How Do I Treat Persistent Sinusitis?

Inflammation of one or more sinuses is called sinusitis. The affected sinuses include: maxillary sinus, ethmoid sinus, frontal sinus, and sphenoid sinus. This is a disease with a high incidence in the population and affects the quality of life of patients. Sinusitis can be divided into acute and chronic sinusitis. Acute sinusitis is mostly caused by upper respiratory tract infections, and bacterial and viral infections can occur concurrently. Chronic sinusitis is more common than acute cases, often involving multiple sinuses at the same time.

Basic Information

English name: sinusitis
Visiting department: ENT
Multiple groups: Young, old and infirm

Common causes: Caused by a respiratory infection
Common symptoms: Persistent upper respiratory infections, nasal congestion, pus, and headache
Contagious: no

Causes of sinusitis

Sinusitis can be divided into acute and chronic sinusitis. The course of acute sinusitis is 12 weeks.

According to the severity visual analog scale (VAS) score (10cm), the disease is divided into mild and moderate / severe: mild = VAS0 ~ 4cm; moderate / severe = VAS 5 ~ 10cm.

Acute sinusitis

Acute sinusitis is mostly caused by upper respiratory tract infections, and bacterial and viral infections can occur concurrently. Common bacterial flora are Streptococcus pneumoniae, Streptococcus hemolyticus, and Staphylococcus, which are a variety of pyogenic cocci, followed by Haemophilus influenzae and Moraxella catarrhalis, which are common in children. Other pathogenic bacteria include streptococci, anaerobic bacteria and Staphylococcus aureus. Caused by dental disease are mostly anaerobic infections, pus often with stench. Fungi and allergies may also be the cause.

Acute sinusitis infections often come from: sinus-derived infections, nasal-cavity infections, adjacent tissue-derived infections, blood-borne infections, trauma-derived infections, and systemic and toxic factors.

2. Chronic sinusitis

(1) The transformation from acute sinusitis is often caused by improper treatment of acute sinusitis, or incomplete treatment of it, resulting in recurrent episodes, which persist without healing and make it chronic. This is the primary cause of this disease.

(2) Obstructive diseases Obstructive diseases in the nasal cavity, such as nasal polyps, turbinate hypertrophy, nasal stones, nasal septum deflection, nasal cavity tumors, nasal packing, etc., obstruct nasal cavity and sinus ventilation and drainage, which are important causes of this disease.

(3) Strong virulence of some pathogenic bacteria Some acutely toxic pathogenic bacteria, such as type B hemolytic streptococcus when suffering from scarlet fever, can cause acute sinusitis which can easily become chronic.

(4) Dental-derived infections Because the roots of the upper molars are adjacent to the base of the maxillary sinus, if the tooth disease is not cured, it is likely to become chronic chronic maxillary sinusitis.

(5) Trauma and foreign body such as trauma fracture, foreign body retention or blood clot infection, etc., cause chronic sinusitis.

(6) Anatomical factors of the sinuses Due to the special or abnormal anatomical structure of each sinuse, it is not conducive to ventilation and drainage, and is also a factor that cannot be ignored.

(7) Systemic factors include various chronic diseases, malnutrition, and low body resistance caused by excessive fatigue. At the same time, there are various allergic factors and the causes caused by bronchiectasis. ^[1]

Clinical manifestations of sinusitis

Acute sinusitis

(1) All populations in high-incidence groups are prone to occur, and those who are young and frail are more common.

(2) Symptoms of the disease

1) Systemic symptoms are often worsened during the course of acute rhinitis, followed by chills and fever, general malaise, loss of appetite, and loss of appetite. The systemic symptoms of acute odontogenic maxillary sinusitis are more dramatic. Children have high fever, and severe cases can cause systemic symptoms such as convulsions, vomiting and diarrhea.

2) Local symptoms Nasal obstruction due to congestive swelling and accumulation of secretions in the nasal mucosa may cause persistent nasal congestion on the affected side. There are more mucopurulent or purulent secretions in the nose of the affected side of pus and sputum. There may be a little blood in the nasal discharge at first, and those with odontogenic maxillary sinusitis have pus and odor. Local pain and headache Acute sinusitis is often accompanied by severe headaches in addition to nasal pain due to inflammation. This is caused by swelling of the sinus mucosa and pressure of secretion retention or emptying of secretions, which stimulates the trigeminal nerve endings. cause. Acute sinusitis pain has regularity in time and location. The sinuses in the anterior group are close to the skull surface, and the headaches are mostly in the forehead, palate, and cheeks. The sinuses in the posterior group are deep in the skull, and the headaches are mostly in the top of the head and posterior occipital. Acute maxillary sinusitis: often forehead, cheek or upper molar pain, light in the morning and heavy in the afternoon. Acute frontal sinusitis caused severe pain in the forehead from the morning, gradually aggravated, relieved in the afternoon, and disappeared in the evening. Ethmoid sinusitis usually has a milder headache and is confined to the inner condyle or the root of the nose. It may also radiate to the top of the head. Sphenoid sinusitis manifests as pain in the deep eyeballs, which can radiate to the top of the head, as well as pillow headaches that are mild in the morning and heavy in the afternoon. However, some people have atypical pain symptoms and cannot determine the affected sinuses based solely on the characteristics of the headache. Smell decreased .

