How To Cure Your Sinus Infection

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When to Request CT in the Management of Rhinosinusitis

CT for rhinosinusitis is best reserved for patients who have not responded to maximum medical treatment. After maximum medical treatment, CT can help confirm that there is paranasal sinus disease and give an indication of the extent of residual disease (Fig. 7.2 a, b). It can also provide a map for the surgeon to use for in-

Acute sinusitis Includes abscess

Excludes sinusitis, chronic or NOS ( J32.- ) J01.0 Acute maxillary sinusitis Acute antritis J01.1 Acute frontal sinusitis J01.2 Acute ethmoidal sinusitis J01.3 Acute sphenoidal sinusitis J01.4 Acute pansinusitis J01.8 Other acute sinusitis Acute sinusitis involving more than one sinus but not pansinusitis J01.9 Acute sinusitis, unspecified

Sinusitis

Scan Sinus Abnormality

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

Acute sinusitis has considerable overlap in its constellation of signs and symptoms with URIs. One half to two thirds of patients with sinus symptoms seen in primary care are unlikely to have sinusitis (35). In 300 patients who presented with a URI, 19 had radiographic evidence of maxillary sinusitis, but had no symptoms of sinus infection (30). URIs are often precursors of sinusitis and at some point symptoms from each condition may overlap. Sinus inflammation from a URI without bacterial infection is also common. In a series of 60 children undergoing computerized tomography (CT) for non-sinus-related diagnoses, 47 had evidence of sinus inflammation with no clinical signs of sinusitis and with complete resolution following their viral illness (36). Acute sinusitis tends to start with a URI that leads to sinus ostial obstruction. The signs and symptoms that increase the likelihood that the patient has acute sinusitis are a double sickening phenomenon whereby the patient seems to...

Factors Promoting Antimicrobial Resistance And Measures To Control Its Spread

Exposure to antibiotics also promotes antimicrobial resistance among pathogens acquired in the community. One example is drug-resistant Streptococcus pneumoniae (DRSP) (9). S. pneumoniae is a frequent cause of outpatient respiratory infections including otitis media, pneumonia, and sinusitis. The strongest risk for developing an infection with DRSP is the prior use of antibiotics, in particular during the 3 previous months (86,87). Other risk factors for DRSP infection relate either directly or indirectly to antibiotic exposure. These risk factors have included young age, white race, higher income, suburban residence, and day care attendance (86,88-91). Day care attendance has been an important risk factor, probably because the environment presents a combination of frequent antibiotic usage with crowding and close contact of a large number of small children who share respiratory and other secretions (92-95).

Complications of GERD Esophagitis Stricture Barretts and Cancer

Gastroesophageal reflux disease (GERD) has become a very prevalent disorder in the United States and the Western hemisphere. It has been estimated that as many as 44 of adults in the United States experience GERD symptoms described as heartburn at least once a month.1 In addition, as many as 10 of adults in the United States experience daily heartburn.2 The true prevalence of reflux disease may be largely underestimated when taking into account atypical manifestations of the disease as well as those patients who self-medicate.3,4 Unfortunately, many of these atypical manifestations often go unrecognized, and may take the form of ear-nose-throat, pulmonary, or laryngeal manifestations such as laryngitis, sinusitis, asthma, bronchitis, chronic cough, chest pain, and halitosis.4 A study by Harding and col-leagues5 showed that among those patients studied with a diagnosis of asthma and who denied reflux symptoms, 29 had abnormal esophageal pH studies. Irwin and Richter,6 when evaluating...

