Sinusitis - Review of Chronic
Sinusitis
Sinusitis can be divided into acute (a result of allergy, infection by
bacteria or virus) and chronic. Acute sinusitis is easily diagnosed
because the offending allergen can be demonstrated, as can also infection.
In the latter situation the nasal secretions are discolored yellow, green
or brown. Acute sinusitis is brief, lasting no more than 3 weeks and is
very responsive to antibiotics, antihistamines, cortisone nose
drops/tablets and decongestants.
Chronic sinusitis is a different story .It can last a lifetime. Causes are
not obvious and usually not determined. The nasal secretions are white or
colorless. Response to treatment is poor. In our further discussion,
unless it is specified otherwise, the term sinusitis will refer to chronic
sinusitis.
Alternative terminology
The term sinusitis is often interchanged with rhinnitis. However ,
rhinnitis refers specifically to that part of the nose from the nostrils
to the back of the nose, whereas sinusitis refers to the symptoms coming
from the nostrils to the upper part of the bronchial tree. Sinusitis is
thus a looser term.
Turbinitis refers to inflammation of the turbinates, the
three protrusions coming from the lateral walls of the nose. This term is
even more specific. These terms can only be used by doctors because only
they are familiar with the anatomy. They use these terms because they
believe inflammation is sourced from there.
Perennial refers to continuous, year in and year out as
opposed to seasonal. This term is often matched with sinusitis or
rhinnitis.
Vasomotor refers to the neurological control of the diameter
of the blood vessels supplying the nose and sinuses. Dilatation is
associated with increased secretions, stuffiness, headaches and pain. It
also aggravates asthma. This term is also matched with sinusitis or
rhinnitis.
A diagnosis of a diagnosis of perennial sinusitis, vasomotor sinusitis,
perennial rhinnitis, or vasomotor rhinnitis is often given to satisfy the
patient. In reality the doctor is saying he has no idea what the cause is
and any treatment to follow is likely to fail.
Epidemiology and Morbidity
There are currently over 37 million sufferers of sinusitis in USA alone
.Sinus sufferers account for the greatest number of doctor visits per
illness. Large sums of money are spent on medications, treatment
procedures and allergy shots which don't work. Sinusitis accounts for much
lost time from work especially when associated diseases such as asthma and
recurrent colds are taken into account.
Applied Clinical Anatomy
The sinuses are large air sacs in the bony structure of the skull located
around the nasal passage. The maxillary sinus, the largest, communicates
with the nasal passage through which all the secretions flow. The other
sinuses are called the frontal, ethmoid, and sphenoid sinuses. Infection
here can cause headaches.
The bony walls of the sinuses are lined with a special membrane consisting
of cells producing sticky mucus. Other cells have hairs or cilia which
vibrate .These cilia move the mucus in the direction of the exit. The
mucus acts as a conveyor belt moving trapped contaminants such as pollen ,
dust, bacteria and virus ultimately to be swallowed. This membrane is
called the respiratory membrane, for it lines the whole of the respiratory
tract. When the ciliary cells are damaged by infection, allergen reaction
or cigarette smoke , hairs are lost. Until they re -grow, which they will
not ,unless the environment is kind, there will be a functional blockage
of mucus flow. Blockage at any level presages infection, just like a
stagnant pond. Infection causes further damage, prolonging recovery.
Stagnation of mucus in the respiratory tract in it minimal form will mean
constant stuffy runny nose. In its most severe form, bronchiectasis,
partial lung resection of that cavity filled with pus is required.
Applied
Clinical Physiology.
There has been much debate on the purposes of the sinuses.. Besides that
already mentioned, the removal of pollutants, the sinuses are involved in
the humidification to 100% of all incoming air to be delivered to the
lungs. Air is also warmed to body temperature. The sinuses also lighten
the skull. Voice production also require the presence of the sinuses. The
autonomic nervous system controls the blood supply to the sinuses and the
bronchial tubes. These same nerves also control the diameter of the
bronchial tubes as it innervates its musculature Inappropriate contraction
of this musculature produces asthma, which is triggered by any irritant.
Thus sinusitis will aggravate asthma. These same nerves are also part of
the emotional expression, which is why we talk about exercise and
emotional induced asthma and sinusitis. For this same reason lack of sleep
often precipitates sinusitis and asthma.
Applied
Pathology and Investigations
The standard investigation, besides laboratory blood work for lowered
immunity and allergy testing is X-Rays and CAT scans. To this may be added
MRI. Sadly, all these expensive investigations do not help in making a
definitive diagnosis, or treatment. This is because sinusitis is a
functional problem, not an anatomical one. True, one does see a swollen
membrane and even polyps. Who is to say that the polyps are not just
exaggerated swellings. Even if they are removed or dealt with by
cauterization, the underlying problem has not been dealt with.
Treatment
Has been standard for decades. It focuses on the use of antihistamines,
decongestants, anti-inflammatory agents, anti-allergy agents and HI
blockers (blocking the release of histamines) orally or topically. Drugs
often have side effects. Allergy desensitization is effective for seasonal
sinusitis (hay fever). Surgery is effective for nasal polyps,
mechanical obstruction as in post fracture deformities and foreign body.
All treatments for sinusitis are expensive. Costs can exceed $1000
annually. This would not be a problem if treatments were effective.
However, they all fail to bring the patient to a happy functional state.
Most folks with partial improvement end up accepting their sinus
condition.
A more recent innovation is the local use of isotonic saline (0.9% salt
solution), packaged of course, sold under brand names at exorbitant cost.
This definitely helps though no one has offered any explanation.
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