Monday, February 27, 2012

Paranasal sinus pain

Paranasal sinus pain

Pain in the sinus area, especially over or under the frontal or maxillary bones, is called sinus pain, which could be unilateral or bilateral. For instance, in case of maxillary sinusitis, pain is over the cheek. In case of ethmoidal or frontal sinusitis, pain is around or above the eyes. In sphenoidal sinusitis, the pain occurs in the rear of the eyes and center of the head.



True pain changes with changes in the day. For example, when patient wakes up, there is no pain. Pain starts in the morning and reaches to its peak in afternoon, and reduces in evening, and mostly absent in the night. This is called diurnal variation. Sinus pain generally worsens by nose blowing. If the pain is associated with sinusitis, the pain over the cheek exacerbates in the afternoon and by blowing the nose. Green mucus is released while blowing the nose. The pain related to nasal congestion improves in the night.
The pain generally resembles throbbing or pressure. Touching the affected sinus makes the pain worse. Since the pain may be associated with allergies, infections in the upper respiratory tract or chronic sinusitis, a visit to ear, nose and throat (ENT) doctor may be helpful. Maxillary teeth’s periapical dental abscesses, migraine headache, nasal polyps and temporal arteritis may mimic the pain. The pain may some times be due to inflammation of the nasal mucosa instead of sinusitis. Sinus pain is common during acute sinusitis and rare in chronic sinusitis.
During acute sinusitis, maxillary sinus pain is concentrated between the eye’s inner canthus and the molars or ears. Ethmoid sinus pain is located in the rear of the eyes and over the nose bridge. This pain some times rises with the movement of the eyes. The frontal sinus pain extends from the forehead to the temporal region and some times to the occiput (posterior of the head). Sphenoid sinus pain may be felt in various areas such as between the head and shoulder. In dentogenic maxillary sinusitis, the dental pain overpowers the sinus pain. The cheek may become sensitive to percussion and pressure.
The sinus pain is one of the common causes of facial pain. The ciliary mucosa of the paranasal sinuses is sensitive to inflammatory, traumatic, metabolic and neoplastic changes that may trigger pain. Change in the sinus pressure and in the pressure in the blood vessels supplying the sinus cause the pain. Bradykinin and other inflammatory agents stimulate endings of the sinus membrane nerves, leading to pain. Mucocele, mucous mass within in the paranasal sinuses, may trigger maxillofacial pain.

Friday, February 24, 2012

Why Nasodren is used just once a day

Why Nasodren is used just once a day

In the first two minutes, the morphological and functional changes that take place in the epithelium and stromal structures of the nasal cavity produce a prompt discharge from seromucous glands, almost immediate dehydration as well as a reduction of the oedematous state in the tissues. Shrinking of swollen mucosa and opening of the swollen ostiomeatal unit is also achieved. This product promotes the increase of mucociliary transport in the nasal cavity.




This stimulated secretion leads to an intense physiological drainage of the paranasal sinuses, resulting in a highly effective therapeutic outcome.
The duration of the alveolar gland cell secretory cycle is 15-16 hours, while that of the tubular-alveolar gland cells is 24 hours (this is the time required to accumulate and remove the secretion). Therefore, after 24 hours, the seromucous glands have recovered and commencemucus secretion in the paranasal sinuses once again. It means that Nasodren should be administered once per day.
(Piskunov. Viability of the indication and use of cyclamen extract in Clinical practice. 22nd Congress of ERS & 27th ISIAN Crete. Greece. 15-19 June 2008).

Thursday, February 23, 2012

Cameras and cleaners for endoscopic sinus surgeries

Cameras and cleaners for endoscopic sinus surgeries

The sinus surgeries are performed in two ways: traditional and modern. The traditional method involves viewing through the endoscope’s eyepiece. The technique aids in assessing the orientation and depth of the surgical site. However, surgeons may have to bend their back or neck while using the traditional method. If during the surgery microdebrider or any other big instrument is also required, the instrument may reach the head of the surgeon, causing discomfort. The traditional method is good because the naked eye offers a good image of the surgical site but the technique may lead to the neck problems in the surgeon.



In modern technique, a video camera is connected to the endoscope so that the surgeon can operate through the monitor. Most of the surgeons prefer a video monitor for its ergonomic advantage, especially, while operating the frontal recess. The surgeon can either stand or sit near the patient without bending the neck or back to have a clear view of the nasal cavity. The video monitor has another advantage: It delivers magnified images of the organs and surgical site. The images are very useful during delicate surgeries involving skull base and optic nerve. The monitor also allows two surgeons to operate the patient simultaneously.
With the monitor, the experienced surgeons can monitor the trainee surgeons during the operation. The trainees can learn nuances of the sinus surgeries by carefully watching the professional surgeons engaged in the surgical process. The nurses can assess the need for instrument required in various steps of the procedure in advance. The anesthetist can supervise and intervene if required during the surgery.
The monitor should be of medical grade. A digital camera or three-chip camera with excellent light source is required. The 3–chip camera produces brilliant image, facilitating detailed paranasal sinus surgeries.  Good lighting is also the prerequisite because redness of the blood absorbs most of the light, and making difficult to visualize the site from a poor image.
Single-chip cameras are unable to cover blood properly during the surgery, therefore, the tissue contrast and depth perception may not be captured correctly on the image. Cheap quality cameras affect orientation and visibility, hindering the surgeon’s work and increasing the chances of complications. A split beam can also be used to view the image, but image will be of low quality. So, use the monitor to operate.
An endoscope cleaner / scrubber washes the endoscope’s lens if blood obscures it, and thereby operation continues without removing the endoscope. There is no need for manual cleaning of the endoscope during the surgeries in case surgical site becomes bloody. As a result, the surgery goes uninterrupted and requires less time. Good visibility reduces chances of errors during the surgery, ensuring safety. The surgeons thus can work easily and quickly.

