Sinusitis Symptoms

Sinuses are hollow spaces in the bone around the nose that connect the nose through small narrow channels. Humans possess 4 paired paranasal sinuses, your cheekbone holds your maxillary sinuses (these are the largest). The low center of your forehead is where your frontal sinuses are located. Between your eyes are your Ethmoid sinuses. Sphenoid sinuses are located in the bone behind your nose. Theta is lined with soft pink tissue called the Mucosa. Sinusitis means your sinuses are inflamed. 98% of sinusitis occurs due to viral infection, it can also be caused due to bacterial infection. While a small population could have it due to the fungal disease. Some predisposing factors make it more likely that you get sinusitis, including allergic rhinitis which makes it easier for infection to occur, exposure to smoke or cigarette smoking, anatomical abnormalities which makes it difficult for the sinuses to drain. The central event in sinusitis is the blockage of sinus openings or Ostia as a result of inflammation. Unable to circulate air and eliminate the secretion that is produced, obstructed sinuses become an ideal environment for bacterial infection. 

Sinusitis is also known as a sinus infection or rhinosinusitis is a very common condition where the paranasal sinuses are inflamed causing congested nose, headache, and facial pain. Paranasal senses are the air cavities in the bones of the skull. There are 4 pairs of sinuses located on either side of the head. They are the maxillary, frontal, ethmoid, and sphenoid sinuses. The sinuses are aligned with respiratory epithelium producing mucus. The mucus drains into the nasal cavity through the small openings. Impaired sinuses drainage has been associated with inflammation of sinuses. When a sinus is blocked, fluids buildup making it a favorable environment for bacteria. A typical sinusitis infection is described as a dull pain or constant pressure commonly localized in the affected in the sinus. The pain my version when the person bends over or while lying down. Symptoms often start from one side of the head then spread to the other side. Acute sinusitis may also be accompanied by a thick nasal discharge of yellow-greenish color. Sinusitis may have different causes which include 

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1. Allergy 

These include allergens, pollen, pet dander may trigger the inflammatory response of the mucosa of the nose and sinuses, resolution in excess mucus production, nasal conjunction, sneezing  and itching 

2. Infection 

Infection usually occurs as a complication of a common cold. Impaired sinus drainage due to inflammation of nasal mucosa during a cold often leads to the infection of the sinus itself. Cold-like symptoms plus headache, facial pain, or pressure are common complaints.  

The other conditions that cause blockage of sinus drainage, these include structural abnormalities such as the deviated nasal septum, the formation of nasal polyps. Treatments depending upon the cause of sinusitis. For allergies, intranasal corticosteroids are commonly used. Symptom relief medications such as nasal spray for irrigation and decongestion are being used for the case of viral infection. Other conservative treatments for common cold such as rest and drinking plenty of fluids. For bacterial infection, antibiotics may be prescribed. For recurrent or chronic sinusitis due to structural abnormalities or nasal polyps, nasal surgery may be recommended to clear up the nasal drainage canal. The types of sinusitis are Acute sinusitis which would last for 4 weeks, Subacute sinusitis which would last for 4 to 12 weeks, Chronic sinusitis which can last more than 12 weeks and can continue for months or even years, Recurrent sinusitis. with several attacks within a year. In sinusitis, the first thing that people will notice is going to be a pain. The pain may be localized to sinus or it can cause generalized pain which may present itself as a headache. If you tap on the sinus involved with fingers, it can produce tenderness. Also since the mucosa is inflamed it will produce a lot of mucus, which is going to drain into the nasal cavity through sinus openings or Ostia. Once it is in the nasal cavity there are only 2 things it can do, 1st  it can come out of your nose so that the people will notice nasal discharge. The 2nd thing it can do is go back to your throat, as the back of your nose is related to the back of your throat and there it causes irritation and causes a cough. Inflammation of mucosa leads to alteration in the way we smell and taste anything. Patients can also have a fever because of inflammation and infection. In most of the cases, the diagnosis of sinusitis is made by observing the symptoms alone.  Common symptoms include nasal or postnasal drip, sinus pain or pressure, nasal congestion, decreased ability to smell, cough, headache, and fever. Sometimes the symptoms are not that clear, in that case, there are some tests that can be used to diagnose. 

A medical practitioner will take a look inside your nose to get a better look at your nasal or postnasal drip called the Rhinoscopy. X Rays can be done to visualize sinuses. The best way to diagnose is CT scan, other tests are only done when needed and in special circumstances. For acute viral sinusitis, which is the most common type of sinusitis there is not a lot we can do to treat the disease but we can treat the symptoms. One of the first drugs used to treat the symptoms is going to be nasal decongestants. These medications shrink swollen nasal passages facilitating the flow of drainage from the sinuses. We can also give mucolytics, which help clear mucus, the patient is asked to remain well hydrated. As being well hydrated helps in drainage of mucus, as the mucus formed is not so sticky that it gets stuck in your body and is well hydrated. Finally, the patent also receives pain killers to help relieve the pain. For acute bacterial sinusitis, the patient receives everything mentioned plus antibiotics for 10 to 14 days. For chronic sinusitis, the patient will receive the same medicine as given for acute bacterial infection, but the antibiotics have to be given for a longer period of time, most of them recommend 4 to 6 weeks of antibiotics. If sinusitis is too severe and the person is at the risk of complications, surgery is recommended.  Surgery may be done to remove small amounts of bone or other material blocking the sinus openings or to remove growths blocking sinuses also called Polyps. Doctors use a special device called the endoscopy which is a very light tool used to insert through the nose, which helps them to locate and remove whatever is blocking the sinuses.

