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| {{Infobox_Disease |
| | #REDIRECT[[Rhinosinusitis]] |
| Name = Sinusitis |
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| Image = Maxilar_sinusites.jpg|
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| Caption = Left-sided maxillary sinusitis (Absence of the air transparency of left maxillary sinus)|
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| DiseasesDB = 12136 |
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| ICD10 = {{ICD10|J|01||j|00}}, {{ICD10|J|32||j|30}} |
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| ICD9 = {{ICD9|461}}, {{ICD9|473}} |
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| ICDO = |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = emerg|
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| eMedicineTopic = 536 |
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| MeshID = D012852 |
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| }}
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| {{SI}}
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| '''For patient information click [[{{PAGENAME}} (patient information)|here]]'''
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| {{CMG}}
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| ==Overview==
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| '''Sinusitis''' is an [[inflammation]] of the [[paranasal sinus]]es, which may or may not be as a result of infection, from [[bacteria]]l, [[fungus|fungal]], [[virus|viral]], [[allergy|allergic]] or [[autoimmunity|autoimmune]] issues. Newer classifications of sinusitis refer to it as '''rhinosinusitis''', taking into account the thought that [[inflammation]] of the sinuses cannot occur without some [[inflammation]] of the [[nose]] as well ([[rhinitis]]).
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| ==Classification==
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| ===By location===
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| There are several paired paranasal sinuses, including the frontal, ethmoid, maxillary and sphenoid sinuses. The [[ethmoid sinus]]es can also be further broken down into anterior and posterior, the division of which is defined as the basal lamella of the middle [[turbinate]]. In addition to the acuity of [[disease]], discussed below, sinusitis can be classified by the sinus cavity which it affects:
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| *'''[[Maxillary]] sinusitis''' - can cause [[Pain and nociception|pain]] or pressure in the maxillary ([[cheek]]) area (e.g., [[toothache]], [[headache]]) (J01.0/J32.0)
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| *'''[[Frontal bone|Frontal]] sinusitis''' - can cause [[Pain and nociception|pain]] or pressure in the [[frontal sinus]] cavity (located behind/above eyes), [[headache]] (J01.1/J32.1)
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| *'''[[Ethmoid]] sinusitis''' - can cause [[Pain and nociception|pain]] or pressure pain between and/or behind [[eyes]], [[headache]] (J01.2/J32.2)
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| *'''[[Sphenoid]] sinusitis''' - can cause [[Pain and nociception|pain]] or pressure behind the [[eye]]s, but often refers to the [[vertex (anatomy)|vertex]] of the [[head]](J01.3/J32.3)
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| Recent theories of sinusitis indicate that it often occurs as part of a spectrum of [[disease]]s that affect the [[respiratory tract]] (i.e. - the "one airway" theory) and is often linked to [[asthma]]. All forms of sinusitis may either result in, or be a part of, a generalized [[inflammation]] of the [[airway]] so other [[airway]] [[symptom]]s such as [[cough]] may be associated with it.
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| ===By duration===
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| Sinusitis can be ''[[Acute (medical)|acute]]'' (going on less than four weeks), ''[[subacute]]'' (4-12 weeks) or ''[[chronic (medicine)|chronic]]'' (going on for 12 weeks or more).
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| All three types of sinusitis have similar [[symptom]]s, and are thus often difficult to distinguish.
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| ====Acute sinusitis====
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| [[Acute (medical)|Acute]] sinusitis is usually precipitated by an earlier [[upper respiratory tract infection]], generally of [[virus|viral]] origin.
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| Virally damaged surface tissues are then colonized by [[bacteria]], most commonly ''[[Haemophilus influenzae]]'', ''[[Streptococcus pneumoniae]]'', ''[[Moraxella catarrhalis]]'' and ''[[Staphylococcus aureus]]''. Other [[bacterial]] [[pathogen]]s include other [[streptococci]] [[species]], [[Anaerobic organism|anaerobic bacteria]] and, less commonly, [[gram negative]] bacteria.
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| Another possible cause of sinusitis can be dental problems that affect the maxillary sinus.
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| [[Acute (medical)|Acute]] episodes of sinusitis can also result from [[fungus|fungal]] invasion.