Wednesday, February 22, 2012

How to identify sinusitis headache

How to identify sinusitis headache

The patients prefer term “sinusitis headache” instead of “tension headache” because the former is ‘publicly’ acceptable. In fact, they may not have either of the headaches. The cause of headache may be something else. For example, the forehead pain may occur owing to common cold or blocked nose. So, it is the duty of otolaryngologist to find the true cause of the headache. The following valuable information will help the physician in distinguishing between a “sinusitis headache” and other headaches.



The retro-orbital headache is related to sphenoid sinusitis.
The maxillary sinus pain may radiate to the temples and canine teeth.
The ethmoid sinus pain occurs in the medial canthal, upper cervical, temporal and parietal areas.
A tension headache, a muscle contraction tension, may lead to tenderness of the scalp and facial muscles. During forehead percussion, pain may occur. The physician may confuse this pain with frontal sinusitis related pain.
In the frontal recess region, swollen agger nasi cells cause pain due to infection or obstructions.
The physicians shall have thorough understanding of drug rebound, cluster, muscle contraction, migraine and other headaches. Tension-type headache is a composite of muscular, neurogenic and vascular headache. The tension-type headache resembles to “tightness” or “pressing” pain. The pressure felt over the head, temples, forehead, shoulders and the neck. Anxiety and stress causes these headaches.
The cluster headaches are uncommon. The patients feel severe pain that begins suddenly and lasts about 45 minutes. The pain episodes occur several times in a day. They may also have facial flushing, nasal congestion and sweating.
A drug rebound headache, the bilateral frontal headache, is felt almost daily for the whole day. It is moderate to mild in intensity.
While treating a sinusitis headache, blocked area needs thorough examination instead of extent of the disease, because even small blockage can cause severe pain. A bunch of sensory nerve fibers may have accumulated around the sinuses ostia, causing lesions and blockage, and pain.
Involvement of the more than one paranasal sinus complicates the symptoms and pain. In these cases, pain spreads to different locations in the body. If the patient also has facial pain owing to other disorders, the confusion increases. The physician shall review headache history of the patient, exact location of the pain, type of the pain, headache frequency, factors worsening or improving the pain, and related sinus symptoms. The pain could be dull, mild, pulsating, severe, sharp, squeezing, stabbing, steady, vicelike, etc.
Barosinusitis may also cause dull ache in divers and flyers.

Tuesday, February 21, 2012

Are enough evidence from the use of antibiotics?


In a systematic review carried out by a Cochrane group, it concluded that in acute maxillary sinusitis antibiotics provide a minor improvement in simple

(uncomplicated) sinus infections. In spite of the fact that acute Rhinosinusitis can lead to severe complications, a study performed by Dr. Klossec also shows that, unfortunately, antibiotics do not seem to prevent these complications, and moreover, may produce a clear resistance to penicillin.





In a Cochrane systematic review on antibiotics in acute maxillary sinusitis authors observe that antibiotics provide a minor improvement in simple (uncomplicated) sinus infections.

However, 8 out of 10 patients improve without antibiotics within two weeks. The small benefit gained may be overridden by the negative effects of antibiotics, both on the patient and on the population in general. This review found that antibiotics help some people very slightly, but do not make a major difference to most people (Ahovuo-Saloranta).



In a double-blind, randomized, placebocontrolled factorial trial of 500 mg of amoxicillin 3 times per day for 7 days and 200 mg of budesonide in each nostril once per day for 10 days in patients with acute no recurrent sinusitis shows that neither an antibiotic nor a topical steroid alone or in combination was effective as a treatment for acute sinusitis in the

primary care setting (Williamson et al).

A study by Prof. Klossek looked at an estimated study population of 12 million in France, and found 30 complicationsper year, of which 11 were intracraneal and 44 of the patients had actually had antibiotics before the complication, 70% of whom had a proven bacterial infection. Acute Rhinosinusitis can lead to severe complications; unfortunately, antibiotics do not seem to prevent these complications. What is more, there is a clear correlation between antibiotic sales and the prevalence of penicillin resistance to normal Streptococcus in those countries where antibiotic use is high.



