Sinusitis
·
Incidence
9/10 people complaining of sinusitis actually have
rhinitis
Rhinitis:
inflammatory state of the anterior nasal passages but not the
sinuses. The common cold. Due to allergies, viruses, hormones, bacteria. OTC sprays and decongestants may give
satisfactory response for viral and allergic etiologies.
Rhinorrhea-watery discharge from nasal
passages. Production increases
infection, polyp, foreign object, irritation.
[FYI: the
nose prods 1-1.5 pints of mucous per day.
Most of this drains down the posterior nasopharynx where the cilia push
it along. Smokers, etc. have more
irritation and produce more mucus.
Sinustis:
the primary cause is blockage of sinuses preventing drainage, which can
produce discomfort.
This does not readily respond to nasal sprays and
decongestants despite the advertising.
It is an inflammatory state of the sinuses due to
allergies, hormones, viruses, tumors, and bacteria.
The primary cause is blockage.
Epitaxis-nose bleed
-typically due to nose picking or other trauma to
Kiesselbach’s plexus of the anterior nasal septum.
-also due to:
anemia, HTN, infections
Note: if the
site of bleeding cannot be visualized, consultation is needed as the bleed is
in the posterior nose which belongs to the external carotid arterial
system. Therefore, serious problems can
occur with tumor, aneurysm, etc.
·
History
Timing:
perennial, seasonal, annual, worse in morning or at work, etc.
Discharge:
due to…
Clear:
allergies, hormones, adenoids, polyps, HTN, foreign object, neoplasm,
asthma, CSF
CSF:
typically post-trauma, leak from subarachnoid space
S&S: intermittent
discharge, when the head is flexed
dries soft
demonstrates a halo due to
glucose
test positive with glucose
stick
must be treated in ER
vasomotor rhinitis:
20 to 40 year old females especially
predisposing
factor: stress [psychological, endocrine, genetic, allergic]
stimulation
of parasympathetics
depression
of sympathetics
leading
to vasodilatation and subsequent increase in secretion
associated
with hormonal changes [puberty, menses, pregnancy, etc.]
neurovascular
reaction
S&S: hypertrophic
mucosa [mulberries] seen on post. rhinoscopy
Profuse,
watery discharge
Decreased
airway- uni. Or bilateral
Swollen
turbinates, esp. the inferior
Deep pink to dusky red mucosa due to vasodilation
Clear with red streaks: CSF
Atrophic rhinitis:
unknown etiology
S&S: copious
amounts of dry crusted material with dry nasal membranes
And
turbinates
Anosmic
[no sense of smell]
Fetid
halitosis [pt. can’t tell due to anosmia]
[halitosis due to lack of mucus]
TX: syringing
the nose TID with syringe or water-pick
Steam
inhalations
Glucose
in glycerin drops
May
be associated with syphilis or tuberculosis
Systemic causes:
HTN, thyroid disorders, drugs [cocaine], trauma
Allergies:
see notes page………..
White to pale yellow: viral infection or old mucus
[Note:
viruses typically have fevers of
less than 101 degrees.]
Bright yellow to green: bacterial infection, fungal infection, atrophic sinusitis,
foreign object, polyp degeneration
Fevers do not necessarily occur with bacterial
infection of the sinuses.
Pain- type and location
Other S&S: stuffiness, tearing, bloodshot eyes
[injection], swelling, headache,
halitosis, disorders of smell, blockage, sneezing,
post-nasal drip, fever, otologic symptoms
facial pain.
·
Examination-
review Bates
Inspection:
swelling, redness, bulging eyes, motion of eyes, etc.
Transillumination:
blockage of sinus or SOL [space occupying lesion]
Direct inspection:
examination of nares or use of mirror
For polyps, mucosal swelling and color, discharge,
foreign objects
-be sure to examine the middle meatus for the
maxillary sinus
-the ostia of the sinus can be examined with a
nasopharyngeal mirror to check for closure, inflammation or drainage.