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| These [[infection]]s are most often seen in [[patient]]s with [[diabetes]] or other [[immunodeficiency|immune deficiencies]] (such as [[AIDS]] or [[transplant]] [[patient]]s on anti-rejection medications) and can be life threatening. In type I diabetes, ketoacidosis causes sinusitis by [[Mucormycosis]].
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| ====Chronic sinusitis====
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| Chronic sinusitis is a complicated spectrum of diseases that share chronic inflammation of the sinuses in common. The causes are multifactorial and may include allergy, environmental factors such as dust or pollution, bacterial infection, and/or fungus (either allergic, infective or reactive). Non allergic factors such as [[Vasomotor rhinitis]] can also cause chronic sinus problems.
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| Symptoms include: [[Nasal congestion]]; facial pain; [[headache]]; [[fever]]; general [[malaise]]; thick green or yellow [[Rhinorrhea|discharge]]; feeling of facial 'fullness' worsening on bending over; aching teeth.
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| Very rarely, chronic sinusitis can lead to [[Anosmia]], the inability to [[olfaction|smell]] or detect odors.
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| In a small number of cases, chronic [[maxillary]] sinusitis can also be brought on by the spreading of bacteria from a dental infection.
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| Attempts have been made to provide a more consistent nomenclature for subtypes of chronic sinusitis. A task force for the American Academy of Otolaryngology - Head and Neck Surgery / Foundation along with the Sinus and Allergy Health Partnership broke Chronic Sinusitis into two main divisions, Chronic Sinusitis without polyps and Chronic Sinusitis with polyps (also often referred to as Chronic Hyperplastic Sinusitis). Recent studies which have sought to further determine and characterize a common pathologic progression of disease have resulted in an expansion of proposed subtypes. Many patients have demonstrated the presence of [[Eosinophil granulocyte|eosinophils]] in the mucous lining of the nose and paranasal sinuses. As such the name Eosinophilic Mucin RhinoSinusitis (EMRS) has come into being. Cases of EMRS may be related to an allergic response, but allergy is often not documentable, resulting in further subcategorization of allergic and non-allergic EMRS.
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| A more recent, and still debated, development in chronic sinusitis is the role that [[fungus]] may play. Fungus can be found in the nasal cavities and sinuses of most patients with sinusitis, but can also be found in healthy people as well. It remains unclear if fungus is a definite factor in the development of chronic sinusitis and if it is, what the difference may be between those who develop the disease and those who do not.
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| =====Role of biofilms=====
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| Biofilms are complex aggregates of extracellular matrix and inter-dependant [[microorganism]]s from multiple species, many of which may be difficult or impossible to isolate using standard [[medical microbiology|clinical laboratory]] techniques. [[Bacteria]] found in biofilms may show increased [[antibiotic resistance]] when compared to free-living bacteria of the same species. It has been hypothesized that biofilm-type [[infection]]s may account for many cases of [[antibiotic]]-refractory chronic sinusitis.<ref>{{cite journal |author=Palmer JN |title=Bacterial biofilms: do they play a role in chronic sinusitis? |journal=Otolaryngol. Clin. North Am. |volume=38 |issue=6 |pages=1193-201, viii |year=2005 |pmid=16326178}}</ref> A recent study found that [[biofilm]]s were present on the [[mucosa]] of 3/4 of patients undergoing [[surgery]] for chronic sinusitis.<ref>{{cite journal | author = Sanclement J, Webster P, Thomas J, Ramadan H | title = Bacterial biofilms in surgical specimens of patients with chronic rhinosinusitis. | journal = Laryngoscope | volume = 115 | issue = 4 | pages = 578-82 | year = 2005 | id = PMID 15805862}}</ref>
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| ====Sinus headache vs migraine====