1. Ahovuo-Saloranta A, Borisenko OV, Kovanen N, Varonen H, Rautakorpi UM, Williams JW, Jr., et al. Antibiotics for acute maxillary sinusitis. Cochrane Database Syst Rev 2008(2):CD000243.

2. Ian G. Williamson, I.G., Rumsby, K.BA; Benge S. Antibiotics and Topical Nasal Steroid for Treatment of Acute Maxillary Sinusitis. A Randomized Controlled Trial. JAMA. 2007;298(21):2487 2496.

3. M. Desrosiers, J-M Klossek, M. Benninger. Management of acute bacterial rhinosinusitis: current issues and future perspectives. International Journal of Clinical Practice. 2006; 60(2):190–200. DOI: 10.1111/j.1742- 1241.2006.00753.

Monday, February 20, 2012

4 diseases causing pain-sinus

4 diseases causing pain-sinus

Pain in sinus is generally attributed to sinusitis. However, granulomatous inflammation and sinonasal malignancies may also trigger the pain.
Churg Strauss Syndrome (CSS)
CSS, the allergic angiitis, is the granulomatous inflammation of the vessels of lungs, peripheral nerves and skin. The patients suffering from asthma and rhinitis are prone to the syndrome. It may lead to chronic or acute paranasal sinus pain. Other symptoms of the syndrome include polyposis, rhinitis and the sinus’ opacification on radiograph.




Sinusitis
Sinusitis related pain may be a result of the pressure change, inflammation and / or blockage of the sinuses. To study the pain-sinus, heat, cold and electric probe stimulation has been used. The studies concluded that the mucosa lining the ostia (nasal opening) of the paranasal sinuses is the most pain prone region. Some times pain is associated with the sinus cavity, but the mucosal cavity located in the sinus is not very sensitive to pain.
Sinonasal cancers and tumors
The sinonasal cancers and tumors affect the nasal cavity and paranasal sinuses. The sinonasal tumors are generally diagnosed in the advance stage as no significant symptoms or signs appear in the early stages. The cancer and tumor symptoms are similar to that of sinus disease symptoms, such as nasal discharge and pain in the sinuses. The most common sinonasal malignancy is maxillary sinus carcinoma. The ethmoid sinus is the second most common place where tumors and cancers develop.
Wegener’s granulomatosis (WG)
The paranasal sinuses host a wide range of granulomatous conditions that are rare but could be risky. For instance, Wegener’s granulomatosis. Wegener’s, a rare medical condition, involves vasculitis of the nasal mucosa, the sinus and the respiratory tract, and granulomatous inflammation. If recurrent or chronic sinusitis patients have concurrent cutaneous, pulmonary or renal abnormalities, or inflammation of the nasal septa, they should be examined for Wegener’s signs. Wegener’s granulomatosis may lead to the pain-sinus. Clinical features of the WG include bloody or purulent nasal discharge, perforation in the nasal septa and the nose deformity. WG patients are administered cyclophosphamide and prednisone.

Thursday, February 16, 2012

Acute maxillary sinusitis: symptoms, microbiology and treatment

Acute maxillary sinusitis: symptoms, microbiology and treatment

Generally, acute maxillary sinusitis is related to viral infections of the upper respiratory tract. However, other factors, such as dental problems may also cause acute maxillary sinusitis. The sinusitis symptoms affect day-to-day life, including school / office and leisure activities. Some of the common symptoms follow:




Headache

Painful sensation

Maxillary tooth pain

Facial pressure or pain

Swelling over the sinus

Moderate to severe nasal obstruction

Pus coming out from the middle meatus

Extremely stale and bad smelling breath

Pain may vary from moderate to severe.

Pain increases while pressing the maxilla.

Numbness in maxillary premolars and molars

Posterior and / or anterior nasal drainage (rhinorrhea)

Pain may occur in different parts such as ear, posterior teeth and cheek.

Microbiology
The acute maxillary sinusitis microbiology is well defined. The main pathogens are facultative anaerobic and aerobic bacteria. The facultative anaerobes depend on fermentation process for energy required to grow when oxygen is inadequate, and use oxygen if it is available in sufficient amount. The following bacteria have been found in the adult patients with acute maxillary sinus symptom (s):
Anaerobes

Enterobacter

Escherichia coli

Haemophilus influenze

Moraxella catarrhalis

Neisseria coli

Pesudomonas aeruginosa

Staphylococcus aureous

Streptococcus penumoniae

Streptococcus sp


There are two (2) types of strains of the facultative gram-negative coccobacillus Haemophilus influenzae: encapsulated and unencapsulated.  The unencapsulated strains cause bronchitis, otitis media, sinusitis and other infections of upper respiratory tract. Streptococcus penumoniae, a ά-hemolytic group of streptococci, are resistant to various antibiotics. The aerobic and gram-negative coccobacilli Moraxella catarrhalis are also resistant to some isolates.
These three bacteria also cause acute maxillary sinus symptom(s) in children. However, Moraxella catarrhalis-related infections are common in children than adults, since respiratory aerosols spread the infection.