Palpation:
for pain, swelling, temperature
Lab:
cultures, nasal swab
Eosinophilia: greater than 400 to 500 cells/mm3 will
support but not confirm a diagnosis of allergy
Hansel’s Stain-used for leukocytes and
eosinophils. Therefore, this stain will
help you differentiate an infection from an allergy
-Most common organisms:
Strep pneumo
Hemophillus influenza
Staph aureaus
Beta strep
Skin test: false negatives are not infrequent.
A negative response does not exclude allergy and a
positive response is not absolute proof that the specific allergen is the
causative agent.
Shots due not remove the allergy.
The principle in the production of IgG antibody to
prevent the antigen from binding to the IgE.
Asthma and Allergy Foundation 692-2422
Pollen and mold counts St Louis County Health Dept.
854-6825
Imaging:
flat plate, MRI, etc.
-radiographs:
Upright Water’s View: for maxillary and sphenoid
Caldwell View:
for the frontal and ethmoid
Lateral Sinus
Submental Vertex
Examining for:
proliferation and thickening of the lining of the sinuses,
polyps, fluid/air levels.
Anatomy
Vascular supply-primarily the facial and ophthalmic
arteries
1.
external
and internal carotid supply the nose
2.
anterior
and posterior ethmoidal arteries supply the area above the middle turbinate
3.
sphenopalatine
and labial arteries supply the remaining structures
4.
venous
drainage of the external nose is by the facial and ophthalmic veins to the
cavernous sinus
Therefore, a superficial infection of the nasal lining
may involve the cavernous sinus.
Neurologic supply- primarily the ophthalmic and
maxillary nerves
The primary sensory supply is: maxillary division of the trigeminal nerve
Other sensory supply is: facial nerve
Facial pain- due to the distribution of the
trigeminal nerve
Pterygopalatine ganglion supplies the sympathetic
and parasympathetic supply.
Secretory glands are under the autonomic system.
Nasal vascular supply is constricted by the
sympathetic system and dilated by the parasympathetic system.
The ethmoid sinus walls are every thin which allows
an infection or tumor to spread easily to adjacent structures.
The sphenoid sinus in adjacent tot he internal
carotid artery, optic nerve and the cavernous sinus.
The cavernous sinus contains the oculomotor,
trochlear, abducens and the 1st and 2nd division of the trigeminal
nerves. The pituitary fossa lies
posterior to the sinus.
The torus tubaris [opening of the eusatchian tube]
lies just superior to the tonsillar tissue in the pharynx. It can become blocked by mucus draining from
the sinuses or post-nasal drip. This
causes the otologic symptoms.
Halitosis [bad breath] is due to the post-nasal
drip. It is most often due to poor
dental hygiene and poor diet though.
·
Treatments:
Antihistamines:
actually thicken the discharge and decrease the drainage
Moist heat or diathermy: if not bacterial, to thin
mucus
Vasoconstrictor:
Constricts the vasculature to shrink the nasal mucosa and reduce the
inflammation
[to open the os and allow drainage].
Spray once, wait five minutes and spray again.
Breathe through a wet, steamy towel or use a steam
apparatus.
Then, with the patient supine and the affected sinus
up,
Hang the head over the edge of the bed to promote
drainage
Perform a minimum of 5 minutes/3x/da/3-4 wk.
BUT they should not use these for more than 4 to
7 days
or they will acquire a sensitivity. Note:
overutilization can lead to Rebound Phenomenon causing chronic
blockage.
The condition is then called Rhinitis Medicamentosa.
This is a constant reactive vasodilatation of the
mucosa due to acquired sensitivity.
Topical steroids may be needed to wean the patient off the
vasoconstrictor or they may experience severe blockage.
Saline spray- may be used to thin mucus and lead to
drainage
Nasal wash
Saline solution deep sprays for allergies- 1 qt.
