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Sinusitis, also known as rhinosinusitis, is an
inflammation Inflammation (from ) is part of the biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or irritants. The five cardinal signs are heat, pain, redness, swelling, and loss of function (Latin ''calor'', '' ...
of the mucous membranes that line the sinuses resulting in symptoms that may include production of thick nasal mucus, nasal congestion, facial congestion, facial pain, facial pressure, loss of smell, or
fever Fever or pyrexia in humans is a symptom of an anti-infection defense mechanism that appears with Human body temperature, body temperature exceeding the normal range caused by an increase in the body's temperature Human body temperature#Fever, s ...
. Sinusitis is a condition that affects both children and adults. It is caused by a combination of environmental and a person's individual health factors. It can occur in individuals with
allergies Allergies, also known as allergic diseases, are various conditions caused by hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include Allergic rhinitis, hay fever, Food allergy, food al ...
, exposure to environmental irritants, structural abnormalities of the
nasal cavity The nasal cavity is a large, air-filled space above and behind the nose in the middle of the face. The nasal septum divides the cavity into two cavities, also known as fossae. Each cavity is the continuation of one of the two nostrils. The nas ...
and sinuses and poor immune function. Most cases are caused by a
viral infection A viral disease (or viral infection) occurs when an organism's body is invaded by pathogenic viruses, and infectious virus particles (virions) attach to and enter susceptible cells. Examples include the common cold, gastroenteritis, COVID-19, t ...
. Recurrent episodes are more likely in persons with
asthma Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wh ...
,
cystic fibrosis Cystic fibrosis (CF) is a genetic disorder inherited in an autosomal recessive manner that impairs the normal clearance of Sputum, mucus from the lungs, which facilitates the colonization and infection of the lungs by bacteria, notably ''Staphy ...
, and
immunodeficiency Immunodeficiency, also known as immunocompromise, is a state in which the immune system's ability to fight infectious diseases and cancer is compromised or entirely absent. Most cases are acquired ("secondary") due to extrinsic factors that aff ...
. The diagnosis of sinusitis is based on the symptoms and their duration along with signs of disease identified by endoscopic and/or radiologic criteria. Sinusitis is classified into acute sinusitis, subacute sinusitis and chronic sinusitis. In acute sinusitis, symptoms last for less than 4 weeks, and in subacute sinusitis they last between 4 and 12 weeks. In chronic sinusitis symptoms must be present for at least 12 weeks. In the initial evaluation of sinusitis an otolaryngologist, also known as an ear, nose and throat (ENT) doctor, may confirm sinusitis using nasal endoscopy. Diagnostic imaging is not usually needed in acute stage unless complications are suspected. In chronic cases, confirmatory testing is recommended by use of computed tomography. Prevention of sinusitis focuses on regular hand washing, staying up-to date on vaccinations, and avoiding
smoking Smoking is a practice in which a substance is combusted, and the resulting smoke is typically inhaled to be tasted and absorbed into the bloodstream of a person. Most commonly, the substance used is the dried leaves of the tobacco plant, whi ...
. Pain killers such as naproxen, nasal steroids, and nasal irrigation may be used to help with symptoms. Recommended initial treatment for acute sinusitis is
watchful waiting Watchful waiting (also watch and wait or WAW) is an approach to a medical problem in which time is allowed to pass before medical intervention or therapy is used. During this time, repeated testing may be performed. Related terms include ''expe ...
. If symptoms do not improve in 7–10 days or worsen, then an
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
may be implemented or changed. In those in whom antibiotics are indicated, either amoxicillin or amoxicillin/clavulanate is recommended first line, with amoxicillin/clavulanate being superior to amoxicillin alone but with more side effects. Surgery may be recommended in those with chronic disease who have failed medical management. Sinusitis is a common condition. It affects between about 10 and 30 percent of people each year in the United States and Europe. The management of sinusitis in the United States results in more than 11 billion in costs.