Treatment
Acute maxillary sinusitis lasts for four or less weeks and sinus symptom(s) appear suddenly.  Subacute maxillary sinusitis signs persist from four (4) to twelve (12) weeks. If treated in time and completely, acute maxillary sinusitis is resolved fully. The therapy may consist of intranasal corticosteroids, nasal lavage and vasoconstrictors. The oral treatment may include antibiotics, analgesics, mucolytics and antipyretics. The acute sinusitis caused by H. influenzae, S. pneumoniae or M. catarrhalis can be treated with macrolides.

Wednesday, February 15, 2012

Treatment of maxillary sinusitis

Treatment of maxillary sinusitis

General medications for acute and chronic maxillary sinusitis are similar. However, anti-microbial medication prescription may require extra care in chronic and acute exacerbation of chronic condition due to chronic inflammation of the mucosa and variation in microbiology of the former. In both acute and chronic maxillary sinusitis, culture-based therapy is selected.  A short-term course of antibiotics may be helpful in case of acute exacerbation of chronic maxillary sinusitis.



Acute maxillary sinusitis is mainly infectious disease, whereas more than one factor is responsible for chronic maxillary sinusitis. The purpose of the treatment of acute sinusitis is to eliminate infection and reduce symptoms. However, treatment of chronic sinusitis is complex due to need for examining and resolving other associated problems, such as anatomical defects, atopy and immunodeficiency. Thus, treatment of chronic maxillary sinusitis spreads over long period of time. And, it requires reviewing and reassessing the selected therapy.
The treatment for both forms of maxillary sinusitis consists of anti-inflammatory, decongestants and mucus modulation medicines.

Anti-inflammatory medications
Anti-inflammatory medications are divided into six (6) subcategories: allergen-specific drugs, antihistamines, leukotriene modifiers, mast cell stabilization, monoclonal antibodies and steroids.
Allergen-specific therapy involves elimination of foods causing allergy and immunotherapy. The patients who do not respond to medications or whose symptoms last for six (6) months are advised to undergo immunotherapy.
Physicians may choose from first- and second- generation of oral, and topical intranasal antihistamines for the treatment. Azelastine and olopatadine are commonly used topical intranasal medications. The first-generation oral antihistamines comprise brompheniramine, chlorpheniramine and diphenhydramine. The range of second-generation oral antihistamine consists of cetirizine, desloratadine and fexofenadine.

The leukotriene modifiers consist of 5-lipoxygenase inhibitors and leukotriene receptor antagonists.  Cromolyn sodium is used for mast cell stabilization. Monoclonal antibodies include antiimmunoglobuline E and antiinterleukin-5.
There are three different types of steroids used in the treatment. Intranasal corticosteroids include budesonide, ciclesonide, flunisolide, mometasone furoate and triamcinolone acetonide. Oral corticosteroids consist of methylprednisolone and prednisone. Budesonide respules is an example of topical steroid medication.

Decongestants
Doctors may prescribe oral or topical decongestants such as oxymetazoline, phenylephrine and pseudoephedrine.

Mucus modulation
Anticholinergics, mucolytics and nasal saline are used for mucus modulation. The topical anticholinergic nasal spray, ipratropium bromide is generally used with topical nasal steroids. The spray reduces rhinorrhea. However, it should not be used for chronic maxillary sinusitis because its continuous use results in prolonged thick discharge. Although the spray is safe, not much research has been done on its efficacy in respect to acute and chronic maxillary sinusitis.

Tuesday, February 14, 2012

Does Nasodren® have an effect similar to that of peppermint?

Does Nasodren® have an effect similar to that of peppermint?


Peppermint, Mentha piperita, comes from the Greek Mintha. There are 25-30 species of Peppermint. Peppermint has different components, among which there are the essential oils like menthol, neomenthol, isomenthol, neoisomenthol, piperitoles, piperitenol, isopiperitenol. The pharmacology of peppermint focuses almost entirely on its menthol components. Peppermint oil vapor is used as an inhalant for respiratory congestion.


Peppermint and menthol are essential oils that are used as an external nasal decongestant, menthol does not objectively decrease nasal decongestion (1-7), in spite of the fact that there is a subjective improvement in the sensation of easier breathing by subjects.


While Nasodren® has had its objective decongestant effect proved by different controlled studies, it offers therapeutically multi-action functions, opening the ostiomeatal complex, and activating the mucociliary system. Consequently, it increases the drainage of mucus retained in the sinonasal area; produces fast dehydration and a detumescent effect (calms and relieves swelling). Unlike other products used in Rhinosinusitis treatment, Nasodren® is not indicated for a specific etiology, but rather aimed at improving the symptomatology regardless of the cause that produces it.


1. Eccles R, Griffiths DH, Newton CG, Tolley NS. The effects of menthol isomers on nasal sensation of airflow. Clinical Otolaryngology & Allied Sciences 1988; 13:25-9.

2. Eccles R, al e. The effects of D and L Isomers of menthol upon nasal sensation of airflow. The Journal of Laryngology and Otology 1988; 102:506-508.