Water, 1 tsp. Sodium bicarbonate [buffer], 3 tsp. Canning salt without iodine
Vitamin therapy
Antibiotics- if bacterial
Ethmoid- pain at bridge of nose
Most
frequent sinus involved
Occurs
especially in children
May
have pain on eye movement
Maxillary- pain in teeth and cheeks 10% are from dental
infections
Pain
in several teeth, not just one
Also
frequent after the cold or flu
Face
may be puffy
Innervated
by infraorbital nerves
Sphenoid-occipital pain may have dizziness
Innervated by the ophthalmic
and maxillary nerves
Supplied
by the internal carotid
Frontal- pain on eye motion
also after cold or flu
Supra-orbital pain
Severe in mid-day and then
gets better
Edema
in eyelids
Pain aggravated by posture
changes
Innervated
by the supra-orbital n.
Types of rhinitis and sinusitis:
Allergies
10-20% of the population have some nasal symptoms of
antigen-antibody type 1 hypersensitivity reaction
The allergen binds to IgE which binds to mast
cells. The mast cells degranulate and
release mediator substances such as histamine, leukotrienes, etc.
Histamine: chemical produced during allergic
reactions by mast cells. This leads to
dilation of blood vessels and contraction of muscles. It permeates the nasal tissue and causes capillaries to swell and
ooze. Fluid from the capillaries pass
through tissue into the nasal cavity resulting in a runny nose [rhinnorhea].
Exposure to allergen leads to histamine response
with vasodilatation [blue] with seepage, due to increased capillary
permeability, resulting in swelling and the irritation leads to an increase in
the number of goblet cells [make mucus] to move allergen from surface.
No known reason for allergies. Another appendix?
May have concurrent history of asthma, eczema,
allergic dermatitis, drug allergies, aspirin sensitivity.
Recurrent exposure to allergens can lead to
formation of polyps
Allergies, if uncontrolled, can result in upper respiratory infections and serious
bouts of asthma.
Allergies
S&S: Profuse,
clear, thin discharge from the ant. and post. nose
-
Mucosa
is pale and boggy [blue]
-
Primary
symptom may be nasal obstruction from engorged and swollen inferior turbinates
-
may
or may not have obstruction or discharge
-
no
fever or body pain
-
may
have full feeling or pain in involved sinus
-
may
have coughing/sneezing [due to mucosal stimulation]
-
may
have itchy/watery eyes
-
puffiness
and discoloration around the eyes
-
may
become severe and debilitating
-
tension
headache may overly the original pattern and complicate diagnosis
-
watch
for timing/setting
Note: year
round allergies [mold, etc.] S&S are less severe.
Polyps: due to recurrent swelling
Often associated with vasomotor rhinitis [see page
1] and allergic rhinitis.
These have an increased number of goblet cells
therefore they produce more mucus and chronic post-nasal drip, cough,
halitosis, etc.
They can grow back after surgical removal if
allergies are not managed.
-most often found at the middle meatus
-gray, pale, spherical, mobile and insensitive to a
probe
Note: if
polyps are found in children… perform a chloride sweat test to rule out cystic fibrosis
adults… consider neoplasm
More about allergies
Primarily due to tree and grass pollens: olive, elm,
oak, bermuda and blue [list is extensive]
Aggravated by low humidity,
dust, wind and pollution, and yet can be worse in warm months due to warm humid
air and a lack of breeze which traps airborne allergens in the area.
Pollen counts are highest
from 1 AM to 9 AM.
Pollen counts are lowest in
the later afternoon and evening.
August
to October to first frost: typically weeds [especially
lamb’s quarter and ragweed]
Often
referred to as hay fever
If
symptoms continue past first frost,
then possibly the patient is
sensitive to mold spores.
March
through May: typically tree pollens
June
to first frost: grasses
Due to house dust, dust mites, mold spores, pet dander, saliva and urine, feather pillows, pollens, foods and are aggravated by pollution
S&S are the same as the seasonal but are
constant and less severe
Note: wheat, milk and nuts may be aggravating
factors
Due to fumes from cleansers, solvents and industrial
chemicals, molds, pollens and dust as they collect on furniture or in air ducts
S&S: sneezing, watery eyes, runny nose,
headaches and dry scratch throat only while in workplace. Commuters exposed to pollens and smog on the
way to work may mistakenly attribute their symptoms to the workplace.
