis?
Viral sinusitis typically lasts for 7 to 10 days, whereas bacterial sinusitis is more persistent. Approximately 0.5% to 2% of viral sinusitis results in subsequent bacterial sinusitis. It is thought that nasal irritation from nose blowing leads to the secondary bacterial infection.
Acute episodes of sinusitis can also result from fungal invasion. These infections are typically seen in patients with diabetes or other immune deficiencies (such as AIDS or transplant patients on immunosuppressive anti-rejection medications) and can be life threatening.
Chemical irritation can also trigger sinusitis, commonly from cigarette smoke and chlorine fumes. Rarely, it may be caused by a tooth infection.
Chronic sinusitis, by definition, lasts longer than three months. Symptoms of chronic sinusitis may include any combination of the following: nasal congestion, facial pain, headache, night-time coughing, an increase in previously minor or controlled asthma symptoms, general malaise, thick green or yellow discharge, feeling of facial ‘fullness’ or ‘tightness’ that may worsen when bending over, dizziness, aching teeth, and/or halitosis.
Often chronic sinusitis can lead to anosmia (loss of sense of smell), a reducedsense of smell. In a small number of cases, acute or chronic maxillary sinusitis is associated with a dental infection.
Chronic sinusitis represents a multifactorial inflammatory disorder, rather than simply a persistent bacterial infection.
The location of a given sinus may also give rise to specific symptoms.
Maxillarysinusitis affects the maxillary sinuses found under the cheeks. It can cause pain or pressure in the maxillary (cheek) area as well as toothache and headaches.
Frontal sinusitis affects the frontal sinuses. It can cause pain or pressure above eyes and headache, particularly in the forehead.
Ethmoidal sinusitis can cause pain or pressure pain between/behind the eyes, the sides of the upper part of the nose (the medial canthi), and headaches.
Sphenoidal sinusitis can cause pain or pressure behind the eyes, but often refers to the skull vertex, (top of the head), over the mastoid processes (back of the ear), or the occiput (back of the head).
Generally, there is a headache/facial pain or pressure of a dull, constant, or aching sort over the affected sinuses is common with both acute and chronic stages of sinusitis. This pain is typically localized to the involved sinus and may worsen when the affected person bends over or when lying down. Pain often starts on one side of the head and progresses to both sides.
Acute and chronic sinusitis may be accompanied by thick nasal discharge that is usually green in colour and may contain pus (purulent) and/or blood. Often a localized headache or toothache is present, and it is these symptoms that distinguish a sinus-related headache from other types of headaches, such as tension and migraine headaches.
Other symptoms of sinusitis include bad breath and Post-nasal drip.
Some complications of sinusitis
The commonest complications of sinusitis is the spread of infection to nearby structures to cause cellulitis and abscesses such as Pre-septal cellulitis, Orbital cellulitis, Sub-periosteal abscess and Orbital abscess.
Infection of the eye socket is possible, which may result in the loss of sight and is accompanied by fever and severe illness. Another possible complication is osteomyelitis. This is infection of the bones of the forehead and other facial bones also known as Pott’s puffy tumor.
Sinus infections can also cause middle ear problems due to the congestion of the nasal passages. This can be demonstrated by dizziness, “a pressurized or heavy head”, or vibrating sensations in the head.
The close proximity of the brain to the sinuses makes it the most dangerous complication of sinusitis, particularly involving the frontal and sphenoid sinuses, infection of the brain by the invasion of anaerobic bacteria through the bones or blood vessels. Abscesses, meningitis, and other life-threatening conditions may result. In extreme cases the patient may experience mild personality changes, headache, altered consciousness, visual problems, seizures, coma, and possibly death.
Predisposing factors of sinusitus
Factors which may predispose someone to developing sinusitis include: allergies; structural abnormalities, such as a deviated septum, small sinus opening, nasal polyps, carrying the cystic fibrosis gene.Both smoking and second hand smoke are associated with chronic sinusitis.
Dental infections may also travel to the Maxillary sinus and cause sinusitis there.
How is sinusitis treated?
It is very important to see you doctor or ENT specialist if you have sinusitis symptoms that tend to persist. The will prevent the occurrence of any complications of the disease.
Nasal irrigation may help with symptoms of chronic sinusitis. This involves washing of the sinuses with specially prepared liquid. This liquid washes out any accumulation of mucus and sooths the mucous membrane. This procedure is best done at the ENT clinic.
Decongestant nasal sprays containing for example oxymetazoline may provide relief, but these medications should not be used for more than the recommended period. Longer use may cause rebound sinusitis.
Other recommendations include applying a warm, moist cloth to the affected areas several times a day; drinking sufficient fluids in order to thin the mucus; and inhaling low temperature steam two to four times a day.
The vast majority of cases of sinusitis are caused by viruses and will therefore resolve without antibiotics. However, if symptoms do not resolve within 10 days, amoxicillin is a reasonable antibiotic to use first for treatment, withstronger and broader spectrum antibiotics being indicated when the person’s symptoms do not improve after 7 days on amoxicillin alone. Antibiotics are specifically not recommended in those with mild / moderate disease during the first week of infection due to risk of adverse effects, antibiotic resistance, and cost.
For chronic or recurring sinusitis, referral to an otorhinolaryngologist or ENT specialist may be indicated, and treatment options may include nasal surgery. Surgery should only be considered for those patients who do not experience sufficient relief from optimal medication.
Maxilliaryantral washout involves puncturing the sinus and flushing with saline to clear the mucus.
Source: Dr Emmanuel K. Coomson
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