3. Eccles R, Jones AS. The effect of menthol on nasal resistance to air flow. J Laryngol Otol 1983; 97:705-9.

4. Nishino T, Tagaito Y, Sakurai Y. Nasal inhalation of l-menthol reduces respiratory discomfort associated with loaded breathing. Am J Respir Crit Care Med 1997; 156:309-13.

5. Eccles R, Jawad MS, Morris S. The effects of oral administration of (-)-menthol on nasal resistance to airflow and nasal sensation of airflow in subjects suffering from nasal congestion associated with the common cold. J Pharm Pharmacol 1990; 42:652-4.

6. Eccles R, Morris S, Jawad MS. The effects of menthol on reaction time and nasal sensation of airflow in subjects suffering from the common cold. Clin Otolaryngol 1990; 15:39-42.

7. Burrow A, Eccles R, Jones AS. The effects of camphor, eucalyptus and menthol vapour on nasal resistance to airflow and nasal sensation. Acta Otolaryngol (Stockh) 1983; 96:157-61.

Monday, February 13, 2012

Nosocomial sinusitis

Nosocomial sinusitis

Patients who have to spend long time in an intensive care unit (ICU), or  other parts of the hospital, and / or use nasogastric or endotracheal tubes may suffer from nosocomial sinusitis, a ‘hospital-borne’ infection. The prolonged usage of nasogastric or endotracheal tubes increase chances of developing signs of sinus infection. Many patients using nasotracheal tubes for more than five days suffer from nosocomial sinusitis. The hospital stay of patients with burns and serious trauma, and patients who have undergone surgery may prolong, increasing risk of catching the sinusitis. Head trauma and neurological disorders may also trigger the sinusitis.



The nasogastric or nasotracheal tubes plug the sinus ostia and thereby the secretions accumulate in the area. As a result, the drainage system of the paranasal sinuses is affected severely. This mechanical obstruction hinders normal bacteria drainage process. The bacteria, therefore, multiply in the sinuses causing inflammation and other signs of sinus infection.
Gram-negative enterics, including Serratia marcescens, Proteus mirabilis, Enterobacter species, Klebsiella pneumoniae and Pseudomonas aeruginosa are the main pathogens causing nosocomial sinusitis. Nosocomial sinusitis is a non-airborne infection because endogenous microbes causing the disease come in direct contact of the sinus via intubations.
In the patients with acute nosocomial sinusitis associated with nasogastric and nasotracheal tubes, population of gram-negative organisms, such as Staphylococcus aureus and Staphylococcus epidermidis, is large. Common signs of the sinusitis include leukocytosis and fever. The patients may also complain about purulent rhinorrhea.
The signs of sinus infection may develop in the patients using mechanical ventilation for a long time and oropharyngeal tubes simultaneously, or nasoenteric tubes. Anaerobes, including S. aureus, Acinetobacter spp. and P. aeruginosa are the primary source of sinus infection in these patients. They may also suffer from sepsis and fever.
During microbiological analysis of the acute nosocomial sinusitis, polymicrobial infection in conjunction with Bacteroides species, P. aeruginosa and S. aureus has been identified.  If younger patients use blind nasotracheal intubations in emergency, chances of staphylococci infection are high. If older patients who are operated in an ICU or operating room require elective intubations, gram-negative organisms may cause the sinusitis. 
The organisms causing a wide range of nosocomial infections are also responsible for nosocomial sinusitis. For example, gram-positive cocci and gram-negative enterics, such as Proteus mirabilis, Enterobacter sp, K. pneumoniae and P. aeruginosa, are the main pathogens associated with nosocomial infection.  The bacteriology of chronic and acute nosocomial sinusitis is quite similar if edema and inflammation of tissue play an important role.  An untreated infectious nosocomial sinusitis may lead to nosocomial pneumonia. So, timely treatment is necessary. Here is an overview of the sinusitis treatment:
Lavage and drain the sinus.

Administer the suitable antibiotics.

Remove all types of nasal tubes to minimize mucosal edema and nasal irritation.

If a maxillary puncture is done to diagnose the disease, a simultaneous antral wash will be useful.

Elevate the patients’ head and use topical nasal vasoconstrictor drops to open the sinus ostia for draining out the accumulated mucus.

Thursday, February 9, 2012

Maxillary sinusitis: classification and microbiology

Maxillary sinusitis: classification and microbiology

Classification

Maxillary sinusitis refers to the inflammation and infection of the maxillary sinuses. The sinusitis is categorized based on its etiology and symptom duration. According to etiology, the maxillary sinusitis could be of odonotgenic and non-odontogenic origin. Just 10% of all maxillary sinusitis cases are of odontogenic origin. Non-odontogenic factors, such as allergic reactions and infections of the upper respiratory tract, are primary cause of the sinusitis. Based on duration of the sinus infection’s symptoms, infectious maxillary sinusitis is divided into two (2) categories: acute and chronic.  


Acute maxillary sinus infection’s symptoms, such as purulent nasal discharge accompanied by facial fullness, pressure or pain, and / or nasal congestion, last up to twenty-one (21) days. However, chronic maxillary sinus infection’s symptoms persist for more than two and a half months.