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| Headache is rarely a symptom of sinusitis and a "sinus headache" is often a misdiagnosis of a [[migraine]]. Acute sinusitis can cause pressure within the sinus cavities of the head, but this typically has associated pain to palpation of the sinus area and purulent greenish discharge from the nose. The use of the term ''sinus headache'' therefore is often misleading and results in underdiagnosis of migraine. Recent studies indicate that up to 90% of "sinus headaches" are migraine <ref>{{cite journal |author=Schreiber C, Hutchinson S, Webster C, Ames M, Richardson M, Powers C |title=Prevalence of migraine in patients with a history of self-reported or physician-diagnosed "sinus" headache |journal=Arch. Intern. Med. |volume=164 |issue=16 |pages=1769-72 |year=2004 |pmid=15364670}}</ref><ref name="pmid16213917">{{cite journal |author=Mehle ME, Schreiber CP |title=Sinus headache, migraine, and the otolaryngologist |journal=Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery |volume=133 |issue=4 |pages=489-96 |year=2005 |pmid=16213917 |doi=10.1016/j.otohns.2005.05.659}}</ref> This confusion occurs in part because migraine involves activation of the [[trigeminal nerves]] which innervate both the sinus region but also the meninges which surround the brain. As a result, direct determination of the site of pain origination can be confused on a cortical level. Additionally, nasal congestion is not an uncommon result of migraine headaches, further confusing the issue. A recent study further demonstrated that most patients with "sinus headache" respond to triptan migraine medications, and state dissatisfaction with their treatment when they are treated with decongestants or antibiotics.<ref>{{cite journal| author= |title= |journal=Clin Ther |year=2007 |month=Jan |volume=29 |issue=1 |pages=99-109}}</ref>. The subtlety is that while most patient with sinusitis have some sort of facial pain, pressure, or headache, not all patients who attribute the symptom of headache to their sinuses may have legitimate diseases of the sinus. Acute and chronic sinusitis can cause pressure within the sinus cavities of the head, but this is associated with pain on palpation of the sinus area.
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| ====Diagnosis====
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| [[Image:Fungal tounge.jpg|thumb|upright|left|Asymmetric growth of tongue plaque due to drainage from a fungal sinus infection.]]
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| Factors which may predispose to developing sinusitis include: [[allergy|allergies]]; structural problems such as, for example, a [[deviated septum]], small sinus ostia; smoking; [[nasal polyp]]s; carrying the [[cystic fibrosis]] gene (research is still tentative); prior bouts of sinusitis as each instance may result in increased inflammation of the nasal or sinus mucosa and potentially further narrow the openings.
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| Several prediction rules have been developed to aid in diagnosis based on the history and physical <ref name="pmid1416571">{{cite journal |author=Williams JW, Simel DL, Roberts L, Samsa GP |title=Clinical evaluation for sinusitis. Making the diagnosis by history and physical examination |journal=Ann. Intern. Med. |volume=117 |issue=9 |pages=705-10 |year=1992 |pmid=1416571 |doi=}}</ref><ref name="pmid3389120">{{cite journal |author=Berg O, Carenfelt C |title=Analysis of symptoms and clinical signs in the maxillary sinus empyema |journal=Acta Otolaryngol. |volume=105 |issue=3-4 |pages=343-9 |year=1988 |pmid=3389120 |doi=}}</ref>. The most consistenly identified predictor is the presence of purulent rhinorrhea<ref name="pmid1416571"/><ref name="pmid3389120"/>
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| When imaging techniques are required for diagnosis [[Computed tomography|CT scanning]] is the method of choice. If allergies are suspected, allergy testing may be performed
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| ==Treatment==
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| ===Acute sinusitis===
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| There are over the counter medicines that can relieve some of the symptoms associated with sinusitis. i.e. headaches, pressure, fatigue and pain. Usually these are a combination of some kind of antihistamine along with decongestant or pain reliever. Seeing a doctor will usually result in a prescription for antibiotics and a recommended rest. Furthermore, there have been studies that have concluded allergy testing results in detection of inhaled allergens that lead to inflammation which can trigger sinusitis.<!--
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| --><ref>{{cite journal | author = Staevska M Baraniuk JN | title = Persistent nonallergic rhinosinusitis. | journal =Curr Allergy Asthma Rep. | volume = 5 | issue = 3 | pages = 233-42 | year = 2005 | id = PMID 15842962}}</ref>
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| Therapeutic measures range from the medicinal to the traditional and may include [[nasal irrigation]] or jala neti using a warm saline solution, hot drinks including [[tea]] and chicken soup, inhaling steam, over-the-counter [[decongestant]]s and nasal sprays, and getting plenty of rest. Analgesics (such as [[aspirin]], [[paracetamol]] (acetaminophen) or [[ibuprofen]]) can be used, but caution must be employed to make sure the patient does not suffer from [[Samter's triad|aspirin-exacerbated respiratory disease]] (AERD) as this could lead to [[anaphylaxis]].