Signs and symptoms

Acute sinusitis can present as facial pain and tenderness that may worsen on standing up or bending over, headache, cough, bad breath, nasal congestion, ear pain, ear pressure or nasal discharge that is usually green in color, and may contain pus or blood.Dental pain can also occur. A way to distinguish between toothache and sinusitis is that sinusitis-related pain is usually worsened by tilting the head forward or performing the Valsalva maneuver. Chronic sinusitis presents with more subtle symptoms of nasal obstruction, with less fever and pain complaints. Symptoms include facial pain,
headache A headache, also known as cephalalgia, is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of Depression (mood), depression in those with severe ...
, night-time coughing, an increase in previously minor or controlled asthma symptoms, general malaise, thick green or yellow nasal discharge, feeling of facial fullness or tightness that may worsen when bending over, dizziness, aching teeth, and bad breath. Often, chronic sinusitis can lead to anosmia, the loss of the sense of smell. A 2005 review suggested that most "sinus headaches" are migraines. The confusion occurs in part because migraine involves activation of the trigeminal nerves, which innervate both the sinus region and the meninges surrounding the brain. As a result, accurately determining the site from which the pain originates is difficult. People with migraines do not typically have the thick nasal discharge that is a common symptom of a sinus infection.


By location

The four paired
paranasal sinuses Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sphe ...
are the frontal, ethmoidal, maxillary, and sphenoidal sinuses. The ethmoidal sinuses are further subdivided into anterior and posterior ethmoid sinuses, the division of which is defined as the basal lamella of the middle nasal concha. In addition to the severity of
disease A disease is a particular abnormal condition that adversely affects the structure or function (biology), function of all or part of an organism and is not immediately due to any external injury. Diseases are often known to be medical condi ...
, discussed below, sinusitis can be classified by the sinus cavity it affects: * Maxillary – may cause pain or pressure in the maxillary (cheek) region, often experienced as toothache or headache. * Frontal – may cause pain or pressure in the frontal sinus cavity (above the eyes), often experienced as headache, particularly in the forehead area. * Ethmoidal – may cause pain or pressure pain between or behind the eyes, along the sides of the upper nose ( medial canthi), and headaches. * Sphenoidal – may cause pain or pressure behind the eyes, though it is often felt at top of the head, over the mastoid processes, or the back of the head.


Complications

Complications are thought to be rare (1 case per 10,000). Infectious complications of acute bacterial sinusitis include eye,
brain The brain is an organ (biology), organ that serves as the center of the nervous system in all vertebrate and most invertebrate animals. It consists of nervous tissue and is typically located in the head (cephalization), usually near organs for ...
and
bone A bone is a rigid organ that constitutes part of the skeleton in most vertebrate animals. Bones protect the various other organs of the body, produce red and white blood cells, store minerals, provide structure and support for the body, ...
complications.


Orbital complications

The Chandler Classification is used to group orbital complications into five stages according to their severity. Stage I, known as preseptal cellulitis, occurs when an infection develops in front of the orbital septum. It is thought to result from restricted venous drainage from the sinuses and affects the soft tissue of the eyelids and other superficial structures. Stage II, known as orbital cellulitis, occurs when infection develops behind the orbital septum and affects the
orbits In celestial mechanics, an orbit (also known as orbital revolution) is the curved trajectory of an physical body, object such as the trajectory of a planet around a star, or of a natural satellite around a planet, or of an satellite, artificia ...
. This can result in impaired eye movement, protrusion of the eye, and eye swelling. Stage III, known as subperiosteal abscess, occurs when pus collects between walls of the orbit and the surrounding periosteal structures. This can result in impaired eye movement and acuity. Stage IV, known as orbital abscess, occurs when an abscess forms within the orbital tissue. This can result in severe vision impairment. Stage V, known as cavernous sinus thrombosis, is considered an intracranial complication. It can occur as bacterial spread progresses, triggering blood clots that become trapped within the cavernous sinus. This can result in previously described symptoms within the opposite eye and in severe cases, meningitis.


