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Overview |
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Definition |
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Sinusitis is an inflammation and infection of the paranasal sinuses that
causes impaired sinus mucociliary clearance. It affects approximately 31 million
adults and children in the United States. Sinusitis has many similar
characteristics to rhinitis, and can also be called
rhinosinusitis. |
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Etiology |
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Sinusitis is most often caused by an upper respiratory tract infection or
through bacterial infection (Streptococcus pneumoniae, Haemophilus
influenzae, or by fungal or viral entities). This is followed by allergic
rhinitis, dental infection or manipulation, and trauma to the sinuses. Disease
of the anterior ethmoid-middle meatal complex (ostiomeatal complex) is the most
frequent local cause of chronic sinusitis. |
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Risk Factors |
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- Upper respiratory infections
- Allergic rhinitis
- Immunodeficiency, Kartagener's syndrome, and cystic
fibrosis
- Nosocomial sinusitis from foreign nasal bodies
- Nasal polyps, nasal septal deviation, and spurs
- Anatomic abnormalities that narrow the ostiomeatal channels
- Cold air, cigarette smoke, decongestants, and metal
vapors
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Signs and Symptoms |
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- Inflammation and edema of nasal mucosa, purulent sinonasal secretion
(yellow or green), or postnasal drip
- Headache, pain, sinus tenderness, or toothache
- Cough or pharyngitis
- Fever, in half of patients
- Loss of smell
- General malaise
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Differential
Diagnosis |
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- Upper respiratory tract infection (common cold)
- Tension and vascular headaches
- Meningitis
- Brain and epidural abscesses
- Viral, allergic, or vasomotor rhinitis
- Tumors or cysts
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Diagnosis |
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Physical Examination |
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Physical findings may include tenderness, purulent sinonasal obstruction and
secretion, and postnasal drip. Look for three of the following findings:
maxillary toothache, colored nasal discharge, poor response to nasal
decongestants, abnormal sinus transillumination, purulent
secretions |
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Laboratory Tests |
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- Culture and biopsy for chronic and fungal sinusitis
- Microscopic examination shows sheets of polymorphonuclear neutrophils
as well as bacteria
- Skin test to determine underlying allergy
- Blood test to reveal immunoglobulin serum levels and antibody
response to specific antigens (i.e., allergies)
- Nasopharyngeal culture
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Pathology/Pathophysiology |
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- Bacterial titers exceeding 1,000 CFU per ml, primarily S.
pneumoniae, H. influenzae, and Branhamella (Moraxellla) catarrhalis
for acute sinusitis
- Anaerobes of the Bacteroides, Fusobacterium, Streptococcus,
Veillonella, and Corynebacterium species as well as anaerobic
gram-positive cocci for chronic sinusitis (some studies show this to be
inaccurate with anaerobes found in as few as 7.6% of cases)
- Gram-negative bacteria, such as Pseudomonas aeruginosa, Klebsiella
pneumoniae, and Enterobacter species for nosocomial
sinusitis
- Normal ciliated epithelium replaced by stratified squamous epithelium
in chronic sinusitis
- Goblet cell hyperplasia, mononuclear cell infiltration, and basement
membrane thickening
- Edema, inflammation, and thickened
mucosa
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Imaging |
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- Computed tomography (CT)—shows the
ostiomeatal complex as well as other sinuses; evaluates disease, anatomic
obstructions, fine bony structure, and soft-tissue complications; diagnoses
fungal sinusitis
- Conventional sinus radiograph—diagnoses
maxillary and frontal sinus disease; poor for ostiomeatal complex
- Flexible fiberoptic rhinoscopy—reveals
purulent drainage in sinus ostia
- Transillumination—maxillary and frontal
sinuses; often inaccurate
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Other Diagnostic
Procedures |
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- Endoscopy exam—differentiates between
purulence and allergic mucosal thickening; reveals ostiomeatal
disease
- Irrigation of the maxillary
antrum—distinguishes between purulence and allergic
mucosal thickening; identifies
tumors
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Treatment Options |
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Treatment Strategy |
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Nonsurgical treatment includes antibiotics, decongestants, avoiding
allergens, steam or mist inhalation for drainage and symptom relief, and
hydration to thin secretions. Surgical treatment for restoration of ventilation
and mucociliary functioning is attempted when nonsurgical measures have failed.
