inflammatory condition involving the four PARANASAL SINUSESSINUSITIS The term rhinosinusitis is used because sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa.• maxillary sinus is most commonly involved Next, in order of frequency, are the ethmoid, frontal, and sphenoid sinuses.• Most cases are due to a viral infection.• Classification: by duration, by etiology and by the offending pathogen type (viral, bacterial, or fungal).
ACUTE SINUSITIS• <4 weeks duration (Harrison).• Majority of sinusitis cases.• Preceding viral URI.• Antibiotics are prescribed frequently (in 85–98% of all cases) for this condition.• Sub acute rhinosinusitis: Duration of 4–12 weeks.• Recurrent acute rhinosinusitis: Greater than four or more episodes of acute rhinosinusitis per year, with each episode lasting 7–10 days, with symptom resolution between episodes.
ETIOLOGY• Ostial obstruction: infectious and noninfectious causes.Allergic rhinitis (with either mucosal edema or polyp obstruction).Barotrauma (e.g., from deep-sea diving or air travel)Chemical irritants.nasal and sinus tumors (e.g., squamous cell carcinoma) or granulomatous diseases (e.g., granulomatosis with polyangiitis (Wegeners) or rhinoscleroma).Cystic fibrosis.In ICUs, nasotracheal intubation and nasogastric tubes are major risk factors for nosocomial sinusitis.
Viruses: rhinovirus, respiratory syncytial virus, parainfluenza virus, and influenza virus.Bacterial:o S. pneumoniae and nontypable Haemophilus influenzae most common (50-60%).o Moraxella catarrhalis (20%) in children.o S. aureus, Pseudomonas aeruginosa, Serratia marcescens, Klebsiella pneumoniae, and Enterobacter species nosocomial. Fungi:o Rhizopus, Rhizomucor, Mucor, Mycocladus (formerly Absidia), and Cunninghamella rhinocerebral mucormycosis (immunocompromised)o Aspergillus and Fusarium.
CLINICAL MANIFESTATIONS• Most cases of acute sinusitis present after or in conjunction with a viral URI.• Nasal drainage and congestion, facial pain or pressure, and headache.• Nonspecific cough, sneezing, and fever.• Tooth pain (upper molars) and halitosis (bacterial sinusitis).• Advanced sphenoid or ethmoid sinus infectionsevere frontal or retroorbital pain radiating to the occiput, thrombosis of the cavernous sinus, and signs of orbital cellulitis.• Advanced frontal sinusitis Potts puffy tumor subperiosteal abscess associated with osteomyelitis.• Complications: meningitis, epidural abscess, and cerebral abscess.
Major and Minor Factors in the Diagnosisof Rhinosinusitis (1997 Task Force):Major factors• Facial pain or pressure• Facial congestion or fullness• Nasal obstruction or blockage• Nasal discharge, purulence, or discolored postnasal drainage• Hyposmia or anosmia• Purulence in nasal cavity• Fever (in acute rhinosinusitis only)Factors• Headache• Fever (in chronic sinusitis)• Halitosis• Fatigue• Dental pain• Cough• Ear pain, pressure, or fullness
DIAGNOSIS• Bacterial sinusitis "persistent" symptoms (i.e., symptoms lasting >10 days in adults or >10–14 days in children) accompanied by the three cardinal signs of purulent nasal discharge, nasal obstruction, and facial pain.• Signs or symptoms of acute rhinosinusitis worsen within 10 days after an initial improvement.• Viral RhinosinusitisSymptoms of acute rhinosinusitis are present < than 10 days Symptoms are not worsening.
GUIDELINES FOR THE DIAGNOSIS ANDTREATMENT OF ACUTE SINUSITIS
CHRONIC SINUSITIS• >12 weeks (Harrison)• most commonly associated with either bacteria or fungi.• Clinical cure in most cases is very difficult.• Pathophysiology remains incompletely understood, but it is believed to be multifactorial, resulting from interactions between host anatomy, genetics, and the environment. Impairment of mucociliary clearance.• Patients experience constant nasal congestion and sinus pressure, with intermittent periods of greater severity, which may persist for years.• CT can be helpful in determining the extent of disease
ETIOLOGY• With polyps chronic hyperplastic sinusitis• Allergy• Environmental factors such as dust or pollution• Bacterial infection, or fungus (either allergic, infective, or reactive).• Non-allergic factors, such as vasomotor rhinitis, can also cause chronic sinus problems.• Abnormally narrow sinus passagesdeviated septum, can impede drainage from the sinus.
