Sinusitis, or more accurately, rhinosinusitis, literally means ‘inflammation of the nose and sinuses’. Specifically, this relates to the tissue that lines the inside of these structures. The lining of the nose (rhino) is continuous with the lining of the sinuses (sinus) and therefore should be regarded as a single entity – hence ‘rhino-sinus-itis’!
Patients can present with symptoms such as a blocked nose, congestion, nasal discharge (runny nose), facial pain and headaches, or a change in their sense of smell.
There are different causes of rhinosinusitis, and are outlined below.
Acute rhinosinusitis
Causes of acute sinus inflammation are most commonly infections, either viral or bacterial infections. Usually a patient will have a cold caused by a virus, damaging the lining of the nose and sinuses, and also weakening the local body defence mechanisms. As a result, bacteria (which exist in everyone’s noses) also take the opportunity to infect.
These infections usually resolve by themselves in a matter of days and treatment consists of symptom relief medications, such as painkillers and decongestants. However, sometimes antibiotic medication may be required if the infection is prolonged or severe.
Very occasionally, complications can occur whereby the infection can spread into surrounding areas, such as the eye socket. In such situations, hospital admission will be required for intravenous antibiotic treatment, and sometimes, surgery.
Chronic rhinosinusitis
When patients have had symptoms of sinusitis for more than 12 weeks, they are diagnosed with having chronic rhinosinusitis (CRS). This diagnosis is made using a combination of the patient’s symptoms and their duration, findings on endoscopic examination, and the appearance on a CT scan of the sinuses.
The reason that acute sinusitis becomes chronic is because the swelling of the tissues causes the natural drainage pathways of the sinuses (click picture on the right) to become obstructed. As a result, the infected secretions within the sinuses are unable to leave, causing them to stagnate and further injure the sinus lining.
In addition, the cells of the sinus lining contain microscopic hairs which normally sweep away the mucus from the sinuses to the back of the nose and into the throat, from where it is swallowed. If the sinus lining is injured, then these hairs do not function, and so the secretions will not be swept away.
It becomes a vicious circle.
A prolonged course (3 months) of a combination of different medications (both oral and topical) is used to try and treat this problem. This may include steroids, antibiotics and salt water flushes.
Further investigations such as allergy testing, blood tests, culture of the pus from within the nose and sinuses may be used to further identify the cause of the symptoms.
If this treatment does not work, then surgical treatment in the form of FESS/CASS may be required.
Some patients with CRS have a particularly difficult and aggressive type of disease called Allergic Fungal Rhinosinusitis (AFRS). The underlying cause of this is unknown, but is thought to be due to an individual’s reaction to the presence of fungus in our sinuses.
This condition is associated with aggressive polyposis and the presence of a thick, elastic, chewing gum-like mucus (“mucin”) that can fill up all of the sinuses.
Extensive surgery to remove the polyps, open up all of the sinuses, and remove this mucin is almost invariably required. In addition, ongoing medical treatment, long-term surveillance of the sinuses, and occasional ‘rescue’ treatment with oral steroids is needed.
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