Sinusitis
The paranasal sinuses are four pairs of different sizes, each with the name of the bone in which they reside: the maxillary, ethmoid, frontal, and sphenoid sinuses (Figure 1). Paranasal sinuses have controversial functions such as humidifying respiratory air, secreting mucus, alleviating skull bones, contributing to resonance of sound, and isolation of intracranial heat.
Sinusitis is one of the most common causes of applications to health care institutions and is one of the most frequently prescribed antibiotic diseases. It is also an important source of morbidity and a major cause of economic loss. It has been reported that 50 million people in the United States are affected by sinusitis annually, causing 73 million days of labor loss and $ 2.4 billion in medical (excluding surgical and radiological procedures) treatment and endoscopic sinus surgery in 100,000 patients for sinusitis.
Classification
1 - Acute sinusitis: Sudden onset, less than four weeks in a completely healed sinusitis. It often develops after viral upper respiratory tract infection.
2- Subacute sinusitis: It is used for acute rhinosinusitis for more than four weeks and less than 12 weeks.
3- Recurrent sinusitis: In a year, each of which lasts 7 days or more, more than four episodes are experienced.
4- Chronic sinusitis: Sinusitis lasting 12 weeks or more. Acute attacks may develop during the course of chronic sinusitis.
Ethiopathogenesis:
Because of the close proximity of the paranasal sinuses to the nasal mucosa, sinusitis and rhinitis are often found together, and some authors use the term rhinosinusitis more often than sinusitis. The paranasal sinus and nasal mucosa has defense systems such as mucociliary system activity against infection, mucus coverage in the epithelium, antimicrobial agents in the mucus, and immunoglobulins in the mucus. In particular, disruption of mucociliary activity plays an important role in the formation of sinusitis, leading to accumulation of secretions and infection within the sinus.
The anterior ethmoid, maxillary, and frontal sinuses drain to a region called osteomeatal complex in the middle meatus (Figure 2).
Osteomeatal complex stenosis creates a preparatory environment for sinusitis. The ethmoid sinus is usually the first onset of disease and most commonly involved sinus. Anatomical disorders (septal deviations, polyps, ethmoid sinus and middle turbinate variations, foreign bodies, tumors, lateral wall anomalies), mucosal edema (viral upper respiratory tract infections, allergies, hormonal disorders) can be among the causes of obstruction in the osteomeatal complex. In osteomeatal complex obstruction hypoxia develops, mucociliary activity decreases, sinus drainage deteriorates, secretions thicken, mucus stasis occurs. Accordingly, a suitable substrate for secondary bacterial growth is prepared and sinusitis begins.
The most common causes of acute sinusitis are Streptococcus pneumonia, Hemophilus influenza and Moraxella catarhallis, respectively. Hemophilus influenza, staphylococci and anaerobes are important factors in chronic sinusitis. In recent studies, the term allergic fungal sinusitis has been proposed by considering that a significant portion of chronic sinusitis is secondary to fungus. Presence of nasal polyposis, asthma and atopy, presence of dark mucoid secretion, demonstration of fungus in secretions without mucosal invasion, presence of antibodies specific to fungus in serum, monitoring of calcifications in sinuses, allergic fungal sinusitis should be considered. Invasive fungi are an important cause of sinusitis in diabetic and immunocompromised patients.
symptoms
Sinusitis can cause headache, runny nose, nasal congestion, bad breath, cough, ear pain, toothache, fever, hyposmi-anosmia, fatigue. Chronic sinusitis usually presents with milder symptoms. Symptoms are often more frequent at night and early in the morning (due to increased paranasal edema in the supine position and consequently reduced mucociliary activity).