Optimize the Immediate Preoperative Condition

Check that the patient has had maximum preoperative medical treatment. It is surprising how often this is overlooked. Reducing the amount of inflammation at the time of surgery will make the operative field easier work in and will enable the surgeon do a safer and better job. The patient with infective rhinosinusitis should have had at least a minimum of 2 weeks of a broad-spectrum antibiotic with anaerobic cover for example, coamoxiclav or cefuroxime and metronida-zole (Fig. 8.4). For allergic rhinitis, the current ARIA guidelines summarize the best medical treatment (see Chapter 3, Table 3.1). It is particularly important to

Eosinophils And The Upper Respiratory Tract

In fungal disease of the upper respiratory tract the presence of eosinophils is a critical diagnostic feature. Diseases of fungal etiology in the upper respiratory tract primarily involve fungal sinusitis, and both superficial allergic diseases and invasive fungal sinusitis are associated with eosinophilia (Currens et al. 2002 Ferguson 2004 Granville et al. 2004. As reported by the Ponikau et al. (Ponikau et al. 1999 and subsequently by other investigators, allergic fungal sinusitis (AFS) is manifest as nasal polyposis and a strong eosinophilic response. AFS is considered to be among the most prevelant forms of chronic rhinosinusitis (Braun et al. 2003a, 2003B Granville et al. 2004 Ponikau et al. 1999). The condition results from a superficial infection of the sino-nasal mucosal tissue by a variety of different fungal organisms, dematiaceous fungi being the most common (Clark et al. 1996 Katzenstien et al. 1983a, 1983b Gourley et al. 1990 MacMillan et al. 1987 Torres et al. 1996)....

Eosinophils Outside The Lung

Fungal infection of the central nervous system (CNS) has been reported to cause eosinophilic meningitis and blood eosinophilia. Patients infected with Coccid-iodes immitis that has disseminated to the CNS may demonstrate an eosinophilic pleocytosis, or eosinophilic meningitis (Ismail and Arsura 1993 Ragland et al. 1993). In cryptococcal invasion of the CNS, blood and CSF eosinophilia have been reported, and histological examination of cerebral granuloma revealed the presence of eosinophils (Anderson et al. 1985 Kamezawa et al. 2000 Gross et al. 2003). Other reports of CSF eosinophilia include a case of chronic eosinophilic meningitis associated with positive culture for Candida guillermondii, and cases of eosinophilic meningitis associated with Aspergillus sinusitis or disseminated histoplasmosis (Chan et al. 2004 Livramento et al. 1993 Paz-Sendin et al. 1999). The purpose of eosinophils in the CNS is not well understood, nor has it been extensively examined, but is felt to be...

Gram Positive Anaerobic Cocci

Gram-positive, strictly anaerobic cocci are included in the genera Peptococcus and Peptostreptococcus. The only species in the first genus is Peptococcus niger, whereas the latter comprises a number of species. The anaerobic cocci are commonly observed in normal human flora. In a pathogenic context they are usually only encountered as components of mixed florae together with other anaerobes or facultative anaerobes. These bacteria invade tissues through dermal or mucosal injuries and cause subacute purulent infections. Such infections are either localized in the head area (cerebral abscess, otitis media, mastoiditis, sinusitis) or lower respiratory tract (necrotizing pneumonia, pulmonary abscess, empyema). They are also known to occur in the abdomen (appendicitis, peritonitis, hepatic abscess) and female genitals (salpin-gitis, endometriosis, tubo-ovarian abscess). Gram-positive anaerobic cocci may also contribute to soft-tissue infections and postoperative wound infections. See p....

Exercise 20 Staphylococci

Common skin infections caused by S. aureus include pimples, furuncles (boils), carbuncles, and impetigo. Serious systemic (deep tissue) infections that result from S. aureus invasion include pneumonia, pyelonephritis, osteomyelitis, meningitis, and endocarditis. In addition to pneumonia, S. aureus may also produce infections of the sinuses (sinusitis) and middle ear (otitis media).

Treatment Guidelines

Namdar et al. (1998) suggested the following guidelines for treatment in case of associated nasal obstruction or rhinosinusitis, medical therapy with antibiotics, decongestants, and steroids may be appropriate. Whenever medical therapy fails because of tumor location, the lesion is adjacent to frontal sinus os-tium or more than 50 of the frontal sinus is occupied, or a noticeable increase in size has been documented by serial CT scans, surgery is recommended. Finally, chronic headache may be an indication for surgery when other causes are excluded.