Acute Sinusitis 

It is defined as the inflammation of the mucosa of the paranasal senses for a period of 4 weeks. The key elements for acute sinusitis include.

1. Obstruction of Ostia of paranasal sinuses 

2. Malfunction of the ciliary apparatus of the sinus mucosa.

3. Characters of the sinus secretion

Factors Causing Blockage of the Ostia 

The systemic factors causing the blockage of the Ostia include

1. Viral upper respiratory tract infection

2. Allergic inflammation

3. Patients can be born with the problem mucoid secretion like cystic fibrosis

4. Variety of immune disorders

5. Ciliary dyskinesia

6. Tobacco smoke

Local Insults Causing Obstruction of Ostia 

There are some local insults causing the to the face that cause obstruction of Ostia, they can result in bacterial sinusitis which includes

1. Facial trauma 

2. Swimming and diving professionally have sinus

3. High altitude and aviation maneuvers

4. Rhinitis medicamentosa

5. Nasal intubation

Mechanical Obstruction of Ostia 

Coming to mechanical obstruction of Ostia include 

1. Choanal atresia

2. Deviated nasal septum

3. Nasal polyps 

4. Foreign bodies

5. Ethmoid bullae

Consequences of Sinus Ostia Obstruction

1. Transient increase in sinus pressure

2. O₂ absorption into the tissue, which eventually leads to negative pressure in the sinus

3. Nasal and nasopharyngeal  bacteria enters sinus during sniffing, nose-blowing 

4. Fluid status and accumulation of sinus   

Consequences of Dysfunction of Mucociliary Apparatus

1. A progressive loss of ciliated cells during the upper viral upper respiratory infection

2. Alteration in the mucus layer 

3. Aggravated by cigarette smoking 

Acute sinusitis is common, but it is mostly caused by viruses. Children get a common cold 5 to 7 times each year, whereas adults who don’t have children will ger 2 to 3 colds a year.

Viral Upper Respiratory Infection 

1. Nasal conjunction and discharge, it starts out as everybody knows clear and watery, and then later it becomes thick and mucous, even in viral sinusitis, it becomes greenish and yellowish. 

2. A low-grade fever is not common in adults, but it is fairly common in children.

3. The common cold normally lasts 5 to 10 days

Bacterial Sinusitis 

We start to think about the bacterial sinusitis if the patience have 

1. More than 10 days of the nasal discharge

2. If they exhibit low-grade fever 

3. If they seem to show malodorous breath, which reflects the possibility of anaerobic contamination

4. And if the patients have periorbital edema

5. If the condition gets worse the symptoms include 

• Increase discharge and congestion 

• If you develop a new fever 

• Start developing cough during the day time 

Considering Physician Evaluation 

1. The duration of the respiratory symptom is the most useful factor for diagnosing bacterial infection.

2.  Symptoms or signs lasting more than 10 days without clinical improvement. 

3. Purulent nasal discharge and the high fever for 3 to 4 days consecutively. 

4. New fever, headache or increase discharge after 5 to 6 days of typical viral upper respiratory infection which initially improved 

Chronic Rhinosinusitis

This is a systemic inflammation of paranasal sinuses and nasal cavities. This has changed the way we think about chronic sinusitis, which was earlier referred to as an infectious disease now it is more referred to as inflammatory disease. The most common symptoms that people have in chronic rhinosinusitis are nasal obstruction, facial pressure, hyposmia, and discolored nasal discharge.

Diagnosis of Rhinosinusitis 

Some of the things that we need to emphasize are the importance of history and the importance of the physical exam in terms of finding or trying to see some signs of inflammation or discolor discharge or masses and the new change observed is the decrease in emphasis in radiology imaging. There are 3 methods examining the nose, 1st being ant rhinoscopy, the 2nd is called the rigid nasal endoscopy and the 3rd is flexible endoscopy. As we read earlier that practice guideline emphasizes more on the exam and less on imaging, however imagining should be considered early if there are certain symptoms shown such as 

1. Unilateral symptoms 

2. Bleeding 

3. Bad smells or odors 

4. Eye symptoms 

5. Neurologic symptoms

For the patients exhibiting such symptoms, it is recommended to get a non-contrast cat scan of the sinuses with Chrono or facial cuts. 

Pathophysiology of Rhinosinusitis  

Mucociliary Dysfunction 

As our sinuses are lined with cilia that beat at a regular frequency, considering something that causes a dysfunction of the cilia. It can be an anatomical issue or a genetic issue, sometimes it can be an environmental issue such as smoke which can cause ciliary dysfunction. Hence there is stasis or non-movement of the sinus fluids, which can then become infected or can cause inflammation 

Inflammation 

IT is assumed that there is an interplay between the allergy and the inflammation. Considering the TH-1 and TH-2 the different aspects of your immune system and how they react. TH-1 involves neutrophils, this is what we see more in the case of chronic rhinosinusitis without polyp the grape-like structures that we see in the nose. Then there is TH-2 which is more of an allergic response, this is observed with chronic rhinosinusitis with polyps this is more mediated by eosinophils.

Infection 

There can be some level of infection to consider an example of biofilms. Biofilms are communities of bacteria that can later form a community that can adhere to the surface and then is more resistant to treatment. The first line of treatment used is nasal saline.