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1. INTRODUCTION SINUSITIS Sinusitis is an inflammation or swelling of the tissue lining the sinuses. Healthy sinuses are filled with air. But when they become blocked and filled with fluid, germs can grow and cause an infection or Sinusitis can be broadly defined as inflammation of one or more of the paranasal sinuses. The nasal or paranasal sinuses are binds in the bones that surround's the nasal cavity. They play important lightening the skull as well as warming and moisterring the air The host defense system works to keep this pathogen free in a number of ways. In an immunocompetent host, secretory IgA and proper mucocilliary clearance through a patent ostium prevent local mucosal damage.

2. PATHOGENESIS When these sinuses are healthy, they are being filled up with air in the spaces, but when they are not health they turned to filled up with fluid and become blocked which results in invasion of germs causes infection or inflammation . The origin of acute sinus infection is much like that of ear infection (Otitis Media), normally the middle ear and the sinuses are sterile but the adjacent mouth and nose have a norma flora under normal conditions very small hairs called cilia muce mucus along the lining of the nose and respiratory tract keeping the sinuses clean. when ciliary function is gamaged , infections can be established, following a common cold, a decrease in ciliary function,may permit bacteria to remain on the mucous membrane surfaces within the sinuses and to produce a punilent sinusitis and the organism induced is haemophilus influenza, streptococcus pneumoniaae , staphylococcus aureus .

3. SITES WITH SPEICIFIC SYMPTOMS Frontal sinusitis causes: Pain across the lower forehead. Symptoms are worse when lying on the back Maxillary sinusitis causes: Pain over the cheeks that may travel to the teeth Hard palate in the mouth sometimes becomes swollen Symptoms are worse when head is upright Ethmoid sinusitis causes: Pain behind the eyes and sometimes redness and tenderness in the area across the top of the nose

4. Symptoms are worse when coughing, straining , or lying on the back Sphenoid sinusitis: Rarely occurs by itself; when it does, the pain maybe felt behind the eyes, across the forehead, or in the face Symptoms are worse when lying on the back or bending forward

5. TYPES OF SINUSITIS Acute symptoms last less than 4 weeks Subacute symptoms last 4 to 8 weeks Chronic symptoms last longer than 8 weeks Recurrent three or more acute episodes a year Acute sinusitis, also known as a sinus infection or rhinosinusitis , refers to inflammation and infection in one or more of the paranasal sinuses. Acute bacterial sinusitis generally occurs after symptoms have persisted for 7 to 10 days. It often occurs after a cold, when mucus gets trapped in inflamed sinuses and does not drain properly. This condition encourages bacterial growth, or rarely fungal growth, that can lead to infection.

6. CAUSES Sinusitis affects is one of the most common reasons people visit the doctor. It is acute when in the early stages, from 1 to 4 weeks after symptoms start. Subacute or chronic sinusitis has symptoms that last longer than 1 month. Chronic sinusitis is a common condition in which the cavities around nasal passages (sinuses) become inflamed and swollen for at least 12 weeks, despite treatment attempts. Also known as chronic rhinosinusitis , this condition interferes with drainage and causes mucus buildup. Breathing through your nose might be difficult. The area around your eyes and face might feel swollen, and you might have facial pain or tenderness. Chronic sinusitis can be brought on by an infection, by growths in the sinuses (nasal polyps) or by a deviated nasal septum. The condition most commonly affects young and middle-aged adults, but it also can affect children.

7. Causes cont Common causes of chronic sinusitis include: Nasal polyps. These tissue growths can block the nasal passages or sinuses. Deviated nasal septum. A crooked septum — the wall between the nostrils — may restrict or block sinus passages. Other medical conditions. The complications of cystic fibrosis, gastroesophageal reflux, or HIV and other immune system-related diseases can result in nasal blockage. Respiratory tract infections. Infections in your respiratory tract — most commonly colds — can inflame and thicken your sinus membranes and block mucus drainage. These infections can be viral, bacterial or fungal. Allergies such as hay fever. Inflammation that occurs with allergies can block your sinuses.

8. Clinical presentation At least two of the four primary signs and symptoms of chronic sinusitis must be present with confirmation of nasal inflammation for a diagnosis of the condition. They are: Thick, discolored discharge from the nose or drainage down the back of the throat (postnasal drainage) Nasal obstruction or congestion, causing difficulty breathing through your nose Pain, tenderness and swelling around your eyes, cheeks, nose or forehead Reduced sense of smell and taste in adults or cough in children Other signs and symptoms can include: Ear pain

9. Aching in your upper jaw and teeth Cough that might worsen at night Sore throat Bad breath (halitosis) Fatigue or irritability Nausea Chronic sinusitis and acute sinusitis have similar signs and symptoms, but acute sinusitis is a temporary infection of the sinuses often associated with a cold. The signs and symptoms of chronic sinusitis last longer and often cause more fatigue. Fever isn't a common sign of chronic sinusitis, but you might have one with acute sinusitis. Rare complications of sinusitis can produce additional symptoms, which may be severe or even life threatening