Clinical and Endoscopic Findings

Even though painless facial and skull deformities are the most frequently observed signs, symptoms such as nasal obstruction, headache, epistaxis, anosmia, loosening of teeth, facial paralysis, hearing loss, trigeminal neuralgia-like pain, and recurrent rhinosinusitis due to drainage impairment may develop (Bollen et al. 1990 Camilleri 1991 Ferguson 1994 Slootweg et al. 1994 Wenig et al. 1995 Redaelli De Zinis et al. 1996 Chong and Tang 1997 Commins et al. 1998 Muraoka et al. 2001 Cheng et al. 2002). Diplopia, proptosis, loss of visual acuity due to optic nerve compression, epiphora, limitation of ocular motility are other important symptoms and signs indicating an involvement of the orbit and or of the lacrymal pathways (Moore et al. 1985 Osguthorpe and Gudeman 1987 Johnson et al. 1991 Slootweg et al. 1994 Wenig et al. 1995 Redaelli De Zinis et al. 1996). Since both diseases display a submucosal pattern of growth, nasal endoscopy is often negative or shows a lesion covered by intact...

Contraindications

A decongestant is a drug that reduces swelling of the nasal passages, which, in turn, opens clogged nasal passages and enhances drainage of the sinuses. These drugs are used for the temporary relief of nasal congestion caused by the common cold, hay fever, sinusitis, and other respiratory allergies.

Dextrocardia With Situs Inversus

Recently, the term dextrocardia has been used to indicate any congenital right-sided heart regardless of the position of abdominal viscera. To specify the kind of dextrocardia under test, one must affix the status of the abdominal viscera. Dextrocardia with situs inversus means the mirror image of normal. In this situation, the incidence of congenital heart disease is only 5 percent, which is a ninefold increase over the general population. The combination of dextrocardia, sinusitis, and bronchiectasis is known as Kartagener's triad.

Nonspecific Replacement Immune Therapies

The effectiveness of granulocyte transfusions against invasive fungal infections may be lower than that against bacterial infections (10). At this time, there are not sufficient data to recommend routine granulocyte transfusions for neutropenic patients with invasive fungal infections (10). Nevertheless, several reports suggest that granulocyte transfusions can be useful for the therapy of some types of fungal infection in patients with prolonged neutropenia (15-18). Fusarium infections in neutropenic patients respond poorly to antifungal therapy, and resolution usually requires recovery of bone marrow function (16). Some patients with Fusarium infection and neutropenia have responded favorably to CSF-elicited granulocyte transfusions, and it has been suggested that this modality can buy time until recovery from myelosuppression (16). There is one report of a successful therapy of disseminated Fusarium infection using a combination of amphotericin B, granulocyte macrophage (GM)-CSF,...

Clinical Features

When the CD44 T-cell count falls below about 400 per (xl the patient may develop a constellation of constitutional symptoms (fever, night sweats, oral candidiasis, diarrhea, and weight loss) which used to be known as AIDS-related complex (ARC). Early opportunistic infections begin to be seen. At this intermediate stage of immune depletion these infections are generally not life-threatening. They particularly include infections of the skin and mucous membranes such as tinea, seborrheic dermatitis, bacterial folliculitis, warts, molluscum contagiosum, gingivitis, oral and esophageal candidiasis, oral hairy leukoplakia (Fig. 35-10D), and chronic sinusitis. Reactivation of latent herpesviruses, particularly herpes simplex and zoster, also occurs (see Chapter 20). Gastrointestinal infections, caused by any of a wide vanety of organisms, including the yeast Candida albicans and parasites such as Cryptosporidia, are common. Mycobacterial infections are also common in these patients, and this...