CLINICAL MANIFESTATIONSCRS is now (2007) defined as 12 weeks or longer of two or more of the following symptoms:• Mucopurulent drainage (anterior, posterior, or both): discolored 51–83%• Nasal obstruction (congestion): 81–95%• Facial pain-pressure-fullness: 70–85%• Decreased sense of smell: 61–69%Other signs:• Purulent mucus or edema in the middle meatus or ethmoid region• Polyps in the nasal cavity or the middle meatus• Radiographic imaging showing inflammation of the paranasal sinuses.
TREATMENT• Antibiotic therapy is similar to acute, but is longer: 3-4 weeks.• Antimicrobial choice should include drugs effective against staphylococcal organisms.• Adjuvant therapies such as saline nasal irrigation, decongestants, antihistamines, or topical intranasal steroids may be helpful depending on the underlying cause.• Surgical Therapy• Antral lavage• Adenoidectomy• Endoscopic Sinus Surgery• External Drainagereserved for complications
ALLERGIC RHINITIS• Is an allergic inflammation of the nasal airways.• May be seasonal, perennial, or both.• Sneezing, rhinorrhea, lacrimation , and congestion and pruritus of the conjunctiva, nasal mucosa, and oropharynx are the hallmarks of allergic rhinitis.• Can be associated with other chronic conditions, including asthma (40%), otitis media with effusion (OME), rhinosinusitis, nasal polyposis and eczematous dermatitis• Can have multiple triggers, both inhaled and ingested.
May be seasonal, perennial, or both. Characterized by sneezing, itching, rhinorrhea, and congestion. Can be associated with other chronic conditions, including asthma, otitis media with effusion (OME), rhinosinusitis,PREVALENCE and nasal polyposis. Typical symptoms of sneezing, rhinorrhea, and nasal congestion can be associated with viral, bacterial, allergic, and nonallergic etiologies. Can have multiple triggers, both inhaled and ingested. GENERAL CONSIDERATIONS• one of the most common allergic diseases in the United States Allergy is a clinical manifestation of an adverse immune response after repeated contact with usually harmless substances such as pollens, mold spores, animal dander, dust mites, foods, and stinging insects. Allergic rhinitis is an inflammation of the nasal mucous membranes caused by an IgE-mediated reaction to one or more allergens. The prevalence of allergic rhinitis can (20-25%of the population). vary considerably among age groups and locales.• The incidence of onset is greatest in adolescence, with a Allergic rhinitis is one of the most common allergic diseases in the United States, affecting between 20% and 25% of the population (approximately 40 million people). Allergic rhinitis may have its onset at any age, but the incidence of onset is greatest in adolescence, with a decreasing incidence with advancing age. Its peak prevalence is during the third and fourth decreasing incidence with advancing age. Its peak prevalence decades (Figure 14–1). is during theFigure 14–1. fourth decades. third and•
PATHOGENESIS• Type I hypersensitivity reaction IgE antibodies (atopic reaction).• Early-phase (humeral reaction): 10–15 minutes of allergen exposure.• Histamine sneezing, rhinorrhea, itching, vascular permeability, vasodilatation, and glandular secretion.• Late-phase (cellular reaction): 4–6 hours after the initial sensitization and may prolong allergic cascade for as long as 48 hours• Cytokines and leukotrienes influx of inflammatory cells (mainly eosinophils) nasal congestion and postnasal drip
ETIOLOGY1. In infancy and childhood food allergens such as milk, eggs, soy, wheat, dust mites, and inhalant allergies such as pet dander are the major causes of allergic rhinitis and the comorbidities of atopic dermatitis, otitis media with effusion, and asthma.2. In older children and adolescents, pollen allergens become more of a causative factor.3. Genetic susceptibility ( family history)4. Environmental factors (dust and mold)5. Allergens (pollens, animals, and foods)6. Tobacco smoke (early childhood)7. Diesel exhaust particles (in urban areas)
CLASSIFICATIONSeasonal Allergic Rhinitis• certain seasons, usually depending on the pollination of plants to which the patient is allergic.• Characteristic symptoms:o Sneezingo watery rhinorrheao itching of the nose, eyes, ears, and throato red and watering eyeso nasal congestion.Symptoms are usually worse in the morning and are aggravatedby dry, windy conditions and higher concentrations of pollen.