Microbiology
An array of bacterial pathogens causes maxillary sinusitis. The pathogen pattern may vary with individual characteristics of the patient and chronicity of the disease. The primary cause of acute sinus infection is facultative and aerobic organisms, whereas gram-negative rods and anaerobes are mainly responsible for chronic sinus infection.
Several studies focusing on the maxillary sinus microbiology have been conducted, as it is quite safe and easy to access the sinus. Thorough knowledge of bacteriology of maxillary sinusitis will facilitate accurate and successful therapy with a little side effect. For example, the bacteriology study helps in limiting the misuse of antibiotics.
The bacteriological analysis of the sinus also enables documentation of antibiotics and surgical processes’ effectiveness, helping in developing novel therapies. Scientists use both traditional and modern methods and techniques to investigate the bacteria profile. For instance, earlier, the contents of the sinus were only sampled directly, whereas today the direct sample analysis is studied with findings of the minimally invasive procedures using state-of-the-art endoscopic technology.
Prior to the discovery of endoscopes, the maxillary sinus was punctured through the inferior meatus or canine fosa to collect the cultures. However, the traditional procedure not only creates discomfort but also has many other limitations. With the launch of sinonasal endoscopy technology in the1980s, endoscopically guided middle meatus (EGMM) cultures became a reality. A small wire tipped with calcium alginate is used for swabbing the meatus under endoscope.

EGMM vs. MSP
During comparison of EGMM and maxillary sinus puncture (MSP) cultures, it is found out that the former has higher sensitivity and specificity than the latter.  In fact, after some practice, doctors can obtain EGMM cultures easily, and thereby reducing contamination risk, chances of morbidity and discomfort level in patients. 

Wednesday, February 8, 2012

Nosocomial sinusitis

Patients who have to spend long time in an intensive care unit (ICU), or  other parts of the hospital, and / or use nasogastric or endotracheal tubes may suffer from nosocomial sinusitis, a ‘hospital-borne’ infection. The prolonged usage of nasogastric or endotracheal tubes increase chances of developing signs of sinus infection. Many patients using nasotracheal tubes for more than five days suffer from nosocomial sinusitis. The hospital stay of patients with burns and serious trauma, and patients who have undergone surgery may prolong, increasing risk of catching the sinusitis. Head trauma and neurological disorders may also trigger the sinusitis.




The nasogastric or nasotracheal tubes plug the sinus ostia and thereby the secretions accumulate in the area. As a result, the drainage system of the paranasal sinuses is affected severely. This mechanical obstruction hinders normal bacteria drainage process. The bacteria, therefore, multiply in the sinuses causing inflammation and other signs of sinus infection.
Gram-negative enterics, including Serratia marcescens, Proteus mirabilis, Enterobacter species, Klebsiella pneumoniae and Pseudomonas aeruginosa are the main pathogens causing nosocomial sinusitis. Nosocomial sinusitis is a non-airborne infection because endogenous microbes causing the disease come in direct contact of the sinus via intubations.
In the patients with acute nosocomial sinusitis associated with nasogastric and nasotracheal tubes, population of gram-negative organisms, such as Staphylococcus aureus and Staphylococcus epidermidis, is large. Common signs of the sinusitis include leukocytosis and fever. The patients may also complain about purulent rhinorrhea.
The signs of sinus infection may develop in the patients using mechanical ventilation for a long time and oropharyngeal tubes simultaneously, or nasoenteric tubes. Anaerobes, including S. aureus, Acinetobacter spp. and P. aeruginosa are the primary source of sinus infection in these patients. They may also suffer from sepsis and fever.
During microbiological analysis of the acute nosocomial sinusitis, polymicrobial infection in conjunction with Bacteroides species, P. aeruginosa and S. aureus has been identified.  If younger patients use blind nasotracheal intubations in emergency, chances of staphylococci infection are high. If older patients who are operated in an ICU or operating room require elective intubations, gram-negative organisms may cause the sinusitis. 
The organisms causing a wide range of nosocomial infections are also responsible for nosocomial sinusitis. For example, gram-positive cocci and gram-negative enterics, such as Proteus mirabilis, Enterobacter sp, K. pneumoniae and P. aeruginosa, are the main pathogens associated with nosocomial infection.  The bacteriology of chronic and acute nosocomial sinusitis is quite similar if edema and inflammation of tissue play an important role.  An untreated infectious nosocomial sinusitis may lead to nosocomial pneumonia. So, timely treatment is necessary. Here is an overview of the sinusitis treatment:
Lavage and drain the sinus.

Administer the suitable antibiotics.

Remove all types of nasal tubes to minimize mucosal edema and nasal irritation.

If a maxillary puncture is done to diagnose the disease, a simultaneous antral wash will be useful.

Elevate the patients’ head and use topical nasal vasoconstrictor drops to open the sinus ostia for draining out the accumulated mucus.