Intracranial complications

The close proximity of the sinuses to the brain makes brain infections one of the most dangerous complication of acute bacterial sinusitis, especially when the frontal and sphenoid sinuses are involved. These infections can result from invasion of anaerobic bacteria through the bones or blood vessels. Abscesses,
meningitis Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, intense headache, vomiting and neck stiffness and occasion ...
, and other life-threatening conditions may occur. In rare cases, mild personality changes, headache, altered consciousness, visual problems, seizures,
coma A coma is a deep state of prolonged unconsciousness in which a person cannot be awakened, fails to Nociception, respond normally to Pain, painful stimuli, light, or sound, lacks a normal Circadian rhythm, sleep-wake cycle and does not initiate ...
, and even death may occur.


Osseous complications

A rare complication of acute sinusitis is a bone infection, known as
osteomyelitis Osteomyelitis (OM) is the infectious inflammation of bone marrow. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The feet, spine, and hips are the most commonly involved bones in adults. The cause is ...
, which affects the frontal and other facial bones. Specifically, the combination of frontal sinusitis, osteomyelitis and subperiosteal abscess formation is referred to as Pott's puffy tumor. Other complications When an infection originating from a tooth or dental procedure affects the maxillary sinus it can lead to odontogenic sinusitis (ODS). Odontogenic sinusitis can often spread to nearby sinuses including the ethmoid, frontal, sphenoid sinuses, and the contralateral nasal cavity. In rare instances, these infections may spread to the
orbit In celestial mechanics, an orbit (also known as orbital revolution) is the curved trajectory of an object such as the trajectory of a planet around a star, or of a natural satellite around a planet, or of an artificial satellite around an ...
, leading to orbital
cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of ...
.


Causes


Acute

Acute sinusitis is usually precipitated by an earlier upper respiratory tract infection, generally of viral origin, mostly caused by
rhinovirus The rhinovirus (from the "nose", , romanized: "of the nose", and the ) is a Positive-sense single stranded RNA virus, positive-sense, single-stranded RNA virus belonging to the genus ''Enterovirus'' in the family ''Picornaviridae''. Rhinoviru ...
es (with RVA and RVC giving more severe infection than RVB),
coronavirus Coronaviruses are a group of related RNA viruses that cause diseases in mammals and birds. In humans and birds, they cause respiratory tract infections that can range from mild to lethal. Mild illnesses in humans include some cases of the comm ...
es, and influenza viruses, others caused by adenoviruses, human parainfluenza viruses, human respiratory syncytial virus, enteroviruses other than rhinoviruses, and
metapneumovirus ''Metapneumovirus'' is a genus of viruses in the family ''Pneumoviridae''. Taxonomy The genus contains the following two species, listed by scientific name and followed by the exemplar virus of the species: * ''Metapneumovirus avis'', Avian metap ...
. If the infection is of bacterial origin, the most common three causative agents are '' Streptococcus pneumoniae (38%)'', ''
Haemophilus influenzae ''Haemophilus influenzae'' (formerly called Pfeiffer's bacillus or ''Bacillus influenzae'') is a Gram-negative, Motility, non-motile, Coccobacillus, coccobacillary, facultative anaerobic organism, facultatively anaerobic, Capnophile, capnophili ...
(36%)'', and '' Moraxella catarrhalis (16%)''. Text was copied from this source, which is available under a Creative Commons Attribution 4.0 International License . Until recently, ''H. influenzae'' was the most common bacterial agent to cause sinus infections. However, introduction of the ''H. influenzae'' type B (Hib) vaccine has dramatically decreased these infections and now non-typable ''H. influenzae'' (NTHI) is predominantly seen in clinics. Other sinusitis-causing bacterial
pathogen In biology, a pathogen (, "suffering", "passion" and , "producer of"), in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a Germ theory of d ...
s include '' S. aureus'' and other streptococci
species A species () is often defined as the largest group of organisms in which any two individuals of the appropriate sexes or mating types can produce fertile offspring, typically by sexual reproduction. It is the basic unit of Taxonomy (biology), ...
, anaerobic bacteria and, less commonly,
Gram-negative Gram-negative bacteria are bacteria that, unlike gram-positive bacteria, do not retain the crystal violet stain used in the Gram staining method of bacterial differentiation. Their defining characteristic is that their cell envelope consists ...
bacteria. Viral sinusitis typically lasts for 7 to 10 days. Acute episodes of sinusitis can also result from
fungal A fungus (: fungi , , , or ; or funguses) is any member of the group of eukaryotic organisms that includes microorganisms such as yeasts and molds, as well as the more familiar mushrooms. These organisms are classified as one of the tradit ...
invasion. These infections are typically seen in people with
diabetes Diabetes mellitus, commonly known as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough of the hormone insulin, or the cells of th ...
or other immune deficiencies (such as
AIDS The HIV, human immunodeficiency virus (HIV) is a retrovirus that attacks the immune system. Without treatment, it can lead to a spectrum of conditions including acquired immunodeficiency syndrome (AIDS). It is a Preventive healthcare, pr ...
or transplant on immunosuppressive antirejection medications) and can be life-threatening. In type I diabetics, ketoacidosis can be associated with sinusitis due to
mucormycosis Mucormycosis, also known as black fungus, is a severe fungal infection that comes under fulminant fungal sinusitis, usually in people who are immunocompromised. It is curable only when diagnosed early. Symptoms depend on where in the body the ...
.


