Jurnal READING

Acute and Chronic Sinusitis

Causes and Management
Albert Arifin ( 11-2017-189 )
Gabriella S P ( 11-2018-046 )

Kepaniteraan Klinik Ilmu THT

RSPAD Gatot Soebroto
 Abstract

Sinusitis is categorized by inflammation of the lining of the paranasal sinuses.

As the nasal mucosa is instantaneously involved and as sinusitis infrequently occurs without
concurrent rhinitis, rhinosinusitis is currently the preferred term for this condition.
Treatment of sinusitis, whether medical or surgical, is intended at decreasing inflammation and
obstruction in the sinonasal passages. Antibiotics, even though frequently used in sinusitis,
ought to not be managed unless there is suspicion of an acute bacterial infection.
 Introduction

Frequent acute sinusitis is diagnosed when 2-4 episodes of infection happen per
year with no less than 8 weeks between episodes and, as in acute sinusitis, the
sinus mucosa completely normalizes between attacks.
Chronic sinusitis is the perseverance of deceptive symptomatology beyond 12
weeks, with or without acute intensifications.
The literature has reinforced that chronic sinusitis is quite often joined by
simultaneous nasal airway inflammation and is frequently preceded by rhinitis
symptoms; as a result, the term chronic rhinosinusitis (CRS) has developed to all
the more precisely depict this condition. CRS may manifest as one of the three
major clinical syndromes: CRS without nasal polyps, CRS with nasal polyps, or
allergic fungal rhinosinusitis.
Most cases of chronic sinusitis are extensions of unresolved acute sinusitis;
nevertheless, chronic sinusitis typically demonstrates inversely from acute
sinusitis.
Symptoms of chronic sinusitis include nasal stuffiness, postnasal drip, facial
fullness, and malaise.
Chronic sinusitis can be non-infectious and associated to allergy, cystic fibrosis,
gastroesophageal reflux, or exposure to environmental pollutants
Medical treatment is focused toward controlling predisposing factors, treating
concomitant infections, decreasing edema of sinus tissues, and easing the drainage of
sinus secretions.
The objective in surgical treatment is to re-establish sinus ventilation and to redress
mucosal restriction keeping in mind the end goal to re-establish the mucociliary
clearance system.
Surgery strives to re-establish the functional integrity of the aggravated mucosal lining.
In 1996, the American Academy of Otolaryngology-Head & Neck Surgery multidisciplinary
Rhinosinusitis Task Force (RTF) characterized adult rhinosinusitis diagnostic criteria.
Main considerations included facial pain or pressure, nasal obstruction or blockage, nasal
discharge or purulence or discoloured postnasal release, hyposmia or anosmia, purulence in
nasal cavity, and fever.
In 2003, the RTF’s definition was revised to require corroborative radiographic or nasal
endoscopic or physical examination discoveries notwithstanding suggestive history
 Cause of Sinusitis

Sinusitis is for the most part activated by a viral upper respiratory

tract contamination, with just 2% of cases being confounded by
bacterial sinusitis.
 Table 1. List common and rarer reasons for sinusitis

Frequent causes Infrequent causes

• Viral infection • Cystic fibrosis

• Allergic and non-allergic rhinitis • Neoplasia
• Anatomical variations • Mechanical ventilation
Abnormality of the osteomeatal complex • Use of nasal tubes, such as nasogastric
Septal deviation feeding tubes
Concha bullosa • Samter's triad (aspirin sensitivity,
Hypertrophic middle turbinates rhinitis, asthma)
Cigarette smoking • Sarcoidosis
Diabetes mellitus • Wegener's granulomatosis
Swimming, diving, high altitude climbing • Immune deficiency
Dental infections and procedures • Sinus surgery
• Immotile cilia syndrome
 Symptoms or signs of acute rhinosinusitis are present 10 days or more
past the beginning of upper respiratory symptoms.
 Symptoms or signs of acute rhinosinusitis intensify inside 10 days after an
underlying change.
A background marked by purulent discharges and facial or dental agony
are particular side effects that may point to a bacterial etiology. In a
patient in serious care, acute sinusitis ought to be associated in the
nearness with sepsis of obscure beginning.
 Distinguish presumed acute bacterial rhinosinusitis from acute sinusitis
caused by viral upper respiratory infections and noninfectious conditions.