2. Chronic sinusitis

(1) All populations in high-incidence groups are prone to occur, and those who are young and frail are more common.

(2) Symptoms of the disease

1) Local Symptoms Pus and nasal discharge are mostly purulent or sticky purulent, yellow or yellow-green, the amount is uncertain, can flow back to the pharynx, and people with unilateral odor are more common in dental maxillary sinusitis or fungal infections . The severity of nasal congestion varies, mostly due to nasal congestion and swelling and increased secretions. olfactory disorders nasal congestion and inflammatory reactions can lead to olfactory disorders. Headache Chronic sinusitis usually has no obvious local pain or headache. If you have a headache, it usually manifests as dull pain or a heavy head. It is heavy during the day and light at night. Sinusitis in the anterior group mostly showed swelling or stuffiness in the forehead and root of the nose, and headache in the posterior group was at the top of the head and posterior pillow. Suffering from dental maxillary sinusitis, often accompanied by ipsilateral upper tooth pain. Others due to pus flow into the pharynx and long-term mouth breathing, often accompanied by chronic pharyngeal inflammation symptoms, such as phlegm, foreign body sensation or dry throat pain. If it affects the eustachian tube, tinnitus, deafness and other symptoms may also be present.

2) Other symptoms: A sense of pressure on the eyes can cause visual impairment, but it is rare. The head feels heavy pressure, or there is only dull or stuffy pain.

3) Systemic symptoms are mild or inconspicuous. Generally, symptoms include dizziness, fatigue, depression, malaise, poor appetite, insomnia, memory loss, inattention, and reduced work efficiency. Very few cases may have persistent low fever if they have become lesions.

Sinusitis examination

Acute sinusitis

(1) Examination of local redness, swelling and tenderness: In the former group, acute sinusitis may cause redness and swelling of the skin and soft tissues of the affected part because the lesion is close to the skull surface. Since the inflammation spreads to the periosteum, the sinus cavity may have tenderness at the corresponding position on the body surface. . The posterior group of acute sinusitis was deep and had no redness or tenderness on the surface.

(2) Nasal examination Congestion and swelling of the nasal mucosa, especially in the middle turbinate, middle nasal passage and olfactory fissure. Sinusitis in the anterior group showed empyema in the middle nasal passages, and nasal sinus inflammation in the posterior group showed empyema in the olfactory fissure, or pus flowed from the top to the posterior nostril.

(3) Nasal endoscopy revealed pus in the nasal cavity, and congestion and edema of the nasal mucosa.

(4) If the positional drainage is suspected of sinusitis, and no pus is found in the nasal passage, a positional drainage test is feasible to help diagnosis.

(5) X-ray nasal sinus radiography X-ray nasal condyle and nasal frontal radiographs are helpful for diagnosis. In the case of acute sinusitis, swelling of the sinus mucosa, turbidity of the sinus cavity, weakened light transmittance, and sometimes liquid level can be seen. Due to overlapping skulls, the observation effect is not good.

(6) CT of the sinuses shows the fluid level or soft tissue density in the sinuses. Because of its high resolution, CT is more detailed and comprehensive in observing lesions, which is a better indicator for the diagnosis of acute sinusitis.

(7) The nasal sinus T2 signal can be seen by MRI of the sinuses, which can be distinguished from the soft tissue shadow of the sinuses.

2. Chronic sinusitis

(1) The lesions in the nasal cavity examination are mainly the changes in the upper nasal cavity, showing edema or hypertrophy in the middle turbinate, and even polyp-like changes. Some can see multiple polyps. Sinusitis in the anterior group showed sticky purulent secretions on the surface of the middle nasal passage and inferior turbinate. Sinusitis in the back group showed olfactory fissure and mucopurulent deposits in the back of the middle nasal passage. In severe cases, purulent discharge was seen in the nasopharynx.