Chronic


Definition and nomenclature

By definition, chronic sinusitis lasts longer than 12 weeks and can be caused by many different diseases that share chronic inflammation of the sinuses as a common symptom. It is subdivided into cases with and without polyps. When polyps are present, the condition is called chronic hyperplastic sinusitis; however, the causes are poorly understood. It may develop with anatomic derangements, including deviation of the nasal septum and the presence of concha bullosa (pneumatization of the middle concha) that inhibit the outflow of mucus, or with allergic rhinitis, asthma, cystic fibrosis, and dental infections. Chronic rhinosinusitis represents a multifactorial inflammatory disorder, rather than simply a persistent bacterial infection. The medical management of chronic rhinosinusitis is now focused upon controlling the inflammation that predisposes people to obstruction, reducing the incidence of infections. Surgery may be needed if medications are not working. Attempts have been made to provide a more consistent nomenclature for subtypes of chronic sinusitis. The presence of eosinophils in the mucous lining of the nose and paranasal sinuses has been demonstrated for many people, and this has been termed eosinophilic mucin rhinosinusitis (EMRS). Cases of EMRS may be related to an allergic response, but allergy is not often documented, resulting in further subcategorization into allergic and nonallergic EMRS.


Fungi

A more recent, and still debated, development in chronic sinusitis is the role that
fungi A fungus (: fungi , , , or ; or funguses) is any member of the group of eukaryotic organisms that includes microorganisms such as yeasts and mold (fungus), molds, as well as the more familiar mushrooms. These organisms are classified as one ...
play in this disease. Whether fungi are a definite factor in the development of chronic sinusitis remains unclear, and if they are, what is the difference between those who develop the disease and those who remain free of symptoms. Trials of antifungal treatments have had mixed results.


One airway theory

Recent theories of sinusitis indicate that it often occurs as part of a spectrum of diseases that affect the
respiratory tract The respiratory tract is the subdivision of the respiratory system involved with the process of conducting air to the alveoli for the purposes of gas exchange in mammals. The respiratory tract is lined with respiratory epithelium as respirato ...
(''i.e.'', the "one airway" theory) and is often linked to
asthma Asthma is a common long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wh ...
.


Smoking

Both smoking and secondhand smoke are associated with chronic rhinosinusitis.


