What Is Rhinosinusitis?
Rhinosinusitis is an inflammatory condition that affects the nasal sinuses and the nasal cavity. The inflammatory process leads to the obstruction of the ostiomeatal complex, leading to facial pressure and pain. The patient may also experience postnasal drainage, mucopurulence, nasal obstruction, and congestion.
Other symptoms that can be observed in patients having acute rhinosinusitis include anosmia, fever, cough, and fatigue. The patient may also complain of maxillary dental pain and ear fullness. The persistence of these symptoms for more than ten days may indicate an acute rhinosinusitis.
An acute rhinosinusitis lasts less than four weeks. However, it can resolve completely with therapy. The persistence of the symptoms beyond twelve weeks is referred to as chronic rhinosinusitis. The respiratory tract pathogens that cause both acute and chronic rhinosinusitis include Moraxella catarrhalis, Haemophilus influenza, and streptococcus pneumonia.
Types of Rhinosinusitis
Rhinosinusitis is divided into categories depending on the duration of the symptoms. Acute rhinosinusitis only lasts for a relatively short duration while the symptoms associated with chronic rhinosinusitis last for an extended period and take more than twelve weeks to resolve completely.
1. Acute Bacterial Rhinosinusitis
This is a clinical condition that presents with rhinorrhea and nasal congestion that lasts between seven and fourteen days. However, the symptoms cannot go past four weeks. The diagnosis of acute bacterial rhinosinusitis depends on the clinical signs, symptom presentation, and duration of the symptoms. Further diagnosis can be performed through a detailed history and physical examination. The condition commonly begins with a marked mucosal inflammation that originates from a viral upper respiratory tract infection.
The mucosal inflammation together with the retained secretions provides a conducive environment for the growth of bacterial organisms. A diagnosis of bacterial rhinosinusitis is obtained when bacterial superinfections occur. The sites that are commonly affected by this condition include the ethmoid, maxillary, and frontal sinuses.
The primary pathogens involved include Haemophilus influenza, Moraxella catarrhalis, and Streptococcus pneumonia. Other pathogens may include the anaerobes, Streptococcus species, and Staphylococcus aureus.
2. Subacute Rhinosinusitis
Subacute rhinosinusitis is similar to the acute presentation. However, its symptoms last for more than four weeks and less than twelve weeks. The microbiology of acute and subacute rhinosinusitis is believed to be similar. However, subacute rhinosinusitis is associated with other resistant organisms such as Pseudomonas aeruginosa. An appropriate medical therapy can result in complete and long-term resolution of the symptoms.
3. Chronic Rhinosinusitis
The symptoms of chronic rhinosinusitis last for at least twelve consecutive weeks. The term chronic rhinosinusitis is used to describe a group of disorders that present with an inflammation of the nasal and paranasal sinuses. The predisposing conditions for chronic rhinosinusitis include asthma, allergy, cystic fibrosis, and polyposis. Individuals with immunodeficiency syndromes are also likely to get chronic rhinosinusitis.
The causative agents of chronic rhinosinusitis are different from acute rhinosinusitis. The primary pathogens in chronic rhinosinusitis include Staphylococcus aureus, coagulase-negative Staphylococcus, and aerobic and gram-negative bacteria. The difference in bacteriology between acute and chronic sinusitis is thought to be caused by repeated use of antibiotic agents in patients with recurrent rhinosinusitis.
Significant osteitis is also common due to the prolonged inflammation and remodeling that takes place within the bone of the paranasal sinuses. The phenomenon can cause distal submucosal spread to other parts. A recent study revealed that 50 percent of patients undergoing surgery for chronic rhinosinusitis presented with a pathological evidence of osteitis. Experts believe that the finding will influence future management approaches for chronic rhinosinusitis.
Treatments for Rhinosinusitis
Treatment of rhinosinusitis is usually based on the duration and severity of the symptoms. If necessary, a culture should be performed to identify the pathogens involved. Treatment agents will be prescribed based on the causative agents detected in the culture.
Treatment of acute rhinosinusitis involves providing the patient with adequate drainage of the sinuses involved and treatment of the systemic organism present. Drainage can be achieved through a surgical procedure with sinus puncture and irrigation techniques.
The options for medical drainage include:
— The oral alpha-adrenergic vasoconstrictors such as pseudoephedrine and phenylephrine. They should be administered for ten to fourteen days.
— Topical vasoconstrictors: examples include oxymetazoline hydrochloride. They are administered for a maximum of three to five days.
Antibiotic treatment is usually administered for two weeks (14 days). The usual first-line therapy involves one of the following:
— Amoxicillin, administered at double the normal dose of 80-90mg/kg/d. It is commonly recommended in areas where there is a known streptococcus pneumonia resistance.
— Clarithromycin
— Azithromycin
The second-line treatment of rhinosinusitis is only considered for patients presenting with any of the following:
— Patients who reside in areas with a high incidence of resistant bacterial organisms.
— Patients who fail to respond to treatment within 48-72 hours of commencement of therapy.
— Patients whose symptoms persist beyond 10-14 days.
The antibiotic agents that are used for second-line therapy include the following:
— Amoxicillin-clavulanate
— Cephalosporins, second or third generation. They include cefdanir, cefuroxime, and cefpodoxime.
— Macrolides e.g. clarithromycin.
— Fluoroquinolones such as moxifloxacin, levofloxacin, and ciprofloxacin.
— Clindamycin
The following criteria are used in the selection of antibiotic agents based on the disease severity and the previous antibiotic use:
— An adult who presents with a mild illness and has not received antibiotics is given amoxicillin-clavulanate, amoxicillin, cefpodoxime, cefuroxime.
— An adult with a mild disease who has been taking antibiotics for the previous 4-6 weeks and those with a moderate disease will be given: amoxicillin-clavulanate, amoxicillin, or cefixime as recommended.
— Individuals who present with moderate disease and have used antibiotics in the previous 4-6 weeks are put on amoxicillin-clavulanate, levofloxacin, doxycycline, or moxifloxacin.
Adjunctive Therapy for Rhinosinusitis
· Warm compresses
· Smoking cessation
· Balanced nutrition
· Adequate hydration
· Nonnarcotic analgesia
· Humidification/vaporizer
Risk Factors
A person may be at an increased risk of getting rhinosinusitis if they have any of the following conditions:
· Hay fever or any allergic condition that interferes with the sinuses.
· A medical condition such as cystic fibrosis. Disorders of the immune system such as HIV/AIDS may also increase the chances of getting the inflammatory condition.
· Nasal passage abnormality in the form of tumors and nasal polyps.
Rhinosinusitis Conclusion
Most patients with acute rhinosinusitis do not need to see a doctor. However, it is advisable to see a doctor if one has symptoms that do not improve within a few days or worsen. Patients with a persistent fever with a history of recurrent or chronic sinusitis should consider contacting a doctor.