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Drug Therapies |
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- Antibiotics—For first cases of sinusitis,
amoxicillin (500 mg tid) is generally used. With penicillin resistance and
treatment failure, use broad-spectrum antibiotics such as cefuroxime (Ceftin,
250 to 500 mg bid), cefaclor (Ceclor, 500 mg bid), amoxicillin/clavulanic acid
(Augmentin, 500 mg bid), clarithromycin (Biaxin, 250 to 500 mg bid), or an
azithromycin (Zithromax) pack for patients allergic to penicillins. Antibiotics
are taken for 10 to 14 days in acute cases and for up to six weeks in chronic
cases.
- Decongestants—Oral decongestants, such as
pseudoephedrine (60 mg tid to qid), cause urinary retention in older male
patients; monitor their use with hypertensive patients. Nasal sprays, such as
oxymetazoline (Afrin, tid), should be used for three to five days only; there is
a risk of tachyphylaxis and rebound if used longer.
- Nasal steroid spray for allergic/chronic sinusitis (e.g.,
triamcinolone)
Surgical therapies include functional endoscopic surgery
(FESS)—to remove diseased tissue (reduced comorbidity
and damage to normal anatomy compared to external surgery); external
surgery—for osteomyelitis, orbital or intracranial
complications, and failure of FESS |
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Complementary and Alternative
Therapies |
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A combination of physical medicine and herbal or homeopathic treatment is
often effective for treating both acute and chronic rhinosinusitis.
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Nutrition |
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- Vitamin C (1,000 mg tid), zinc (30 to 60 mg/day ), beta-carotene
(15,000 IU/day) to support immunity.
- Bromelain (500 mg tid between meals) and quercetin (500 mg tid
between meals) are anti-inflammatory
- Avoid mucus-producing foods, such as dairy products, bananas and any
known allergens. Drink plenty of fluids. Decrease sugar
intake.
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Herbs |
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Ascertain a diagnosis before pursuing treatment. Herbs may be used as dried
extracts (capsules, powders, teas), glycerites (glycerine extracts), or
tinctures (alcohol extracts). Unless otherwise indicated, teas should be made
with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or
flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be
used singly or in combination as noted.
- Wild indigo (Baptisia
tinctoria)—specific for upper respiratory and sinus
infections, increases phagocytosis
- Eyebright (Euphrasia
officinalis)—anticatarrhal, specific for sinus
- Licorice (Glycyrrhiza
glabra)—antiviral, soothing, especially with
exhaustion and/or heartburn; avoid with hypertension
- Coneflower (Echinacea
purpurea)—stimulates the immune system
- Goldenseal (Hydrastis
canadensis)—antiviral, antibacterial, digestive
tonic
A combination of all of the above herbs, equal parts, may be very effective.
1 cup tea or 30 to 60 drops tincture every two to four hours. May
add:
- Jamaica dogwood (Piscidia piscipula) or St. John's wort
(Hypericum perforatum), in equal parts, may be added for pain
relief.
- Garlic/Ginger tea—two to three cloves of
garlic (Allium sativum) and two to three slices of fresh ginger
(Zingiber officinale). Steep 5 to 15 minutes and drink, breathing in the
steam. Stimulates immune system and stimulates drainage, prevents sinus problems
from extending into lungs.
- Essential oils for bath or steam. For a steam, place 2 to 5 drops in
a pot, bring to a simmer and hold head over the pot. For a bath, add 5 to 10
drops of oil to the bath. Eucalyptus (Eucalyptus globulus), lavender
(Lavandula angustifolia), and thyme (Thymus vulgaris) are specific
for upper-respiratory infections. Lavender and rosemary (Rosmarinus
officinalis) are also calming. These essential oils have antiseptic
properties.
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Homeopathy |
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An experienced homeopath should assess individual constitutional types and
severity of disease to select the correct remedy and potency. For acute
prescribing use 3 to 5 pellets of a 12X to 30C remedy every one to four hours
until acute symptoms resolve.