Air pollution

Exposure to fine particulate matter (PM2.5), which consists of particles less than 2.5 micrometers in diameter, has been associated with an increased risk of developing rhinosinusitis. PM2.5 particles can penetrate deep into the respiratory tract, reaching the nasal and sinus mucosa, leading to inflammation and impaired mucociliary clearance. Individuals living in areas with higher concentrations of PM2.5 experience increased symptoms and exacerbations of chronic rhinosinusitis. The fine particles cause oxidative stress and inflammation, contributing to the pathogenesis of rhinosinusitis. While both PM10 (particles less than 10 micrometers) and PM2.5 can affect the respiratory system, PM2.5 particles are more closely associated with rhinosinusitis due to their ability to reach deeper into the sinus cavities. These smaller particles bypass the nasal hair filtering mechanism and deposit in the mucous membranes of the sinuses, leading to greater inflammatory responses. The World Health Organization (WHO) recommends that annual mean concentrations of PM2.5 should not exceed 5 μg/m3, and 24-hour mean exposures should not exceed 15 μg/m3 to minimize health risks. Exposure to concentrations above these thresholds has been linked to an increased incidence and severity of rhinosinusitis and other respiratory diseases.


Other diseases

Other diseases such as
cystic fibrosis Cystic fibrosis (CF) is a genetic disorder inherited in an autosomal recessive manner that impairs the normal clearance of Sputum, mucus from the lungs, which facilitates the colonization and infection of the lungs by bacteria, notably ''Staphy ...
and
granulomatosis with polyangiitis Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis (WG), after Nazi German physician Friedrich Wegener, is a rare, long-term, systemic disorder that involves the formation of granulomas and vasculitis, inflammatio ...
can also cause chronic sinusitis.


Maxillary sinus

Maxillary sinusitis may also develop from problems with the teeth, and these cases were calculated to be about 40% in one study and 50% in another. The cause of this situation is usually a periapical or periodontal infection of a maxillary posterior tooth, where the inflammatory exudate has eroded through the bone superiorly to drain into the maxillary sinus. An estimated 0.5 to 2.0% of viral rhinosinusitis (VRS) will develop into bacterial infections in adults and 5 to 10% in children.


Pathophysiology

Chronic rhinosinusitis is multifactorial process hypothesized to be caused by inflammatory processes driven by dysfunction between local host and environmental interactions. It is divided into two
phenotype In genetics, the phenotype () is the set of observable characteristics or traits of an organism. The term covers the organism's morphology (physical form and structure), its developmental processes, its biochemical and physiological propert ...
s that depend on the presence or absence of nasal polyps. Chronic rhinosinusitis with nasal polyps and chronic rhinosinusitis without nasal polyps are thought to have two different inflammatory pathways, with the latter form driven by a Th1 response and the former driven by a Th2 response. Both pathways result in an increase in inflammatory molecules (
cytokines Cytokines () are a broad and loose category of small proteins (~5–25 kDa) important in cell signaling. Cytokines are produced by a broad range of cells, including immune cells like macrophages, B cell, B lymphocytes, T cell, T lymphocytes ...
). The Th1 response is characterized by secretion of interferon gamma. The Th2 response is characterized by secretion of interleukin-4 receptor, interleukin 5, and interleukin 13. Both forms of chronic rhinosinusitis are considered to be highly heterogenous, each with the ability to demonstrate three inflammatory endotypes, the third being a Th17 response.


Diagnosis


Classification

Sinusitis (or rhinosinusitis) is defined as an inflammation of the
mucous membrane A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It ...
that lines the
paranasal sinuses Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sphe ...
and is classified chronologically into several categories: * Acute sinusitis – A new infection that may last up to four weeks and can be subdivided symptomatically into severe and nonsevere. Some use definitions up to 12 weeks. * Recurrent acute sinusitis – Four or more full episodes of acute sinusitis that occur within one year * Subacute sinusitis – An infection that lasts between four and 12 weeks, and represents a transition between acute and chronic infection. * Chronic sinusitis – When the signs and symptoms last for more than 12 weeks. * Acute exacerbation of chronic sinusitis – When the signs and symptoms of chronic sinusitis exacerbate, but return to baseline after treatment. Roughly 90% of adults have had sinusitis at some point in their lives.