Perennial Allergic Rhinitis • Symptoms are constant: o Thickening of the sinus membranes (adult life) Nasal congestion and postnasal discharge. o Rhinorrhea and sneezing are less common. o Eye symptoms are less common, except with animal allergies. • Food allergies gastrointestinal problems, urticaria, angioedema, and even anaphylaxis after food is ingested. • Irritants such as tobacco smoke, chemical fumes, and air pollutants can also aggravate symptoms.• Perennial nonallergic rhinitis with eosinophilia syndrome (NARES) occurs in the middle decades of life and is characterized by nasal obstruction, anosmia, chronic sinusitis, and frequent aspirin intolerance.• vasomotor rhinitis or perennial nonallergic rhinitis symptom complex resembling perennial allergic rhinitis occurs with nonspecific stimuli, including chemical odors, temperature and humidity variations, and position changes but occurs without tissue eosinophilia or an allergic etiology.
PHYSICAL EXAMINATION• Seasonal allergic rhinitis:o Include bluish, pale, boggy turbinates.o Wet, swollen mucosa; and nasal congestion and obstruction.• Perennial allergies:o Nasal congestion is the predominant sign, but the nasal examination may appear normal.o Anatomic abnormalities, such as a deviated nasal septum, concha bullosa, and nasal polyps, may be present.o Other signs: conjunctivitis, eczema, and, possibly, asthmatic wheezing.
Environmental control and immunotherapy Immunotherapy: indications for immunotherapy include long-term pharmacotherapy for prolonged periods, the inadequacy or intolerability of drug therapy, and significant allergen sensitivities. Subcutaneous injection (SCIT) and Sublingual immunotherapy (SLIT).
TREATMENT: pharmacologic• ANTIHISTAMINES: are effective in early-phase reaction and therefore reduce sneezing, rhinorrhea, and itching.• INTRANASAL CORTICOSTEROIDS: They act on the late-phase reaction and therefore prevent a significant influx of inflammatory cells. triamcinolone, budesonide, fluticasone propionate, mometasone, fluticasone furoate, and ciclesonide.• SISTEMIC CORTICOSTEROIDS: for severe, intractable symptoms. 3–7 days.• DESCONGESTANTS: α-adrenergic agonists (oxymetazoline) vasoconstriction Use: 3–4 days (rhinitis medicamentosa).• INTRANASAL ANTICHOLINERGIC: ipratropium bromide• INTRANASAL CROMOLYN: used before the onset of symptoms• LEUKOTRIENE INHIBITORS: Montelukast
BIBLIOGRAFÍA:• Anil K. Lalwani. CURRENT Diagnosis & Treatment in Otolaryngology—Head & Neck Surgery. New York: McGraw-Hill, 2012.• Dan L. Longo et al.. Harrisons Principles of Internal Medicine. New York: McGraw-Hill, 2012.• Adkinson, N. Franklin. Middletons allergy: principles & practice. 7th ed. Philadelphia, PA: Mosby/Elsevier, 2009.• Kelley, P. E., and N. R. Friedman. ". Chapter 17. Ear, Nose, & Throat. In W.W. Hay, M.J. Levin, J.M. Sondheimer, R.R. Deterding (Eds)." CURRENT Diagnosis & Treatment: Pediatrics. By P. J. Yoon. N.p.: n.p., n.d. N. pag. Web. 22 Oct. 2012. <http://0- www.accessmedicine.com.millenium.itesm.mx/content.aspx? aID=6581598.>.