Diagnosis
Anterior rhinoscopic and nasal endoscopic examination performed by ENT specialist has an important role in the diagnosis of sinusitis. Especially, purulent drainage in the middle meatus suggests sinusitis. Nasal examination also allows the identification of anatomic anomalies that lead to sinusitis, the detection of the affected sinus, the detection of nasal polyps, tumoral formations or fungal infections, and the differentiation of allergic conditions from infective events. In addition, facial edema, fullness, cervical adenopathy, postnasal discharge, pharyngitis may be detected on physical examination.
Routine radiological examinations such as Waters, Caldwell and lateral head radiography have been used for many years as an adjunct to the diagnosis. On radiographs, opacification and air-fluid levels in acute infections of maxillary, frontal and sphenoid sinuses will facilitate diagnosis.
The fact that routine radiographs are open to different interpretations and inadequate evaluation of the ethmoid sinuses and osteomeatal complex limits its usefulness in patients with chronic sinusitis. In chronic sinusitis resistant to treatment, in patients who may need surgery, in the presence of complications, suspected tumoral formation, coronal and axial planar sinus tomography should be used if necessary.
Treatment
Medical treatment of purulent sinusitis includes antibiotic, decongestant, mucolytic, methods of clearing other nasal secretions, and appropriate addition of topical steroids if necessary. Antibiotic selection is often made empirically according to the causative organisms and the clinician's experience.
Considering that two thirds of acute sinusitis develop secondary to Streptococcus pneumonia and Hemafilus influenza, firstly, the selection of antibiotics that may be effective on these microorganisms would be appropriate. The most commonly prescribed antibiotics for this purpose are amoxicillin, amoxicillin clavunate, clarithromycin, trimethoprim / sulfamethaxole, cefuroxime, cefrozil, loracarbef, cefodoxime, ciprofloxacin, levofloxain. Penicillin, cephalexin, erythromycin, and tetracycline do not include major microorganisms involved in sinusitis.
In some populations, the effectiveness of amoxicillin below 70% due to resistance limits its use. The duration of antibiotic treatment in uncomplicated sinusitis is between ten and 14 days.
In addition to antibiotic treatment, decongestants that reduce mucosal edema and open the sinus osteum can be added topically or systemically. It should be kept in mind that long-term administration of topical decongestants should not be used for longer than 4-5 days, as rebound mucosal edema may lead to rhinitis medicamentosa.
Removal of dark secretion from the sinus cavity can be increased by physical cleaning with saline and, if necessary, mucolytic agents are added to the treatment. It is necessary to avoid the use of antihistamines due to their drying effects on secretions except in allergic conditions. Topical steroids may also be added to treatment in cases of chronic sinusitis and atopy.
Subacute and chronic sinusitis resistant to drug therapy and recurrent acute sinusitis attacks are surgical indications. The aim of sinusitis surgery is to improve ventilation, drainage of sinuses and restore normal functions. Correction of obstruction in the osteomeatal complex and removal of pathologies are the basis of surgery. Endoscopic sinus surgery, which has been widely used for the last 15-20 years, can achieve successful results up to 90%.
Nasal polyposis, mucocele, mucopuyocele, invasive or allergic fungal sinusitis, sinus tumors, acute complicated sinusitis (subperiostal or orbital abscess, brain abscess, meningitis) are certain surgical indications. If a sinusitis complication develops, it should be started for broad-spectrum antibiotics and evaluated for immediate surgical intervention.
After the first-line treatment of sinusitis, which is a common disease, is performed by general practitioners, it would be appropriate to evaluate the patient by an ENT specialist in treatment-resistant cases.
complications
Although sinusitis is a very common disease, complications of sinusitis are rare due to the development of effective antibiotics and surgery. However, it should be kept in mind that untreated sinusitis can lead to fatal complications.
Complications of sinusitis can be classified into 3 groups:
1. Local complications: Osteomyelitis, mucocele, pyocele
2. Orbital complications: Inflammatory edema, orbital cellulitis, subperiostal abscess, orbital abscess, cavernous sinus thrombosis
3. Intracranial complications: Brain abscess, meningitis.
17AXX
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