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| If sinusitis doesn't improve within 48 hours, or is causing significant pain, a doctor may prescribe [[antibiotic]]s ([[Amoxicillin]] usually being the most common) with amoxicillin/clavulanate ([[Augmentin]]/Co-Amoxiclav) being indicated for patients who fail amoxicillin alone. [[Fluoroquinolones]] may be used in patients who are allergic to penicillins.
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| ===Chronic sinusitis===
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| ====Simple measures====
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| [[Nasal irrigation]] and flush promotes sinus cavity health, and patients with chronic sinusitis including symptoms of facial pain, headache, halitosis, cough, anterior rhinorrhea (watery discharge) and nasal congestion found nasal irrigation to be "just as effective at treating these symptoms as the drug therapies." Recently the introduction of pulsatile irrigators specifically for sinus irrigation have been reported best for nasal irrigation <ref> [http://www.pharmacy-solutions.com Health Solutions Web site specializing on Pulsatile Irrigation]</ref> In other studies, "daily hypertonic saline nasal irrigation improves sinus-related quality of life, decreases symptoms, and decreases medication use in patients with frequent sinusitis," and is "recommended as an effective adjunctive treatment of chronic sinonasal symptoms."<!--
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| --><ref>{{cite journal | author = Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R | title = Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. | journal = J Fam Pract | volume = 51 | issue = 12 | pages = 1049-55 | year = 2002 | id = PMID 12540331}}</ref>
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| and irrigation is recommended as an "effective adjunctive treatment of chronic sinonasal symptoms."<!--
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| --><ref>{{cite journal | author = Rabago D, Pasic T, Zgierska A, Mundt M, Barrett B, Maberry R | title = The efficacy of hypertonic saline nasal irrigation for chronic sinonasal symptoms. | journal = Otolaryngol Head Neck Surg | volume = 133 | issue = 1 | pages = 3-8 | year = 2005 | id = PMID 16025044}}</ref><!--
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| --><ref>{{cite journal | author = Tomooka L, Murphy C, Davidson T | title = Clinical study and literature review of nasal irrigation. | journal = Laryngoscope | volume = 110 | issue = 7 | pages = 1189-93 | year = 2000 | id = PMID 10892694}}</ref>
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| ====Medical approaches====
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| For chronic or recurring sinusitis, referral to an [[Otolaryngology|otolaryngologist]] may be indicated for more specialist assessment and treatment, which may include nasal [[surgery]].
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| A relatively recent advance in the treatment of sinusitis is a type of surgery called [[Functional Endoscopic Sinus Surgery|FESS]] - functional [[Endoscope|endoscopic]] sinus surgery, whereby normal clearance from the sinuses is restored by removing the anatomical and pathological obstructive variations that predispose to sinusitis. This replaces prior open techniques requiring facial or oral incisions and refocuses the technique to the natural openings of the sinuses instead of promoting drainage by gravity, the idea upon which the Caldwell-Luc surgery was based.<!--
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| -->[http://www.fasthealth.com/dictionary/c/Caldwell-Luc_operation.php]
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| Another recently developed treatment is [[sinuplasty (procedure)|Balloon Sinuplasty™]]. This method, similar to [[balloon angioplasty]] used to "unclog" arteries of the heart, utilizes balloons in an attempt to expand the openings of the sinuses in a less invasive manner. Its final role in the treatment of sinus disease is still under debate but appears promising.
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| Based on the recent theories on the role that fungus may play in the development of chronic sinusitis, newer medical therapies include topical nasal applications of antifungal agents. Much of the original research indicating fungus took place at the Mayo Clinic and they have since patented this treatment option.<!--
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| --><ref>{{cite web | title=Resources on Chronic Rhinosinusitis | url=http://www.sinusacademy.com | year=2004 | publisher=Accentia Biopharmaceuticals Company and Mayo Clinic}}</ref>
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| Although there are some licensing battles taking place over these drugs as a result of the patent, they are currently available for other uses and therefore can be compounded by pharmacies or even by the patient.
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| ==== Surgical Approach ====
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| The surgical approach to the paranasal sinuses depends on the particular sinus which needs a surgical intervention and on the particular type of manipulation necessary. For this reason there are many different accesses and incisions to perform the reqired intervention in a given paranasal sinus.
