Sinus Illness

The sinuses are cavities within the bones of the head. While these "empty spaces" make our heads lighter and easier to move, they also contain linings that perform the important function of protecting the body from dust, pollen and germs in the air we breathe.

The sinuses are lined with a mucous membrane, a type of soft, moist tissue that is covered with a thin layer of mucus. The surface is covered with cells containing microscopic hair-like "cilia" which, (under normal conditions), continuously sweep the mucus sheet along, carrying trapped particles and germs though the nose and into the throat. From there, the mucus and all it contains is swallowed into the stomach where trapped allergens and bacteria are harmlessly destroyed.

 For the discussion below, you may wish to refer to Learning - The Nose.

The majority of problems referable to the paranasal sinuses are of an inflammatory nature. Mucosal inflammation in the sinuses and their nasal openings (called "ostia") leads to sinus obstruction and stasis of the mucus contents, which in turn, leads to bacterial overgrowth and infection. Over their lifetimes about 25% of people are victims of sinus infection. The maxillary sinus is the most commonly involved in adults, followed by the frontal. The ethmoids are less commonly affected in adults, but are common sites for infection in children. Types of Sinusitis Acute Sinusitis Symptoms as long as 4 weeks Subacute Sinusitis Symptoms persist between 4 to 12 weeks Chronic Sinusitis Persistent Symptoms beyond 12 weeks Recurrent Sinusitis Four or more episodes per year Each episode lasts 7 days or more Symptom free intervals last greater than 2 months

Allergens and air pollutants and tobacco smoke can predispose to sinus infection as can anatomical abnormalities such as nasal polyps and septal deviation. Also, those with mucosal disorders like cystic fibrosis or allergic rhinitis are more likely to suffer sinus trouble. 10-15% of sinus infections are caused by viruses, with rhinoviruses being the most common (adenovirus and influenza virus are also seen). The bacteria most likely to cause acute sinusitis are streptococcus pneumonia and hemophilus influenzae, however, chronic sinusitis is more often caused by anaerobic bacteria such as Bacteroides or gram positive cocci. Diabetics and people with immune compromise (e.g. HIV), may develop sinus infections with fungi or Aspergillis.

Symptoms

Aching pain or "pressure" is commonly felt over the affected sinus, the forehead for frontal sinus, the mid-face and upper teeth for maxillary, and between and behind the eyes for ethmoid. Commonly pain is worsened by leaning forward and is worst in the late morning. Foul, pus-like nasal discharge or "post-nasal drip" are common, and when present for more than 10 days, strongly suggest bacterial sinusitis. A loss of the sense of smell may be seen, together with an increase in snoring, mouth breathing and halitosis. Generalized findings of fever and fatigue may also develop.

High fever (>102.2), double vision, peri-orbital swelling or mental status changes should prompt immediate referral to the head and neck surgeon.

Testing

The head and neck surgeon may perform certain tests to aid in diagnosis and/or treatment. Although nasal swab cultures are unreliable, endoscope-directed micro swab cultures from the "hiatus semilunaris," (the nasal area into which the ethmoid and maxillary sinuses empty), have about 85% accuracy in determining the bacterium responsible for infection. When sinusitis is chronic or recurrent, or if it does not respond to therapy, the surgeon will want to obtain a CT scan to better understand the anatomy and to evaluate the scope of the problem.

Treatment

"Chronic sinusitis" often results from frequent acute episodes that impact the function of mucous membranes. These are usually mixed bacterial infections and may also result from inadequately treated allergic rhinitis. Where proper courses of irrigation and antibiotic treatments fail to solve this problem, surgery may be the best alternative (when allergies and immunological problems are ruled out). Functional Endoscopic Sinus Surgery

(FESS) has made the treatment of these problems both safer and more effective. At the same time, it allows a "minimally invasive" approach that avoids operations with larger incisions and longer recovery. Those with no predisposing factors will have symptom relief about 93% of the time after one FESS procedure. Efficacy fall to 80-85% for those who use tobacco or have asthma.

Among the absolute indications for sinus surgery are:

• Extrasinus spread of infection
• Pyocele
• Mucocele
• Fungal sinusitis
• Large, obstructing nasal polyps