This document discusses sinusitis, rhinosinusitis, and allergic rhinitis. It begins by defining sinusitis and rhinosinusitis, noting that sinusitis usually involves the maxillary sinus and is often due to viral infection. It then covers the classification, symptoms, diagnosis, treatment and etiology of acute and chronic sinusitis. The document also discusses allergic rhinitis in detail, including prevalence, pathogenesis, classification, diagnosis through history and testing, and treatment through environmental control, immunotherapy and pharmacotherapy.

1. Mario Rodríguez y Silva A00809754

3. inflammatory condition involving the four
PARANASAL SINUSES
SINUSITIS 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).

4. 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.

5. 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
(Wegener's) or rhinoscleroma).
Cystic fibrosis.
In ICUs, nasotracheal intubation and nasogastric tubes are
major risk factors for nosocomial sinusitis.

6. 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.

7. 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 infectionsevere frontal
or retroorbital pain radiating to the occiput, thrombosis of the
cavernous sinus, and signs of orbital cellulitis.
• Advanced frontal sinusitis Pott's puffy tumor
subperiosteal abscess associated with osteomyelitis.
• Complications: meningitis, epidural abscess, and cerebral
abscess.

8. Major and Minor Factors in the Diagnosis
of 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

9. 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 RhinosinusitisSymptoms of acute rhinosinusitis are
present < than 10 days Symptoms are not worsening.

10. GUIDELINES FOR THE DIAGNOSIS AND
TREATMENT OF ACUTE SINUSITIS

12. 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

13. 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 passagesdeviated septum, can
impede drainage from the sinus.

14. CLINICAL MANIFESTATIONS
CRS 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.

15. 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 Drainagereserved for complications

17. 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.

18. 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
•

19. 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

20. ETIOLOGY
1. 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)

21. CLASSIFICATION
Seasonal Allergic Rhinitis
• certain seasons, usually depending on the pollination of plants
to which the patient is allergic.
• Characteristic symptoms:
o Sneezing
o watery rhinorrhea
o itching of the nose, eyes, ears, and throat
o red and watering eyes
o nasal congestion.
Symptoms are usually worse in the morning and are aggravated
by dry, windy conditions and higher concentrations of pollen.

22. 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.

23. 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.

24. HISTORY FOR DIAGNOSIS

25. DIFFERENTIAL DIAGNOSIS

26. ALLERGY TESTING
• Skin testing: Epicutaneous, intradermal, or a combination.
o Skin Prick Test  most
common, epicutaneous, quick, specific, safe, and cost-
effective.
o intradermal dilutional testing 1:5 dilutions.
• In vitro serum assays
o Allergen-specific serum IgE testing

27. TREATMENT

28. 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).

29. 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

30. BIBLIOGRAFÍA:
• Anil K. Lalwani. CURRENT Diagnosis & Treatment in
Otolaryngology—Head & Neck Surgery.
New York: McGraw-Hill, 2012.
• Dan L. Longo et al.. Harrison's Principles of Internal Medicine.
New York: McGraw-Hill, 2012.
• Adkinson, N. Franklin. Middleton's 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.
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