10. RISK FACTORS You're at increased risk of getting chronic or recurrent sinusitis if you have: A nasal passage abnormality, such as a deviated nasal septum or nasal polyps Asthma, which is highly connected to chronic sinusitis Aspirin sensitivity that causes respiratory symptoms An immune system disorder, such as HIV/AIDS or cystic fibrosis Hay fever or another allergic condition that affects your sinuses Regular exposure to pollutants such as cigarette smoke

11. PREVENTION Avoid upper respiratory infections. Minimize contact with people who have colds. Wash your hands frequently with soap and water, especially before meals. Manage your allergies. Work with your doctor to keep symptoms under control. Avoid cigarette smoke and polluted air. Tobacco smoke and air contaminants can irritate and inflame your lungs and nasal passages. Use a humidifier. If the air in your home is dry, such as it is if you have forced hot air heat, adding moisture to the air may help prevent sinusitis. Be sure to keep the humidifier clean and free of mold with regular, thorough cleaning.

12. INVESTIGATIONS For sinusitis lasting more than 12 weeks, criteria are lacking. A CT scan. Nasal endoscopy, clinical symptoms A tissue sample for histology and cultures can also be used. Multiple biopsy is informative to confirm the diagnosis. Nasal endoscopy involves inserting a flexible fiber-optic tube with a light and camera at its tip into the nose to examine the nasal passages and sinuses. This is generally a completely painless procedure which takes between 5 to 10 minutes to complete.

13. Treatment in acute sinusitis Conservative measures ibuprofen can relieve some of the symptoms associated with sinusitis, such as headaches, pressure, fatigue and pain. Nasal irrigation using a warm saline solution may also be effective. Antibiotics Evidence indicates that first line antibiotics amoxicillin are extremely effective in treating acute sinusitis. The vast majority of cases resolve without antibiotics, however if the symptoms are prolonged amoxicillin is a reasonable first choice with amoxicillin (Augmentin) being indicated for patients who fail amoxicillin alone. doxycycline, is used in patients who are allergic to penicillins . Corticosteroids

14. Treatment In chronic sinusitis Conservative measures Nasal irrigation may help with symptoms of chronic sinusitis. Medical approaches Surgical treatment For chronic or recurring sinusitis, nasal surgery. However, for most patients the surgical approach is not superior to appropriate medical treatment. Surgery should only be considered for those patients who do not experience sufficient relief from optimal medication. endoscopic sinus surgery (FESS), whereby normal clearance from the sinuses is restored by removing the anatomical and pathological obstructive variations that predispose to sinusitis. This replaces prior open techniques requiring facial or oral incisions and refocuses the technique to the natural openings of the sinuses instead of promoting drainage by gravity, the idea upon which the Caldwell-Luc surgery was based.

15. Treatment Cont A number of surgical approaches can be used to access the sinuses and these have generally shifted from external/ extranasal approaches to intranasal endoscopic ones. The benefit of the Functional Endoscopic Sinus Surgery FESS is its ability to allow for a more targeted approach to the affected sinuses, reducing tissue disruption, and minimizing post-operative complications. For persistent symptoms Caldwell-Luc radical antrostomy (e.g. incision in the upper gum, opening in the anterior wall of the antrum , removal of the entire diseased maxillary sinus mucosa and drainage is allowed into inferior or middle meatus by creating a large window in the lateral nasal wall.)

16. COMPLICATIONS Chronic sinusitis complications include: Meningitis. This infection causes inflammation of the membranes and fluid surrounding your brain and spinal cord. Other infections. Uncommonly, infection can spread to the bones (osteomyelitis) or skin (cellulitis). Partial or complete loss of sense of smell. Nasal obstruction and inflammation of the nerve for smell (olfactory nerve) can cause temporary or permanent loss of smell. Vision problems. If infection spreads to your eye socket, it can cause reduced vision or even blindness that can be permanent.

17. REFERENCE 1. American Academy of Pediatrics (2001): Subcommittee on Management of Sinusitis and Committee on Quality Management. Clinical practice guideline: management of sinusitis. Pediatrics, 108(3):798-808. 2 . Lanza DC and Kennedy DW (1997): Adult rhinosinusitis defined. Otolaryngol Head Neck Surg. 117(3 Pt 2):S1-7. 3 . Meltzer EO, Hamilos DL, Hadley JA et al. (2004): Rhinosinusitis : Establishing definitions for clinical research and patient care. Otolaryngol Head Neck Surg.,131(6):S1-62. 4 . Slavin RG, Spector SL, Bernstein IL et al. (2005):The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol ., 116(6):S13-47. 5 . American Academy of Pediatrics - Subcommittee on Management of Sinusitis and Committee on Quality Management(2001): Clinical practice guideline: management of sinusitis. Pediatrics, 108(3):798-808.

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