- Arsenicum album for sinusitis with watery, excoriating
discharge
- Kali bichromicum for sinusitis with thick "gluey" discharge,
postnasal drip, especially with ulceration
- Pulsatilla for thick, bland, greenish discharge, especially if
patient is weepy and is not thirsty
- Nux vomica for sinusitis with coryza, and a stopped up feeling,
especially if patient is impatient and/or
angry
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Physical Medicine |
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- Contrast hydrotherapy. Alternating hot and cold applications brings
nutrients to the site and diffuses metabolic waste from inflammation. Use
washcloths over the sinus area. Alternate three minutes hot with one minute
cold. Repeat three times to complete one set. Do two to three
sets/day.
- Nasal lavage to shrink membranes/increase drainage. Mix salt and
water to taste like tears. Rinse each nostril by holding head over sink and
letting water run from upper nostril to lower nostril. Keep nostrils lower than
throat to prevent salt water draining into back of throat.
- Craniosacral therapy (osteopathic/chiropractic) can be very effective
at decreasing the frequency of
infections/headaches.
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Acupuncture |
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May be helpful for both acute and chronic
sinusitis. |
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Patient Monitoring |
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Patients not responding to therapy should see an
otolaryngologist. |
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Other
Considerations |
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Fungal sinusitis should be suspected for patients who do not respond to
antibiotic therapy and for immunocompromised patients. |
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Prevention |
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Avoid known allergens, cold air, cigarette smoke, topical drugs, swimming,
and metal vapors, and follow a diet that reduces mucus
production. |
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Complications/Sequelae |
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Orbital infection from acute ethmoid sinusitis requires hospitalization,
surgical drainage, and intravenous culture-specific antibiotics.
- Osteomyelitis of the frontal bones (Pott's puffy tumor), especially
in children
- Intracranial spread of infection results in meningitis, subdural
empyema, and abscesses; male adolescents are most at risk.
- Sphenoid sinusitis—delayed diagnosis is
associated with serious morbidity and mortality.
- Otitis media—frequently present with
children
- Abscess—extradural, subdural, brain, or
retrobulbar
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Prognosis |
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An acute sinus infection lasts no longer than 8 weeks; a chronic sinus
infection lasts for at least 4 weeks after initiation of
treatment. |
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Pregnancy |
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Tetracycline is contraindicated in pregnancy. |
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References |
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Barkin R, Rosen P, eds. Emergency Medicine: Concepts and Clinical
Practice. 4th ed. St. Louis, Mo: Mosby-Year Book; 1996.
Blumenthal M, ed. The Complete German Commission E Monographs: Therapeutic
Guide to Herbal Medicines. Boston, Mass: Integrative Medicine
Communications; 1998:122-123.
Gruenwald J, Brendler T, Jaenicke C, et al., eds. PDR for Herbal
Medicines. Montvale, NJ: Medical Economics Co; 1998:684-685.
Kruzel T. The Homeopathic Emergency Guide. Berkeley, Calif: North
Atlantic Books; 1992:286-290.
Middleton E, ed. Allergy: Principles and Practice. 5th ed. St.
Louis, Mo: Mosby-Year Book; 1998.
Rakel RE. Conn's Current Therapy. 50th ed. Philadelphia, Pa: WB
Saunders Co; 1998. |
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Copyright © 2000 Integrative Medicine
Communications This publication contains
information relating to general principles
of medical care that should not in any event be construed as specific
instructions for individual patients. The publisher does not accept any
responsibility for the accuracy of the information or the consequences arising
from the application, use, or misuse of any of the information contained herein,
including any injury and/or damage to any person or property as a matter of
product liability, negligence, or otherwise. No warranty, expressed or implied,
is made in regard to the contents of this material. No claims or endorsements
are made for any drugs or compounds currently marketed or in investigative use.
The reader is advised to check product information (including package inserts)
for changes and new information regarding dosage, precautions, warnings,
interactions, and contraindications before administering any drug, herb, or
supplement discussed herein. | |