Sinusitis

1. Introduction

  • Definition: Sinusitis, also known as rhinosinusitis, is the inflammation of the paranasal sinuses caused by infections, allergies, or structural abnormalities, leading to symptoms like nasal congestion, facial pain, and discharge.
  • Epidemiology: Affects approximately 1 in 8 adults annually, with acute sinusitis being more common than chronic sinusitis.
  • Significance: While usually self-limiting, untreated or recurrent sinusitis can lead to complications like orbital cellulitis or intracranial infections.

2. Causes and Risk Factors

  • Causes:
    • Viral infections (most common): Rhinovirus, influenza, parainfluenza.
    • Bacterial infections: Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis.
    • Fungal infections (in immunocompromised individuals).
  • Risk Factors:
    • Allergic rhinitis and nasal polyps.
    • Structural abnormalities (e.g., deviated nasal septum).
    • Smoking and air pollution.
    • Asthma or immunosuppression.

3. Pathophysiology

  • Obstruction of sinus drainage pathways due to inflammation or mucosal swelling leads to mucus stasis and microbial overgrowth. This triggers a local immune response, causing further inflammation and worsening symptoms.

4. Symptoms and Features

  • Acute Sinusitis (duration <4 weeks):
    • Nasal congestion or obstruction.
    • Purulent nasal discharge (yellow-green).
    • Facial pain or pressure, especially over the affected sinus.
    • Fever, fatigue, and dental pain in severe cases.
  • Chronic Sinusitis (duration >12 weeks):
    • Persistent nasal congestion and discharge.
    • Reduced or lost sense of smell.
    • Mild facial pain or pressure.

5. Complications

  • Orbital Complications: Orbital cellulitis, abscess, or vision loss.
  • Intracranial Complications: Meningitis, brain abscess, or cavernous sinus thrombosis.
  • Other: Chronic nasal obstruction, anosmia, or recurrent infections.

6. Diagnosis

  • Clinical Features: Diagnosis is usually clinical, based on symptoms persisting beyond 10 days or worsening after an initial improvement.
  • Imaging:
    • CT scan of the sinuses for severe or recurrent cases to assess structural abnormalities or complications.
    • MRI for suspected fungal infections or intracranial involvement.
  • Laboratory Tests: Nasal swabs or cultures in cases unresponsive to standard treatments.

7. Management Overview

  • Goals: Relieve symptoms, eradicate infection (if present), and prevent complications.
  • Approach: Conservative management for viral sinusitis, antibiotics for bacterial cases, and surgery for structural abnormalities or chronic sinusitis.

8. Treatment Options with Cost (USD)

  • Over-the-Counter (OTC) Therapies:
    • Nasal saline irrigation: ~$5–$20 per bottle.
    • Decongestant sprays (e.g., oxymetazoline): ~$5–$15 per bottle.
  • Antibiotics (if bacterial infection is suspected):
    • Amoxicillin: ~$10–$20 per course.
    • Amoxicillin-clavulanate: ~$20–$50 per course.
  • Adjunctive Therapies:
    • Intranasal corticosteroids (e.g., fluticasone): ~$20–$40 per spray bottle.

9. Advanced Treatment Options with Cost (USD)

  • Endoscopic Sinus Surgery: ~$10,000–$20,000 for chronic or refractory cases.
  • Fungal Sinusitis Treatment: Antifungal medications (e.g., voriconazole): ~$1,500–$2,500/month.
  • Allergy Management: Immunotherapy: ~$1,000–$3,000/year.

10. Pharmacological Treatment

  • First-line: Amoxicillin or amoxicillin-clavulanate for bacterial sinusitis.
  • Adjunctive: Intranasal corticosteroids to reduce inflammation and improve drainage.
  • Symptomatic Relief: Decongestants and saline irrigation for viral or allergic sinusitis.