Intravenous Immune Globulin

Although not a classic fungal infection, brief mention will be made of the use of fungal antigens to treat allergic fungal sinusitis. Allergic fungal sinusitis has histologic features resembling those of allergic bronchopulmonary aspergillosis and is characterized by association with asthma, nasal polyps, and allergic mucin, a viscous secretion that contains degenerating eosinophils and Charcot-Leyden crystals (67,68). Aspergillus species are frequently cultured from mucin, but a variety of other fungal species have been cultured from patients with allergic fungal sinusitis including Bipolaris, Curve-laria, Alternaria, and Cladosporium (69). The standard therapy for allergic fungal sinusitis is surgical drainage and corticosteroid administration, but relapses are common (67). Because of the immunologic nature of this disease, immunotherapy has been suggested to be potentially beneficial (69). Immunotherapy for allergic fungal sinusitis involves the injection of fungal antigens to...

Arrival Of Pml Cases And An Electron Microscope

Multifocal Microscopy

In the fall of 1962, a particularly stimulating consultation case was presented to me by the pathologist of a downtown Madison hospital. The patient, a 33-year-old woman with lupus erythematosus, had died after several weeks of progressive cerebellar disease. The slides showed a multifocal demyelinating disease with a most striking combination of giant tumor-like astrocytes and large numbers of oligodendrocytes with greatly enlarged nuclei deeply stained with hematoxylin. There were no distinct inclusion bodies as one sees with herpes viruses. I was fascinated and knew I had never seen this disease before. I showed the slides to a visiting neuropathologist and he, too, was at a loss. At that time I was in the midst of a very time-consuming experiment with a group of sophomore students. It involved the induction of brain tumors in chicken with Rous sarcoma virus. There was no time for a library search. However, I did show the slides to Dr. Chou, and to my utter surprise, and delight,...

Anterior Craniofacial Resection

Anterior Craniofacial Resection

Draf W, Weber R, Keerl R et al (2000) Endonasal and external micro-endoscopic surgery of the frontal sinus. In Stamm A, Draf W (eds) Microendoscopic surgery of the paranasal sinuses and the skull base. Springer-Verlag, Berlin Heidelberg New York, pp 257-278 Draf W, Weber R (1993) Endonasal pansinus operation in chronic sinusitis. I Indication and operation technique. Am J Otolaryngol 14 394-398 Funk GF, Arcuri MR, Frodel JL (1998) Functional dental rehabilitation of massive palatomaxillary defects cases requiring free tissue transfer and osseointegrated implants. Head Neck 20 38-51 turbinate the role of the superior turbinate in endoscopic sinus surgery. Am J Rhinol 13 251-259 Raveh J, Leadrach K, Speiter M et al (1993). The subcranial approach for fronto-orbital and anteroposterior skull-base tumors. Arch Otolaryngol Head Neck Surg 119 385-393 Roger G, Tran Ba Huy P, Froehlich P et al (2002) Exclusively endoscopic removal of juvenile nasopharyngeal angiofibroma trends and limits....

Osteoplastic Flap Sinusotomy

Osteoplastic Flap Procedure

A coronal approach is routinely indicated for osteomyelitis of the frontal bone, which usually complicates an acute frontal rhinosinusitis. The entity of bony resection must be tailored to the extent of the osteomyelitic process. If the anterior wall is involved, obliteration of the sinus with fat is obtained and reconstruction of the bony wall is secondarily performed, when there will be clear clinical and radiological signs that the inflammatory process has been controlled. When osteomyelitis affects the posterior wall of the frontal sinus, this needs to be resected cranialization of the sinus is performed after sealing both frontal infundibula with cartilage or muscle to prevent any contamination from the nasal cavities.

Antrochoanal Polyp Ct

Posterior Ethmoids

Two additional signs are described as common features of sinonasal polyposis. (1) Widening of ethmoid infundibulum can be observed in several different conditions, including antrochoanal polyp and inverted papilloma. The specificity of this finding, however, is increased by bilateral presentation. (2) Truncation of middle turbinate (bilateral in up to 80 of cases) is easily recognized on CT scans as an amputation of the more distal, bulbous part, the vertical lamella usually being spared. In a series of 100 patients (LiANG et al. 1996) affected by chronic rhinosinusitis, this sign was observed exclusively in the subgroup with sinonasal polyposis, in 58 of cases.