Acute

Health care providers distinguish bacterial and viral sinusitis by
watchful waiting Watchful waiting (also watch and wait or WAW) is an approach to a medical problem in which time is allowed to pass before medical intervention or therapy is used. During this time, repeated testing may be performed. Related terms include ''expe ...
. If a person has had sinusitis for fewer than 10 days without the symptoms becoming worse, then the infection is presumed to be viral. When symptoms last more than 10 days or get worse in that time, then the infection is considered bacterial sinusitis. Pain in the teeth and bad breath are also more indicative of bacterial disease. Imaging by either X-ray, CT or MRI is generally not recommended unless complications develop. Pain caused by sinusitis is sometimes confused for pain caused by pulpitis (toothache) of the maxillary teeth, and vice versa. Classically, the increased pain when tilting the head forwards separates sinusitis from pulpitis. For cases of maxillary sinusitis, limited field CBCT imaging, as compared to periapical
radiograph Radiography is an imaging technique using X-rays, gamma rays, or similar ionizing radiation and non-ionizing radiation to view the internal form of an object. Applications of radiography include medical ("diagnostic" radiography and "therapeu ...
s, improves the ability to detect the teeth as the sources for sinusitis. A coronal CT picture may also be useful.


Chronic

For sinusitis lasting more than 12 weeks, a
CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
is recommended. On a CT scan, acute sinus secretions have a radiodensity of 10 to 25 Hounsfield units (HU), but in a more chronic state they become more viscous, with a radiodensity of 30 to 60 HU. Nasal
endoscopy An endoscopy is a procedure used in medicine to look inside the body. The endoscopy procedure uses an endoscope to examine the interior of a hollow organ or cavity of the body. Unlike many other medical imaging techniques, endoscopes are insert ...
and clinical symptoms are also used to make a positive diagnosis. A tissue sample for
histology Histology, also known as microscopic anatomy or microanatomy, is the branch of biology that studies the microscopic anatomy of biological tissue (biology), tissues. Histology is the microscopic counterpart to gross anatomy, which looks at large ...
and
cultures Culture ( ) is a concept that encompasses the social behavior, institutions, and Social norm, norms found in human societies, as well as the knowledge, beliefs, arts, laws, Social norm, customs, capabilities, Attitude (psychology), attitudes ...
can also be collected and tested. Nasal endoscopy involves inserting a flexible
fiber-optic An optical fiber, or optical fibre, is a flexible glass or plastic fiber that can transmit light from one end to the other. Such fibers find wide usage in fiber-optic communications, where they permit transmission over longer distances and at ...
tube with a light and camera at its tip into the nose to examine the nasal passages and sinuses. Sinus infections, if they result in tooth pain, usually present with pain involving more than one of the upper teeth, whereas a toothache usually involves a single tooth. Dental examination and appropriate radiography aid in ruling out pain arises from a tooth. Image:Sinuses and Sinusitis (5937085231).jpg, CT of chronic sinusitis File:CT of chronic sinuitis.jpg,
CT scan A computed tomography scan (CT scan), formerly called computed axial tomography scan (CAT scan), is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers or ...
of chronic sinusitis, showing a filled right maxillary sinus with sclerotic thickened bone File:Brain MRI 112010 rgbca.png, MRI image showing sinusitis. Edema and mucosal thickening appears in both maxillary sinuses. File:RtmaxobitinfectteethCT.png, Maxillary sinusitis caused by a dental infection associated with periorbital cellulitis File:FrontalSinusitisMark.png, Frontal sinusitis File:Maxilar sinusites.jpg,
X-ray An X-ray (also known in many languages as Röntgen radiation) is a form of high-energy electromagnetic radiation with a wavelength shorter than those of ultraviolet rays and longer than those of gamma rays. Roughly, X-rays have a wavelength ran ...
of left-sided maxillary sinusitis marked by an arrow. There is lack of the air transparency indicating fluid in contrast to the other side.


Treatment

Recommended treatments for most cases of sinusitis include rest and drinking enough water to thin the mucus. Antibiotics are not recommended for most cases. Breathing high-temperature steam such as from a hot shower or gargling can relieve symptoms. There is tentative evidence for nasal irrigation in acute sinusitis, for example during upper respiratory infections. Decongestant nasal sprays containing oxymetazoline may provide relief, but these medications should not be used for more than the recommended period. Longer use may cause rebound sinusitis. It is unclear if nasal irrigation,
antihistamine Antihistamines are drugs which treat allergic rhinitis, common cold, influenza, and other allergies. Typically, people take antihistamines as an inexpensive, generic (not patented) drug that can be bought without a prescription and provides ...
s, or decongestants work in children with acute sinusitis. There is no clear evidence that plant extracts such as '' Cyclamen europaeum'' are effective as an intranasal wash to treat acute sinusitis. Evidence is inconclusive on whether anti-fungal treatments improve symptoms or quality of life.