11. Medication Tables

Table 1: Doses and Side Effects

DrugIndicationDoseCommon Side Effects
AmoxicillinBacterial sinusitis500–875 mg every 8–12 hoursDiarrhoea, rash
Amoxicillin-clavulanateResistant bacterial sinusitis875/125 mg every 12 hoursGI upset, yeast infections
Fluticasone sprayNasal inflammation2 sprays per nostril dailyNasal dryness, irritation
OxymetazolineNasal congestion2–3 sprays per nostril twice daily (≤3 days)Rebound congestion (prolonged use)
Saline irrigationNasal symptom relief1–2 rinses dailyNasal irritation

Table 2: Brand Names and Approximate Costs (USD)

DrugBrand NamesApprox. Cost
AmoxicillinAmoxil$10–$20 per course
Amoxicillin-clavulanateAugmentin$20–$50 per course
Fluticasone sprayFlonase, Veramyst$20–$40 per bottle
OxymetazolineAfrin$5–$15 per bottle
Saline irrigationNeilMed Sinus Rinse$5–$20 per bottle

12. Lifestyle Interventions

  • Drink plenty of fluids to thin mucus.
  • Use a humidifier to keep nasal passages moist.
  • Avoid allergens or irritants, such as smoke or strong odours.
  • Practice proper nasal hygiene with saline rinses.

13. Monitoring Parameters

  • Symptom resolution, including reduced pain, nasal congestion, and discharge.
  • Watch for complications like persistent fever, swelling, or worsening pain.
  • Assess for side effects of medications, particularly with prolonged antibiotic or decongestant use.

14. Patient Counseling Points

  • Explain that most cases of sinusitis are viral and self-limiting, requiring only symptomatic care.
  • Stress the importance of adhering to antibiotic courses if prescribed for bacterial sinusitis.
  • Advise against prolonged use of decongestant sprays to avoid rebound congestion.
  • Encourage nasal saline rinses and hydration to promote sinus drainage.

15. Special Populations

  • In Children: Use weight-based antibiotic dosing and avoid decongestant sprays.
  • In Pregnancy: Prefer saline irrigation and intranasal corticosteroids; avoid certain antibiotics (e.g., doxycycline).
  • In Elderly: Monitor for medication side effects, especially with corticosteroids or antibiotics.

16. Prevention

  • Maintain good hand hygiene to prevent infections.
  • Manage allergies with appropriate treatment.
  • Avoid smoking and exposure to air pollutants.
  • Consider flu and pneumococcal vaccinations for high-risk populations.

17. FAQs

  1. What is sinusitis?
    Answer: Inflammation of the sinuses, often due to infections or allergies.
  2. What causes sinusitis?
    Answer: Viral, bacterial, or fungal infections; allergies; or structural abnormalities.
  3. How is sinusitis treated?
    Answer: Symptomatic relief for viral sinusitis; antibiotics for bacterial cases.
  4. Can sinusitis go away on its own?
    Answer: Yes, most viral sinusitis resolves within 10 days without treatment.
  5. What are the symptoms of sinusitis?
    Answer: Nasal congestion, facial pain, purulent discharge, and headache.
  6. How is bacterial sinusitis diagnosed?
    Answer: Symptoms persisting >10 days or worsening after initial improvement.
  7. Are antibiotics always needed for sinusitis?
    Answer: No, they are only prescribed for confirmed bacterial infections.
  8. What is chronic sinusitis?
    Answer: Sinusitis lasting >12 weeks, often with persistent symptoms.
  9. Can allergies cause sinusitis?
    Answer: Yes, allergies can lead to inflammation and mucus buildup, causing sinusitis.
  10. Is saline irrigation effective?
    Answer: Yes, it helps clear mucus and reduce symptoms.
  11. What are the complications of untreated sinusitis?
    Answer: Orbital cellulitis, brain abscess, or meningitis.
  12. Can children get sinusitis?
    Answer: Yes, especially following colds or allergies.
  13. What is rebound congestion?
    Answer: Worsened nasal congestion from prolonged use of decongestant sprays.
  1. When should I see a doctor for sinusitis?
    Answer: If symptoms persist >10 days, worsen after initial improvement, or include fever or swelling.
  2. How can sinusitis be prevented?
    Answer: Good hygiene, managing allergies, and avoiding irritants.