Contraindications To Surgery

Macroadenoma Pituitary Mri

Sinus infection may also contraindicate the transsphenoidal approach, although this is generally responsive to appropriate antibiotic therapy. Very rarely MRI may reveal ectatic and tortuous carotid arteries that protrude from the region of the cavernous sinus and obstruct transsphenoidal access.

Case 69 Left Lower Lobe Collapse

Bronchiectasis Right Lower Lobe

This patient has obvious dextrocardia (the heart is on the right side) and situs inversus (the stomach bubble is also on the right side instead of the left). There is also right lower lobe bronchiectasis (Fig. 70.2) as evidenced by bronchial wall thickening, bronchial opacification (bronchocele), and loss of volume. Dextrocardia and situs inversus may be associated with ciliary dysfunction causing sinusitis and bronchiectasis. This is called Kartagener's Syndrome.

Complications of the Transsphenoidal Approach

Mri Scan Aneurysm

Diastasis or fracture of the hard palate or the cribriform plate, the latter being another source of CSF rhinorrhea. In the postoperative period, the mucosa of the sphenoid sinus may become infected, giving rise to a febrile sinusitis and the eventual development of a mucocele. Inadequate hemostasis in the nasal portion of the procedure may lead to superficial would hemorrhage and swelling. Careless handling of the nasal mucosa, the nasal septum, and the nasal spine may result in an external nasal deformity, which may be distressing, both cosmeti-cally and functionally. Loss of smell can also occur, presumably because of damage to nerve endings in the nasal mucosa. Finally, overaggressive enlargement of the basal pyriform aperture can damage distal branches of the alveolar nerves and or vessels, which may devitalize or desensitize the teeth and gums of the maxilla.

Can You Get Pain At The Glabella With Sinusitus

Inferior Turbinate Meatus

Many patients with chronic rhinosinusitis present nasal obstruction as the primary complaint. Other symptoms include nasal discharge, postnasal drip, facial pain, dysosmia, chronic cough, and headache. Headache is usually dull and radiating to the top of the calvarium or bitemporal for sphenoid or posterior ethmoid disease. Pain at the glabella, inner can-thus, or between the eyes suggests anterior ethmoid or frontal rhinosinusitis. Pain over the cheeks most frequently suggests maxillary rhinosinusitis. Patients with sinonasal polyposis complain of symptoms similar to those reported by patients with chronic rhinosinusitis, as the two diseases frequently coexist. Conversely, when an isolated polyp arises in a nasal fossa, unilateral signs and symptoms are generally reported. Among sinonasal inflammatory diseases, sinonasal polyposis is the one most frequently associated with bronchial hyperresponsiveness, with a percentage of up to 50 (HoLmstRom et al. 2002). This association is more...

Definition Epidemiology Pathophysiology and Etiology

Rhinosinusitis is defined as an inflammation of the mucosa of the nose and paranasal sinuses. It is classified as acute, subacute, and chronic according to whether the duration of symptoms persists as long as 4 weeks, between 4 and 12 weeks, and more than 12 weeks, respectively (Brook et al. 2000). More than 2 billion is spent annually in the United States for over-the-counter medications for rhinosinusitis (National Center for Health Statistics 1994). Even though data regarding the incidence of rhi-nosinusitis in the world population are scarce in the literature, every year approximately 16 of adults in the United States receive a diagnosis of rhinosinusitis (National Center for Health Statistics 1994). If the forms of rhinosinusitis exclusively arising in a single paranasal sinus, such as the maxillary sinus, in relation to tooth disease, facial trauma, or paranasal sinus neoplasms are excluded, the first step in the pathophysiology of most rhinosinusitis is almost invariably an...