Antibiotics

Most sinusitis cases are caused by viruses and resolve without antibiotics. However, if symptoms do not resolve within 10 days, either amoxicillin or amoxicillin/clavulanate are reasonable antibiotics for first treatment with amoxicillin/clavulanate being slightly superior to amoxicillin alone but with more side effects. A 2018 Cochrane review, however, found no evidence that people with symptoms lasting seven days or more before consulting their physician are more likely to have bacterial sinusitis as one study found that about 80% of patients have symptoms lasting more than 7 days and another about 70%. Antibiotics are specifically not recommended in those with mild / moderate disease during the first week of infection due to risk of adverse effects,
antibiotic resistance Antimicrobial resistance (AMR or AR) occurs when microbes evolve mechanisms that protect them from antimicrobials, which are drugs used to treat infections. This resistance affects all classes of microbes, including bacteria (antibiotic resis ...
, and cost. Fluoroquinolones, and a newer macrolide antibiotic such as clarithromycin or a tetracycline like
doxycycline Doxycycline is a Broad-spectrum antibiotic, broad-spectrum antibiotic of the Tetracycline antibiotics, tetracycline class used in the treatment of infections caused by bacteria and certain parasites. It is used to treat pneumonia, bacterial p ...
, are used in those who have severe allergies to
penicillin Penicillins (P, PCN or PEN) are a group of beta-lactam antibiotic, β-lactam antibiotics originally obtained from ''Penicillium'' Mold (fungus), moulds, principally ''Penicillium chrysogenum, P. chrysogenum'' and ''Penicillium rubens, P. ru ...
s. Because of increasing resistance to amoxicillin the 2012 guideline of the Infectious Diseases Society of America recommends amoxicillin-clavulanate as the initial treatment of choice for bacterial sinusitis. The guidelines also recommend against other commonly used antibiotics, including azithromycin, clarithromycin, and trimethoprim/sulfamethoxazole, because of growing antibiotic resistance. The FDA recommends against the use of fluoroquinolones when other options are available due to higher risks of serious
side effect In medicine, a side effect is an effect of the use of a medicinal drug or other treatment, usually adverse but sometimes beneficial, that is unintended. Herbal and traditional medicines also have side effects. A drug or procedure usually use ...
s. A short-course (3–7 days) of antibiotics seems to be just as effective as the typical longer-course (10–14 days) of antibiotics for those with clinically diagnosed acute bacterial sinusitis without any other severe disease or complicating factors. The IDSA guideline suggest five to seven days of antibiotics is long enough to treat a bacterial infection without encouraging resistance. The guidelines still recommend children receive antibiotic treatment for ten days to two weeks.


Corticosteroids

For unconfirmed acute sinusitis, nasal sprays using
corticosteroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are invo ...
s have not been found to be better than a
placebo A placebo ( ) can be roughly defined as a sham medical treatment. Common placebos include inert tablets (like sugar pills), inert injections (like saline), sham surgery, and other procedures. Placebos are used in randomized clinical trials ...
either alone or in combination with antibiotics. For cases confirmed by radiology or nasal endoscopy, treatment with intranasal corticosteroids alone or in combination with antibiotics is supported. The benefit, however, is small. For confirmed chronic rhinosinusitis, there is limited evidence that intranasal steroids improve symptoms and insufficient evidence that one type of steroid is more effective. There is only limited evidence to support short treatment with corticosteroids by mouth for chronic rhinosinusitis with nasal polyps. There is limited evidence to support corticosteroids by mouth in combination with antibiotics for acute sinusitis; it has only short-term effect improving the symptoms.


