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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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