Tuesday, February 7, 2012

Signs of a sinus infection of odontogenic origin

Signs of a sinus infection of odontogenic origin

Since the upper jaw teeth are located close to the maxillary sinus, the sinus infection may spread to the oral cavity or vice versa. This odontogenic maxillary sinusitis is ascribed to anaerobic organisms that dominate the oral cavity. The sinusitis could be acute and chronic. The management, microbiology and pathophysiology of odontogenic maxillary sinusitis, which is unilateral, are different from that of non-odontogenic maxillary sinusitis.




Causes of odontogenic sinusitis

Odontogenic cysts

Periapical abscesses

Alveolar or dental trauma

Maxillary osteomyelitis

Perforations in the sinus while extracting the tooth

Secondary infection and irritation due to intra-antral foreign objects

Damage to the Schneiderian membrane owing to periodontal disease

Inadvertent displacement of bone graft materials, dental implants and other foreign bodies during dental surgeries and treatments

Microbiology of odontogenic sinusitis

Many similarities have been identified while analyzing microbiology of odontogenic sinusitis and a dentoalveolar abscess. Anaerobes, such as Fusobacterium, Prevotella, Porphyromonas and Peptostreptococcus, and viridians streptococci are commonly associated with both the conditions. The bacteria sitting in the nasophrynx and nasal cavity may also live in the odontogenic sinusitis' microflora. Thus, a wide range of organisms may trigger the odontogenic sinusitis.
The bacteriological analysis could not distinguish between chronic and acute odontogenic maxillary sinusitis. However, anaerobe, gram-negative bacilli- Fusobacterium sp. and Peptostreptococcus- are the primary organisms responsible for the infection. Two aerobes, S. aureus and ά-hemolytic streptococci, play major role in case of mixed infection.

Acute and chronic of odontogenic sinusitis

If the inflammation in the antral mucosa prolongs after acute odontogenic maxillary sinusitis, symptoms of chronic odontogenic sinusitis develop. The antral mucosa thickens due to fibers, leukocytes and edema during the chronic condition. In some cases, polyps may also develop.

Symptoms and signs of acute form

Malaise

Headache

Oral malodor

Pressure-like dull pain

Mucopurulent rhinorrhea

Occasional eyebrow edema

Nasal obstruction or congestion

Erythema i.e. redness of the skin

Swelling of the anterior maxilla and cheeks

Fullness or pressure near the maxillary sinus

Smelly mucopurulent material draining into the nasophrynx and the nasal cavity

If a periapical abscess is the source of the infection, swelling may occur in the buccal vestibule and gingiva.

Symptoms and signs of chronic form

Malodor

Dull headache

Nasal congestion

Constant pus from the oroantral fistula

Nasal discharge with / without postnasal drip

Tenderness in anterior maxillary area

Pain in tooth while chewing
However, signs of a sinus infection are subtle in chronic form.

Treatment of odontogenic sinusitis

As maxillary sinusitis and odontogenic infections are related, the oral cavity of the patients having signs of a sinus infection  should also be examined. Dental infections shall be treated simultaneously with maxillary sinusitis.

Monday, February 6, 2012

Rhinorrhea: anterior and posterior

Both paranasal sinuses and nasal cavities’ membranes secrete mucus regularly. Normally, the mucus is swallowed with saliva. However, the mucus starts dripping if

its production increases,

it does not evaporate,

it does not flow normally through the throat and the nose as an even thin film,

its chemistry / composition alters due to changes in secretion,

bacteria causing infections change its composition and / or

sinus cilia paralyze.



Changes in the mucus irritate the throat, causing rawness that creates a desire to clear the throat constantly. In some cases, hard and thick phlegm even accumulates in the nose and throat. It is difficult to remove this phlegm. The irritation may extend into the lung, the bronchi and the windpipe. Although many remedies have been invented to treat the drip, resolving nasal obstruction and congestion is the best therapy.
In medical terminology, this excessive nasal discharge is called nasal drip (rhinorrhea). The rhinorrhea could be anterior or posterior. The discharge draining from the nares is called anterior rhinorrhea. The anterior nasal drip is generally associated with allergic or viral rhinitis. The phlegm dripping into the throat from the nose is referred to as posterior nasal drip (posterior rhinorrhea). The color of rhinorrhea is greenish or yellowish in purulent sinusitis and transparent or white in vasomotor rhinitis.
Postnasal drip during acute sinusitis, cough and nasal congestion can cause pain in the face and headache. The drip may also occur in chronic sinusitis, but the pain is generally non-existent. The drip invariably accompanies nasal obstruction. Most of the asthma patients have nasal congestion, thus, they also suffer from the drip.
Posterior nasal drip may occur in the patients suffering from nasal polyposis. The drip may worsen the cough in the night while the patient is lying down. Reoccurring pharyngitis is also associated with the drip.
In non-smokers, posterior nasal drip syndrome (PNDS) is one of main causes of chronic cough. Diagnosis of which is based on a number of symptoms, such as nasal congestion, postnasal drip, swelling of inferior turbinates and mucus draining into the posterior pharynx.  But, the syndrome diagnosis is not always precise. The differential diagnosis (Dx) of the syndrome includes rhinitis medicamentosa, vasomotor rhinitis, non-perennial non-allergic rhinitis and hay fever. Oral decongestants, inhaled steroids and / or first generation antihistamines are administered to treat the syndrome.