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| Examples of the approaches include:
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| 1. Trans oral eg. the Caldwell Luc Procedure
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| 2. Trans Nasal eg. the Naso-antral lavage and window, ethmoidectomy, sphenoidectomy.
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| 3. Skin incision eg. Lynch procedure, osteoplastic flap, Weber Furguson approach, frontal trephine.
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| When entry is gained into the paranasal sinus, surgery can be extended to another sinus eg. the transantral approach to the ethmoids and the sphenoid. Also it can be extended to other adjacent anatomical structures eg. transantral ligation of internal maxillary artery and transantral approach to the pterygopalatine fossa and sphenopalatine ganglion.
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| ====Other approaches====
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| [[Phage therapy]]: Since the discovery of spontaneous bacterial lysis (from [[bacteriophages]]) by [[Frederick Twort]] and by [[Felix d'Herelle]], [[phage therapy]] (treatment with bacterial viruses) has been used extensively with miscellaneous bacterial infections in the areas of [[otolaryngology]], [[stomatology]], [[ophthalmology]], [[dermatology]], [[pediatrics]], [[gynecology]], [[surgery]] (especially against wound infections), [[urology]], and [[pulmonology]].<!--
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| --><ref name=jctb>{{cite journal | author=N Chanishvili, T Chanishvili, M. Tediashvili, P.A. Barrow | title=Phages and their application against drug-resistant bacteria | journal=J. chem. technol. biotechnol. | year=2001 | volume=76 | pages=689-699 | url=http://cat.inist.fr/?aModele=afficheN&cpsidt=1096871 }}</ref><!--
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| --><ref name="pmid8571474">{{cite journal |author=Perepanova TS, Darbeeva OS, Kotliarova GA, ''et al'' |title=[The efficacy of bacteriophage preparations in treating inflammatory urologic diseases] |language=Russian |journal=Urol. Nefrol.|volume= |issue=5 |pages=14-7 |year=1995 |pmid=8571474 |doi=}}</ref><!--
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| --><ref>{{cite journal | title=Application of Phages in Urology | author=Tsulukidze AP | journal=Urology | volume=XV(1) | pages=10-13 | year=1938}}</ref>
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| Treatment with phages was developed in the Soviet Union in parallel to the western development of antibiotics. Currently phage therapy for chronic Sinusitis is available at the Phage Therapy Center, Tbilisi, Republic of Georgia,<!--
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| -->[http://www.phagetherapycenter.com/pii/PatientServlet?command=static_sinusitis] or in Poland.<!--
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| -->[http://www.iitd.pan.wroc.pl/phages/phages.html]
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| ==References==
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| * {{cite journal | author = Ramadan H, Sanclement J, Thomas J | title = Chronic rhinosinusitis and biofilms. | journal = Otolaryngol Head Neck Surg | volume = 132 | issue = 3 | pages = 414-7 | year = 2005 | id = PMID 15746854}}
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| * {{cite journal | author = Bendouah Z, Barbeau J, Hamad W, Desrosiers M | title = Biofilm formation by Staphylococcus aureus and Pseudomonas aeruginosa is associated with an unfavorable evolution after surgery for chronic sinusitis and nasal polyposis. | journal = Otolaryngol Head Neck Surg | volume = 134 | issue = 6 | pages = 991-6 | year = 2006 | id = PMID 16730544}}
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| ==Footnotes==
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| <div class="references-small"><references/></div>
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| ==External links==
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| * [http://www.medterms.com/script/main/art.asp?articlekey=32138 Sinus Headache - Medterm.com]
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| * [http://www.medicinenet.com/sinusitis/article.htm Sinus infection - MedicineNet.com].
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| * [http://www.mayoclinic.com/invoke.cfm?id=DS00170 Acute sinusitis - MayoClinic.com], from the Web site of the [[Mayo Clinic]].
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| * [http://www.mayoclinic.com/health/chronic-sinusitis/DS00232 Chronic sinusitis - MayoClinic.com], from the Web site of the [[Mayo Clinic]]
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| * [http://www.niaid.nih.gov/factsheets/sinusitis.htm NIH]
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| * [http://www.nhsdirect.nhs.uk/en.aspx?articleID=338 NHS Direct]
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| * [http://www.sinusdynamics.com/ Sinus Dynamics]
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| {{Respiratory pathology}}
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| {{SIB}}
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