Selective IgA Deficiency

IgA deficiency is the most common of all immunodeficiencies. Depending on the country, the incidence is between 1 400 and 1 3000. There is an increased incidence oflgA deficiency in subjects with defects in chromosome 18, connatal rubellasyndrome, andataxia telangiectasia(Mietens, 1983). Associatedwith the deficiency are recurrent bacterial infections, bronchitis, sinusitis, pneumonia, allergies, and autoimmune diseases (Schaffer etal., 1991). B-cell differentiation arrest preventing isotypic switching from IgG to IgA is the central defect in the immunodeficiency.

Sarcoid And Maxillary Sinus

Sarcoid The Sinuses

A very limited number of studies in the literature focus on imaging findings of sinonasal sarcoidosis - reflecting the low incidence of this condition. CT and MR findings may consist, in moderate stages, of isolated mucosal thickenings, intrasinusal air-fluid levels, and hypertrophy of turbinates, impossible to differentiate from a mere chronic sinusitis (KrESPi et al. 1995). In advanced stages, submucosal granulomas and bone erosions may be observed, shifting the differential diagnosis towards Wegener granu-lomatosis and cocaine induced midline destructive lesions. MR signal pattern of sarcoid granulomas resembles that of Wegener granulomatosis lesions (T2 T1 hypointensity, variable enhancement) (Fig. 6.32). Bone destruction may be rather extensive, both the hard and soft palate may be affected. thrombosis secondary to sinusitis. J Otolaryngol 31 165-169 Bachert C, H rmann K, M sges R et al (2003) An update on the diagnosis and treatment of sinusitis and nasal polyposis. Allergy 58...

Anatomical Variations

Pneumatized Agger Nasi Cell

The prevalence of anatomical variations is well documented, and it appears that they are not consistently different between asymptomatic groups and those with proven rhinosinusitis. This is contrary to early reports that labeled them as anatomical abnormalities, for they now appear to be normal variations. This implies that anatomical variations play a minor role, if any at all, in initiating rhinosinusitis or causing it to persist. Perhaps the primary concern of anatomical variations is their tendency to lead the surgeon astray during an operation. For example, a septal deviation is often found with a compensatory concha bullosa on the contralateral side. These findings are as common in an asymptomatic population as in a population with rhinosinusitis (Havas et al., 1988 Lloyd, 1990 Lloyd et al., 1991 Bolger et al., 1991 Jones et al., 1997 a).

Mast Cells And Basophils

Mast Cells Fungi

Mast cells and basophils are responsible for the initiation of IgE-mediated hypersensitivity responses. Many fungal organisms produce allergens that result in allergic fungal diseases including rhinitis, fungal sinusitis, asthma, and allergic bronchopulmonary mycosis (ABPM). These diseases are associated with elevated serum and fungal specific IgE, and by implication, type-1 hypersensitivity (Horner et al. 1995 Bush et al. 2004 Khun and Swain 2003 Kurup 2000). Although it is presumed that IgE-mediated mast cell and basophil reactions are central to fungal allergy, the strict requirement for IgE-mediated reactions is still debated. There is even more limited information on the contribution of mast cells or basophils to host defense against fungal pathogens, though there is the potential to regulate immune responses. Overall, in the host response to fungi, mast cells and basophils make versatile contributions to allergy, inflammation and host defense (Figure 1).

Eosinophil Mediators And Granule Proteins

Important intracellular constituents of the eosinophil include the membrane-disrupting major basic protein (MBP). MBP is a marker for eosinophilic degranulation, and is toxic to both microorganisms and mammalian cells. Degranulation is evidenced by extracellular deposition in biopsy specimens from patients infected with Paracoccidoides brasiliensis (Wagner et al. 1998). In patients with allergic fungal sinusitis, chronic rhinosinusitis and ABPM, it may contribute to the pathogenesis of fungal disease (Khan et al. 2000 Manning and Holman, 1998 Ponikau et al. 2005 Slavin et al. 1988). Eosinophil cationic protein, a toxin secreted by activated eosinophils, is significantly increased in the mucin of patients with allergic fungal sinusitis and at even higher levels in patients with nasal polyposis of fungal etiology, making it a potentially important contributor to these clinical conditions (Feger et al. 1997 Di Lorenzo et al. 2001). Additionally, treatment of ABPM with itraconazole...