Surgery

For sinusitis of dental origin, treatment focuses on removing the infection and preventing reinfection, by removal of the
microorganism A microorganism, or microbe, is an organism of microscopic scale, microscopic size, which may exist in its unicellular organism, single-celled form or as a Colony (biology)#Microbial colonies, colony of cells. The possible existence of unseen ...
s, their byproducts, and pulpal debris from the infected root canal. Systemic
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy ...
s are ineffective as a definitive solution, but may afford temporary relief of symptoms by improving sinus clearing, and may be appropriate for rapidly spreading infections, but debridement and disinfection of the root canal system at the same time is necessary. Treatment options include non-surgical root canal treatment, periradicular surgery, tooth replantation, or extraction of the infected tooth. For chronic or recurring sinusitis, referral to an otolaryngologist may be indicated, and treatment options may include nasal surgery. Surgery should only be considered for those people who do not benefit with medication or have non-invasive fungal sinusitis. It is unclear how benefits of surgery compare to medical treatments in those with nasal polyps as this has been poorly studied. A number of surgical approaches can be used to access the sinuses and these have generally shifted from external/extranasal approaches to intranasal endoscopic ones. The benefit of functional endoscopic sinus surgery (FESS) is its ability to allow for a more targeted approach to the affected sinuses, reducing tissue disruption, and minimizing post-operative complications. However, if a traditional FESS with Messerklinger technique is followed the success rate will be as low as 30%, 70% of the patients tend to have recurrence within 3 years. On the other hand with use of TFSE technique along with navigation system, debriders and balloon sinuplasty or EBS can give a success rate of over 99.9%. The use of drug eluting stents such as propel mometasone furoate implant may help in recovery after surgery. Another recently developed treatment is balloon sinuplasty. This method, similar to balloon angioplasty used to "unclog" arteries of the heart, utilizes balloons in an attempt to expand the openings of the sinuses in a less invasive manner. The effectiveness of the functional endoscopic balloon dilation approach compared to conventional FESS is not known.
Histopathology Histopathology (compound of three Greek words: 'tissue', 'suffering', and '' -logia'' 'study of') is the microscopic examination of tissue in order to study the manifestations of disease. Specifically, in clinical medicine, histopatholog ...
of sinonasal contents removed from surgery can be diagnostically valuable: File:Histopathology of sinonasal inflammatory polyp with mixed inflammation, annotated.jpg, Benign chronic mixed inflammation of an inflammatory sinonasal polyp File:Histopathology of acute sinusitis.png, Acute inflammation characterized by
neutrophil Neutrophils are a type of phagocytic white blood cell and part of innate immunity. More specifically, they form the most abundant type of granulocytes and make up 40% to 70% of all white blood cells in humans. Their functions vary in differe ...
s File:Histopathology of extranodal NK-T cell lymphoma, nasal type.png, Extranodal NK/T cell lymphoma, nasal type. It may be incidentally discovered in people undergoing surgery for sinusitis.


Treatments directed to rhinovirus infection

A study has shown that patients given spray formulation of 0.73 mg of Tremacamra (a soluble intercellular adhesion molecule 1 CAM-1receptor) reduced the severity of illness.


Prognosis

A 2018 review has found that without the use of antibiotics, about 46% were cured after one week and 64% after two weeks.


Epidemiology

Sinusitis is a common condition, with between 24 and 31 million cases occurring in the United States annually. Chronic sinusitis affects approximately 12.5% of people.


Research

Based on recent theories on the role that
fungi A fungus (: fungi , , , or ; or funguses) is any member of the group of eukaryotic organisms that includes microorganisms such as yeasts and mold (fungus), molds, as well as the more familiar mushrooms. These organisms are classified as one ...
may play in the development of chronic sinusitis, antifungal treatments have been used, on a trial basis. These trials have had mixed results.


See also

* Fungal sinusitis * Odontogenic sinusitis


References


External links

* {{Authority control Nose disorders Headaches Inflammations Wikipedia medicine articles ready to translate Wikipedia emergency medicine articles ready to translate Rhinology