 Confirm a clinical diagnosis of chronic sinusitis with objective

documentation of sinonasal inflammation, which may be accomplished
using anterior rhinoscopy, nasal endoscopy, or computed tomography.
 Acute sinusitis symptoms Chronic sinusitis symptoms

Fever Nasal obstruction, blockage, congestion, stuffiness

Cough Sneezing
Hyposmia/anosmia Nasal discharge (of any character from thin to thick and from
Nasal congestion clear to purulent)
Nasal drainage Postnasal drip
Fatigue Chronic unproductive cough (primarily in children)
Maxillary dental pain Sore throat
Postnasal drip Stuffy ears
Facial pain or pressure (especially unilateral) Fetid breath
Ear fullness/pressure Malaise
Easy fatigability
Anorexia
Exacerbation of asthma
Dental pain (upper teeth)
Visual disturbances
Unpleasant taste
Fever of unknown origin
Hyposmia or anosmia (more with nasal polyposis)
Facial fullness, discomfort, pain, and headache (more with
nasal polyposis)
 Treatment of sinusitis
Antimicrobial Treatment

– Antimicrobial treatment is the backbone of medical treatment in sinusitis. Choice of

antibiotic depends on whether the sinusitis is acute, chronic, or recurrent. The AAAAI
2005 practice parameter states that choice of antibiotic ought to be based on
anticipated effectiveness, cost, and side effects.
– Antibiotics are shown for sinusitis that is believed to be bacterial, including sinusitis that
is extreme or includes the frontal, ethmoid, or sphenoid sinuses, since this kind of
sinusitis is more inclined to confusions.
 Penicillins, cephalosporins, and macrolides appear to be similarly strong. A 5-to 10-day
regimen of amoxicillin 500 mg 3 times each day is suggested as first-line treatment
One examination proposes that a solitary measurement of 2 g of broadened discharge
azithromycin might be more viable than a 10-day course of amoxicillin/clavulanate.
 However, azithromycin is not likely a decent decision in sinusitis since manifestations
may enhance simply because of the calming adequacy of the specialist and on the
grounds that it has poor viability against S pneumoniae and H influenzae.
 CRS without nasal polyps is treated with prednisone 20-40 mg day by day decreased
more than 10 days in addition to an intranasal steroid. Anti-microbial treatment is
frequently required for up to a month and a half or more and ought not to be stopped
until the point when the patient is asymptomatic.
 Discontinuation of antimicrobial therapy prior to complete resolution increases the
probability of relapse. Difficult-to-treat chronic sinusitis is associated with nasal
polyps, asthma, and aspirin-exacerbated respiratory disease.
Symptomatic Treatment

Symptoms may be relieved with topical decongestants, topical steroids, antibiotics, nasal
saline, topical cromolyn, or mucolytics.
Symptomatic or adjunctive therapies may include the following:
– Humidification/vaporizer
– Balanced nutrition
– Smoking cessation
– Warm compresses
– Adequate hydration
– Nonnarcotic analgesia
Surgical Treatment

Surgical care is generally saved for cases that are headstrong to medicinal
treatment and for patients with anatomic check.

The objective in surgical treatment is to restore sinus ventilation and to

adjust mucosal resistance with a specific end goal to re-establish the
mucociliary leeway framework. Surgery endeavors to re-establish the
practical respectability of the aggravated mucosal covering
 FESS simplifies the removal of disease in key areas, re-establishes
adequate aeration and drainage of the sinuses by establishing patency
of the ostiomeatal complex, debulks severe polyposis, and causes less
harm to normal nasal functioning.
FESS is effective in re-establishing sinus health, with complete or at
least moderate relief of symptoms in 80-90% of patients.

Figure 1. Sinus CT scan showing the frontal and sphenoid sinuses.

 Acute Maxillary Sinusitis

– Numerous techniques have been defined for drainage of the maxillary sinus. The
inferior meatus and canine fossae are optimal drainage sites on account of their ease
of availability and comparatively thin well-vascularized bone.
– Three main surgical options are available for chronic maxillary sinusitis:
• Endoscopic uncinectomy with or without maxillary antrostomy
• Caldwell-Luc procedure
• Inferior antrostomy (naso-antral window).

Figure 2. Scan of Maxillary Sinusitis

 Fungal Sinusitis

The desired treatment for chronic fungal sinusitis is surgical debridement.

Mycetomas or fungus balls are best treated by means of surgical exclusion.
Allergic fungal sinusitis, which generally manifests as nasal polyps and allergic
sinusitis, is treated by means of systemic steroids and surgical removal of polyps and
mucinous secretions.
Prolonged postoperative tapering doses of prednisone and anterior nasal
glucocorticoid steroids are specified to suppress the symptoms of fungal CRS.
 Conclusion

Several therapies have been proven by studies with a high level of evidence to
improve clinical symptoms and objective results. Several therapies still need
validation over well-conducted studies, in which randomized controlled trials may be
a difficult task due to confounding factors and trial participation.
Although it remains a challenge to cure the root cause of sinusitis, an algorithm of
multidrug regimen and endoscopic sinus surgery after fully implemented medication can
help to reduce the disease burden and advance the quality of life of this group of patients.