(2) Auxiliary examination Endoscopic examination refers to anterior and posterior nostril examination. The nasal mucosa is contracted with ephedrine, and then all parts of the nasal cavity are examined carefully. Edema, pus or polyps can be seen. Postural drainage examination is possible when chronic sinusitis is suspected and no pus remains in the middle nasal passage or olfactory fissure. Maxillary sinus puncture and irrigation Maxillary sinus puncture and irrigation is both a diagnostic method and a treatment measure for maxillary sinusitis. The effluent should be used for aerobic bacterial culture and drug sensitivity. X-ray sinus radiography can assist diagnosis if the diagnosis is not clear or if other lesions are suspected. Examination of teeth In case of suspected odontogenic maxillary sinusitis, a special examination of teeth should be performed. CT diagnosis of sinuses CT of sinuses helps to define the scope of lesions, helps to identify local bone changes, and helps distinguish them from nasal tumors. Because of its higher resolution, CT is more detailed and comprehensive in observing lesions, which is a good indicator for the diagnosis of chronic sinusitis. Sinus MRI MRI has a good discrimination between soft tissues and fluids in the sinuses, and it is beneficial to develop a complete surgical plan before surgery.

Sinusitis diagnosis

Diagnosis can be confirmed based on typical symptoms and related examinations.

Differential diagnosis of sinusitis

Acute sinusitis

It is mainly distinguished from other diseases that cause headaches, such as migraine and intracranial tumors; because of nasal congestion, it must be distinguished from nasal cavity and sinus tumors, such as nasal papilloma and nasal squamous cell carcinoma. The pathological diagnosis can be clear.

2. Chronic sinusitis

It is mainly distinguished from other diseases that cause headaches, such as migraine and intracranial tumors; due to nasal congestion, it must be distinguished from nasal cavity and sinus tumors, such as nasal papilloma and nasal squamous cell carcinoma. Pathological diagnosis can be clear.

Sinusitis complications

Acute sinusitis

The disease affects patients' quality of life, may cause lower respiratory tract infections, and severe cases may cause orbital and intracranial complications.

Ocular complications: orbital bone wall osteitis, periostitis, orbital wall subperiosteal abscess, intraorbital cellulitis, intraorbital abscess, retrobulbar optic neuritis.

Intracranial complications: epidural abscess, subdural abscess, suppurative meningitis, brain abscess, cavernous sinus thrombophlebitis.

2. Chronic sinusitis

Affect the patient's quality of life, aggravate the symptoms of respiratory infections in patients, severe cases may cause craniocerebral pulmonary complications, cause vision changes, and even exacerbate the infection and die.

Ocular complications: orbital bone wall osteitis, periostitis, orbital wall subperiosteal abscess, intraorbital cellulitis, intraorbital abscess, retrobulbar optic neuritis. Intracranial complications: epidural abscess, subdural abscess, suppurative meningitis, brain abscess, cavernous sinus thrombophlebitis.

Sinusitis Treatment

Acute sinusitis

(1) Adequate antibiotics are used for systemic treatment to control infections. Most of them are cocci infections, and penicillins and cephalosporins are the first choice drugs. Drug treatment emphasizes the selection of sensitive antibiotics and the use of sufficient quantities and foot courses. If the headache or local pain is severe, sedatives or analgesics can be used appropriately. The general treatment is the same as for acute rhinitis. The traditional Chinese medicine treatment is mainly based on removing wind and clearing heat, fragrant Tongqiao, supplemented by detoxification and removing blood stasis.

(2) Drugs containing 1% ephedrine are commonly used to improve nasal sinus drainage , which reduces nasal cavity and improves drainage. Acute sinusitis can also reduce headaches by changing the position and improving ventilation and drainage of the sinuses.

(3) Maxillary sinus puncture and flushing Acute maxillary sinusitis should be performed after systemic symptoms have subsided and local acute inflammation has been basically controlled. After rinsing, inject antibacterial solution once or twice a week.

(4) Sinus replacement therapy is suitable for children with multiple groups of sinusitis.

(5) If the etiology treatment is odontogenic maxillary sinusitis, dental disease should be treated at the same time.

(6) Mucus drainage promoting agent treatment can use mucus drainage promoting agent to improve the properties of secretions and facilitate excretion.

(7) Hormonal therapy can use nasal local hormones or systemic hormones to improve local inflammation and enhance drainage.

(8) Surgery Acute sinusitis can be treated with endoscopic sinus surgery when the drug control is unsatisfactory or complications occur. Endoscopic guided direct access to the lesion, opens the sinus opening, clears lesions, improves local drainage, and restores normal physiological functions of the sinuses. ^[2]

2. Chronic sinusitis

(1) The antibiotic Macrolides (macrolide antibiotics), although not able to remove bacteria, can reduce the toxicity of chronic bacterial infections and reduce cell damage. In cases of hormonal failure, selective long-term low-dose macrolide antibiotics are effective. The specific mechanism of action is not very clear, but may be related to the down-regulation of the local host's immune response and the weak toxicity of reproduction bacteria

(2) Vasoconstrictor can shrink the swollen mucosa of the nasal cavity to facilitate sinus drainage. However, vasoconstrictors should not be used for a long time, and may cause secondary drug rhinitis.