Friday, February 3, 2012

What are the differences between sinusitis, rhinosinusitis and the common cold?

What are the differences between sinusitis, rhinosinusitis and the common cold?


Cold also known as viral upper respiratory tract infection, acute viral rhinopharyngitis, acute coryza, or common cold is a contagious, viral infectious disease of the upper respiratory system mainly caused by rhinoviruses and coronaviruses. Symptoms include a sore throat, runny nose, and fever. There is no cure, however symptoms usually disappear spontaneously in 7 to 10 days. It is one of the most frequent infectious diseases in humans, with two to four infections a year in adults and up to 6 - 12 in children.



Sinusitis is an inflammation of the nasal passages, which may or may not be as a consequence of infection, from bacterial, fungal, viral, allergic or autoimmune issues.


Rhinosinusitis, however, is an inflammation of the nose and paranasal sinuses, the consequence of an infection, from bacterial, fungal, viral, allergic or autoimmune issues, characterized by nasal blockage, obstruction, congestion or nasal discharge (anterior or posterior nasal drip), with or without facial pain and pressure and/or reduction or loss of smell.
   Newer classifications of sinusitis refer to it as rhinosinusitis, taking into account the thought that inflammation of the sinuses cannot occur without some inflammation of the nose as well (rhinitis).

Acute Rhinosinusitis (ARS) lasts less than 12 weeks. It is usually an early upper respiratory tract infection of viral, bacterial or fungal aetiology. Viral Rhinosinusitis could be a common cold or acute viral rhinosinusitis (lasting from 7 to 10 days), while a non-viral rhinosinusitis presents an increase of symptoms after 5 days or persistence of symptoms after 10 days, but lasting less than 12 weeks.

Chronic Rhinosinusitis (with or without nasal polyps) (CRS) is when symptoms last more than 12 weeks without complete relief. It is usually produced by factors such as dust or pollution, aerobic and anaerobic bacterial infection, or fungus (either allergic, infective, or reactive). Non-allergic factors such as vasomotor rhinitis can also produce chronic sinus problems. Other etiologic factors are abnormally narrow sinus passages (such as a deviated septum), which can impede drainage from the sinus cavities.
Rhinosinusitis symptoms may include any combination of the following: nasal congestion; facial pain; headache; night-time coughing; an increase in previously minor or controlled asthma symptoms; general malaise; thick green or yellow discharge; feeling of facial 'fullness' or 'tightness' which may worsen on bending over; aching teeth, and/or halitosis. Chronic Rhinosinusitis can often lead to anosmia, a reduction in the ability to smell or detect odours. In a small number of cases, acute or chronic maxillary sinusitis is associated with a dental infection.
Other common symptoms include sinus headache. Acute and chronic sinusitis may be accompanied by thick purulent nasal discharge and localized headache (toothache) or migraine misdiagnosis. The confusion with migraine stems from activation of the trigeminal nerves, which innervate both the sinus region and also the meninges that surround the brain.

Thursday, February 2, 2012

Review of Acute Rhinosinusitis

Review of Acute Rhinosinusitis

ABSTRACT:


Acute rhinosinusitis is a common ailment accounting for millions of

office visits annually, including that of Mrs D, a 51-year-old woman

presenting with 5 days of upper respiratory illness and facial pain.

Her case is used to review the diagnosis and treatment of acute rhinosinusitis.

Acute viral rhinosinusitis can be difficult to distinguish from acute

bacterial rhinosinusitis, especially during the first 10 days of symptoms.

Evidence-based clinical practice guidelines developed to guide

diagnosis and treatment of acute viral and bacterial rhinosinusitis

recommend that the diagnosis of acute rhinosinusitis be based on the

presence of "cardinal symptoms" of purulent rhinorrhea and either facial

pressure or nasal obstruction of less than 4 weeks' duration.



Antibiotic treatment generally can be withheld during the first 10 days

of symptoms for mild to moderate cases, given the likelihood of acute

viral rhinosinusitis or of spontaneously resolving acute bacterial rhinosinusitis.

After 10 days, the likelihood of acute bacterial rhinosinusitis

increases, and initiation of antibiotic therapy is supported by practice guidelines. Complications

of sinusitis, though rare, can be serious and require early recognition and treatment.


COMMENTS:

Antibiotics are not recommended during the first 10 days of symptoms due

to the fact that the main etiology of Acute Rhinosinusitis is viral, and therefore

symptomatic treatment is indicated. Nasodren®, which acts locally

within the nasal sinuses, facilitates natural secretion and drainage, thereby

reducing the signs and symptoms of the underlying inflammatory process

associated with Rhinosinusitis. Nasodren® can be used as monotherapy

or adjunctive therapy.
Peter H. Hwang, MD, Discussant

JAMA. 2009; 301(17): 1798-1807.

Wednesday, February 1, 2012

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