3.1. Epidemiology and Clinical Relevance
It is estimated that sinusitis affects 16% of the United States population annually, leading to approx 16 million office visits and a yearly expenditure of approx 2 billion dollars on its medical therapy (29). Sinusitis, an infection of one or more of the paranasal sinuses, usually begins as a complication of viral upper respiratory tract infection in the elderly population. Obstruction of sinus drainage and retention of secretions are the fundamental events in sinus infection. Geriatric patients may be predisposed to sinusitis by several conditions that compromise the integrity of the sinus ostia, thereby interfering with aeration of the sinuses and creating a closed space that is susceptible to bacterial infection. Sinusitis is, therefore, more likely in the elderly with allergic rhinitis, nasal septal deviation, nasal fractures, nasal polyps or tumors. About 5-10% of cases of bacterial maxillary sinusitis are secondary to dental root infection. Sinusitis is generally subdivided into acute sinusitis (symptoms less than 3 wk), subacute sinusitis (symptoms lasting 3 wk-3 mo) and chronic sinusitis (symptoms lasting longer than 3 mo). Sinusitis may potentially cause serious intracranial suppurative complications such as meningitis, brain abscess, epidural abscess, and subdural empyema.
Acute bacterial sinusitis is commonly due to S. pneumoniae and H. influenzae. Less frequently isolated organisms include Streptococcus pyogenes, a-hemolytic streptococci, S. aureus, and M. catarrhalis (30). The ^-lactamase production by most strains of M. catarrhalis and a variable proportion of H. influenzae strains may lead to therapeutic failure of p-lactam agents such as amoxicillin in treating sinusitis due to these organisms. Over 200 viruses associated with the common cold have been implicated in acute sinusitis (31). Ventilator-associated sinusitis is most frequently caused by S. aureus, followed by P. aeruginosa, enteric Gram-negative bacilli, and various Streptococcus spp. (32). The risk of developing bacterial sinusitis on a ventilator increases both with the duration of nasal canulation and the size of the cannula (33). Among patients who have been ventilator-treated for >1 wk, the occurrence of bacterial sinusitis is approximately 10% (32). Chronic sinusitis, on the other hand, is caused by H. influenzae (in approx 60%), S. aureus, and anaerobes. P. aeruginosa may be the causative agent in patients with nasal polyps and cystic fibrosis. Fungal organisms such as mucor should be considered in the setting of diabetes mellitus and an immunocompromised host.
Acute sinusitis is usually preceded by a viral infection of the upper respiratory tract; an estimated 0.5% of common colds evolve into acute sinusitis. No single clinical finding is predictive of acute sinusitis. Three symptoms (maxillary toothache, poor response to decongestants, and history of colored nasal discharge) and two signs (purulent nasal secretion and abnormal transillumination) are the best clinical predictors of acute sinusitis. Sinusitis should be considered when purulent nasal or pharyngeal discharge and cough persist for over a week following a cold. The elderly may complain of headache, facial pain or tightness over the involved sinus, nasal obstruction, nasal quality of voice, and a fever (34). Nasal examination may reveal mucosal hyperemia and mucopurulent discharge. Purulent secretion from the middle meatus is highly predictive of maxillary sinusitis. Direct inspection of the posterior pharynx or use of a pharyngeal mirror may reveal posteriorly draining purulent secretions. Tenderness over the maxillae or the frontal bone suggesting an underlying sinusitis occurs much less commonly. Transillumination may be used to evaluate the maxillary and frontal sinuses, but its value is controversial. In chronic sinusitis, persistent nasal drainage, postnasal drip, persistent cough, foul breath, and altered taste may be noted. Neglected sinusitis may exacerbate an underlying chest disease leading to increased morbidity in the elderly (35). Sinusitis should be distinguished from several disease entities such as those listed in Table 3.
Differential Diagnosis of Sinusitis in the Elderly
Viral upper respiratory infection
Rhinitis medicamentosa (topical decongestant use) Drug-induced rhinitis (e.g., reserpine, prazosin,
ACE, angiotensin-converting enzyme.