(3) Mucus drainage promoting agent Adding mucus drainage promoting agent to the standard treatment method can obtain better treatment effect, mainly can reduce treatment time.

(4) Antihistamines Although antihistamines are not recommended for the treatment of chronic rhinosinusitis, in the United States, a study shows that antihistamines are often used in the treatment of chronic rhinosinusitis. When used, it can significantly reduce the symptoms of sneezing, runny nose and nasal congestion, but has no significant effect on the size of nasal polyps.

(5) Hypertonic saline Hypertonic saline can improve the cilia clearance of nasal mucosa. Clinical trials have shown that hypertonic saline has obvious effects in various evaluation indicators of cough, runny nose, and postnasal drip.

(6) Chinese medicine and traditional Chinese medicine are based on the principles of fragrant Tongqiao, clearing away heat and detoxifying, and removing dampness and purging.

(7) Physical therapy generally uses ultra-shortwave diathermy therapy to assist treatment.

(8) The sinus replacement method is suitable for multiple sinus inflammation and children.

(9) Surgical treatment

1) Endoscopic sinus surgery is currently the preferred method. Under clear vision of the nasal endoscope, the sinus lesions are completely removed, the sinus openings are fully opened, the sinus drainage is improved, and the normal tissue is preserved as much as possible. It is a minimally invasive operation that retains the function as much as possible.

2) Other operations: Maxillary sinus intranasal fenestration, maxillary sinus radical surgery, intranasal ethmoidectomy, extranasal ethmoidectomy, frontal sinus drilling, frontal sinusotomy, and sphenoidotomy.

For a patient with confirmed chronic sinusitis, the recommended treatment procedure should be: first drug treatment (including local and systemic application), CT scan of the sinuses if the drug treatment fails, if there are imaging changes and surgical indications, Then perform nasal endoscopic surgery. ^[3]

Prognosis of sinusitis

Acute sinusitis

Most acute sinusitis can be cured in a short period of time with reasonable medical treatment. In some cases, it can turn into chronic sinusitis and complications of the eyes or skull.

2. Chronic sinusitis

Most patients can be cured by drugs and surgery. A few patients with allergies, asthma, aspirin intolerance and other specific constitutions often have recurrent attacks.

Sinusitis prevention

Acute sinusitis

(1) Strengthen physical exercise, strengthen physical fitness, and prevent colds.

(2) Acute rhinitis (cold) and dental disease should be actively treated.

(3) Don't blow your nose when there is secretion in the nasal cavity. You should block the nostril on one side and clear the nasal secretion, and then block the other on the other side.

(4) timely and thoroughly treat acute inflammation of the nasal cavity and correct anatomical deformities of the nasal cavity, and treat chronic rhinitis and nasal septum deviation.

(5) Avoid diving and snorkeling when swimming.

(6) When suffering from acute rhinitis, it is not advisable to fly.

(7) Properly treat allergic diseases and improve nasal cavity and sinus ventilation and drainage.

2. Chronic sinusitis

(1) Strengthen physical exercise, strengthen physical fitness, and prevent colds.

(2) Acute rhinitis (cold) and dental disease should be actively treated.

(3) Don't blow your nose when there is secretion in the nasal cavity. You should block the nostril on one side and clear the nasal secretion, and then block the other on the other side.

(4) timely and thoroughly treat acute inflammation of the nasal cavity and correct anatomical deformities of the nasal cavity, and treat chronic rhinitis and nasal septum deviation.

(5) Avoid diving and snorkeling when swimming.

(6) When suffering from acute rhinitis, it is not advisable to fly.

(7) Properly treat allergic diseases and improve nasal cavity and sinus ventilation and drainage.

References:

[1] Chinese Academy of Otorhinolaryngology Branch, Chinese Journal of Otorhinolaryngology Editorial Board, Clinical Classification and Staging of Chronic Sinusitis and Nasal Polyps and Endoscopic Sinus Surgery Evaluation Standards (1997 Haikou) [J]: Chinese Journal of Otolaryngology , 1998: 33 (3): 134.

[2] Xu Geng, Shi Jianbo, Wen Weiping, etc. Standardized diagnosis and treatment of rhinosinusitis in children [J]: Chinese Otorhinolaryngology Head and Neck Surgery, 2005: 12 (7): 407-410.

[3] Xu Geng. Interpretation of EPOS-2007 [M]. 2008 National Conference on the Diagnosis and Treatment of Chronic Rhino-Sinusitis, 2008, 6-12.