Allergy myths:
allergies are psychosomatic, moving to Arizona will help, short haired
pets do not cause allergies, allergies are just sniffles and itching and no one
ever dies form them, you can catch poison ivy by standing near the plant
Chronic sinusitis:
-
Complication
of any acute sinusitis.
-
Pain
is worse on arising due to decreased drainage while recumbent.
-
Movement
promotes drainage.
-
No
temperature and minor tenderness over sinus.
-
Usually
hx of URI
-
Pain
in area
-
Possible
redness and tenderness in area
-
Mucosa-
angry red, swollen
-
Neutrophils
on nasal smear
-
Clouding
or even fluid line on flat plate film
-
Very
resistant to antibiotics
-
Severe
complications are possible.
The location of the primary infection will typically dictate what the complication will be.
Ethmoid orbital cellulitis, periorbital abscess
Frontal meningitis, osteomyelitis, brain abscess
Sphenoid meningitis
Any sinus cavernous sinus thrombosis
Orbital cellulitis
Pus penetrates the lateral wall of the ethmoid to
form an abscess between the ethmoid plate the fascial lining of the orbit.
S&S: increase
in fever
Pain
on eye movement
Edema
and tenderness between the inner canthus and the bridge of the nose
Pus
may press the eye down and laterally
No chemosis [ swelling of
the conjunctiva].
Orbital cellulitis
Pus breaks through the orbital plate to form an abscess
between the orbital bones and the eye which infects the skin in the area.
S&S: may
be heralded by chill, high fever and dull pain in the eye.
Pain
on ocular motion.
Edematous eyelids,
especially the upper lid and, more so, at the inner canthus
Chemosis [edema of the
conjunctiva and cornea] beginning at the inner canthus.
The eye will eventually
become immobile.
Very ill and requires
immediate surgery if not treated quickly.
Complete
immobilization of the globe occurs gradually but affects CN III, IV, and VI at
one time.
Meningitis
Infection travels along the veins between the
periosteum.
S&S: daily
spiking fever, stiff neck.
Immediate intervention
Brain abscess:
Infection travels along the veins to penetrate dura
and arachnoid layers.
S&S: weight
loss & anorexia
Vomiting
and nausea
Headache
and low-grade afternoon fever
Frontal osteomyelitis
S&S: redness
and swelling
Extremely
tender
Looks
like an acute bacterial infection but hurts more
Can
be seen on flat plate film
Cavernous sinus thrombosis
Infection spreads through the angular vein to the
cavernous sinus
Septic thrombosis results
Worst complication
50% mortality rate
can also be secondary to infection of the middle
ear, mastoid or oropharynx.
Collateral venous drainage may be compromised
If this occurs: seizures, increased intracranial
pressure and LOC
S&S: deep
pain in the eyes, headaches and rigors [shaking chills]
diplopia, photophobia,
orbital edema, progressive exophthalmos;
CN III, IV, V [ophthalmic
division], and VI
with loss of motion [picks
one nerve at a time and occurs early on]
and fixed pupil in
mid-dilation,
loss of corneal reflex,
decreased sensation over lateral and upper face.
Early
on…prostrated developing rapidly to coma.
Early
on…selective ocular palsy and eventually exopthalmos
Eventually, both eyes fixed
with proptosis and chemosis.
High dose antibiotics may help for infection if
introduced early on.
Venous blockage from the eye can lead to: papilledema, retinal hemorrhage, visual
loss.
Involvement of the superior sagital sinus: leg
weakness and hydrocephalus.
Involvement of lateral sinus over the ear: pain over the ear and mastoid with edema
Fistulas, trauma, aneurysms and meningiomas in the
cavernous sinus can also cause these symptoms.
Further, a cavernous sinus thrombosis can lead to
pituitary lesions and hypopituitarism from an infarction of the pituitary. Resulting in TSH, ACTH, etc. decreases.