Radiologic studies are not routinely performed for the evaluation of sinus infection. Basic radiographic examination of the paranasal sinuses includes four views: the Waters view (occipitomental), to evaluate the maxillary sinuses; the Caldwell view (angled posteroanterior), to evaluate the ethmoid and frontal sinuses; the lateral view, to evaluate the sphenoid sinuses and to confirm disease in the paired maxillary, ethmoid, and frontal sinuses; and the submentovertex view, to evaluate the sphenoid and ethmoid sinuses. This last view is also useful for examining the lateral walls of the maxillary sinuses. All radiographs are done with the patient erect in order to evaluate air-fluid levels. Most studies have demonstrated that sinusitis involves the maxillary sinuses in approx 90% of cases. Therefore, most cases of sinusitis would be diagnosed using only the Waters view. Radiographic evidence of acute sinusitis consists of sinus opacifica-tion, mucosal thickening of >5 mm, and the presence of air-fluid level in the affected sinus. A computed tomographic (CT) scan is more sensitive than sinus radiography for evaluating sinus disease and is particularly helpful in delineating the osteomeatal complex (36). The CT scan appears to be more sensitive than plain radiography for detecting sinus abnormalities, particularly in the sphenoid and ethmoid sinuses. However, due to its cost and poor specificity, which is around 60%, CT scanning of sinuses is not indicated for patients with uncomplicated acute bacterial sinusitis. In one study, 40% of asymptomatic patients and 87% of patients with colds had sinus abnormalities on CT scanning (37). This study should be reserved for patients with recurrent disease,
orbital or central nervous system complications, or when surgical intervention is contemplated due to a protracted sinus disease. The use of MRI scan may be helpful in select patients in distinguishing soft-tissue tumors from inflammatory lesions (see Fig. 1).
Surface colonization of the nasal passage makes the nasal purulence or the sinus exudate obtained by rinsing through the natural sinus ostium unsuitable for microbiologic diagnosis. Sinus puncture and quantitative cultures of the aspirated exudates remain the gold standard for reliable microbiologic diagnosis. However, such a procedure is not performed in an average case due to its invasive nature and the rather predictable bacteriology of acute sinusitis. Sinus puncture is reserved for patients with unusually severe disease, those responding inadequately to medical therapy or suspected of having intracranial extension, and when sinusitis occurs in an immunocompromised individual.
The management of sinusitis has been recently reviewed (38-40). Because the distinction between viral and bacterial etiology of acute sinusitis is difficult based on clinical findings, patients with acute sinusitis are generally treated for a presumed bacterial etiology. The antimicrobial therapy is directed at S. pneumoniae and H. influenzae. The commonly prescribed antimicrobial agents and their recommended dosages are listed in Table 4. The antibiotic therapy is generally administered for 14 d. Many clinicians are reluctant to prescribe amoxicillin or ampicillin for therapy due to the increasing frequency of P-lactamase-producing H. influenzae and M. catarrhalis in acute sinusitis. Quinolones with limited activity against S. pneumoniae, e.g., ciprofloxacin, should not be used for therapy of acute sinusitis. Fungal sinusitis, such as mucor, requires aggressive surgical debridement and appropriate antifungal therapy for cure.
Antimicrobial Therapy of Acute Sinusitis in the Elderly
Commonly prescribed dose
Cefuroxime axetil Clarithromycin Azithromycin Levofloxacin
500 mg q6 h 500 mg qS h 500/125 mg qS h 160 mg/800 mg bid 500 mg q6 h 250 mg q12 h 500 mg q12 h
500 mg day 1, and 250 mg qd, days 2-5. 500 mg qd bid, twice a day; qd, once a day; q8 h, once every 8 hours.
The nasal spray decongestants such as phenylephrine hydrochloride (0.5%) and oxymetazoline hydrochloride (0.05%) are frequently used to treat acute sinusitis. However, there are no published placebo-controlled studies proving their role or efficacy. Rebound vasodilatation may occur in patients who use such agents frequently or for longer periods. Oral decongestants (pseudoephedrine and phenylpropanolamine) are a-adrenergic agonists that reduce nasal blood flow. Theoretically, oral preparations can penetrate the ostiomeatal complex, where topical agents may not penetrate effectively. The use of oral decongestants has been shown to improve nasal patency. These agents can increase the functional diameter of the maxillary ostium. Some oral decon-gestants are available in combination with mucoevacuants, which may help to thin secretions and facilitate drainage. The antihistamines have not proven to be effective in the management of acute sinusitis. Their use may be counterproductive as the dryness of mucous membranes caused through their anticholinergic action may interfere with the clearance of purulent mucous secretions. Topical corticosteroid preparations have not shown convincing benefit in the treatment of sinusitis. There have been no controlled clinical trials of systemic glucocorticosteroid therapy for acute sinusitis.
Surgery may be necessary to facilitate drainage of the involved sinus and to remove the diseased mucosa. In acute bacterial sinusitis, surgical intervention is reserved for its complications, or lack of appropriate response to medical therapy. Functional endoscopic sinus surgery has revolutionized the surgical approach to sinus disease. With this approach, the affected tissue is removed and the normal tissue is left in place. Functional endoscopic sinus surgery can surgically correct anatomic obstructions and has been shown to result in moderate to complete relief of symptoms in 80-90% of patients.
Annual immunization with the influenza and pneumococcal vaccines, aggressive management of upper respiratory infections, and the prevention or treatment of upper respiratory allergies may reduce the incidence of sinusitis in the elderly. A high index of suspicion of sinusitis and its prompt therapy may prevent complications. Corrective surgery for nasal abnormalities to establish sinus drainage reduces the risk of sinusitis.
Good dental hygiene and prompt treatment of maxillary tooth root infection will prevent the onset of maxillary sinusitis as its complication.
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