Frequently Ill Children

FIC vary (1) upper airways (nasopharyngitis, acute otitis, sinusitis, and tonsillitis), (2) false croup and laryngotracheobronchitis, and (3) inferior airway infections (bronchiolitis and pneumonia). Consecutive infections may be caused by (i) bacteri-ums, (ii) viruses, or (iii) pathogenic organisms Chlamydia pneumonia and Mycoplasma pneumonia.

Viral Damage to Tissues and Organs

Diarrhea Rotavirus

As well as having direct adverse effects, viral infections olten predispose epithelia to secondary bacterial infections, increasing the susceptibility of the respiratory tract, for example, to bacteria that are normal commensals in the nose and throat (see Fig. 9-1). Thus, infections with influenza virus may destroy ciliated epithelia and cause exudation, allowing pneumococci and other bacteria to invade the lungs and cause secondary bacterial pneumonia, which is often the cause of death in elderly people suffering from influenza. Conversely, proteases secreted by bacteria may activate influenza virus infec-tivity by proteolytic cleavage of the hemagglutinin. Rhinoviruses and respiratory syncytial virus damage the mucosa of the nasopharynx and sinuses, predisposing to bacterial superinfection which commonly leads to purulent rhinitis, pharyngitis, sinusitis, and sometimes otitis media. Similarly, in the intestinal tract, rotavirus infections may lead to an increase in susceptibility...

Confirm the Diagnosis

Turbinate Hypertrophy

Patients with genuine chronic bacterial rhinosinusitis who do not respond to medical treatment are often helped by surgery, unless they are immuno-suppressed, when caution is needed (Fig. 8.1). It is important to make sure as far as possible that your patient has a diagnosis that is likely to respond, at least in part, to surgical intervention. Operating on a patient who has only allergic rhinitis is very unlikely to help them (Fig. 8.2). If their CT is normal or shows turbinate hypertrophy without evidence of sinus disease, retake

Wegener Granulomatosis 6511

Sinus Lesions

Acute fulminant fungal rhinosinusitis. TSE T2 axial plane (a), Gd-DTPA SE T1 axial plane (b), VIBE coronal plane (c). Inhomogenous inflammatory material centered at the level of vertical process of maxillary bone and along medial wall of maxillary sinus. Note the absence of contrast uptake, related to ischemic necrosis (invasion and obliteration of vessels). Extensive bone destruction is detected, involving nasal septum (1), infiltration of premaxillary subcutaneous fat tissue (2), middle turbinate (3), hard palate and alveolar process of maxillary bone (4). The lesion contacts the ethmoid roof (5) with no signs on intracranial extension Fig. 6.22a-c. Chronic invasive fungal rhinosinusitis. Coronal Gd-DTPA SE T1 (a), coronal Gd-DTPA VIBE (b), reformatted sagittal Gd-DTPA VIBE (c). A hypointense fungus ball is retained within the sphenoid sinus. At the level of the sinus roof both the hyperintense mucosa and the hypointense cortical bone are focally interrupted (arrows)....

Interdisciplinary Cooperation

The surgeon and the radiologist can get the most out of imaging techniques by working together. Each needs to learn from the other. Radiologists need to understand the pathology of rhinosinusitis, otherwise they are in danger of writing misleading statements like mucosal thickening showing rhinosinusitis when a better interpretation would be mucosal thickening consistent with rhinosinusitis. On the other hand, the surgeon needs to know the CT parameters for window settings and how these affect the images. It is important that the surgeon knows how to interpret CT films and does not rely on a written report, because words cannot adequately describe patterns of changes or the complexity of anatomy.

Physiologic Factors Affecting Resistance

Children with protein deficiency of the kind found in many parts of Africa are highly susceptible to measles. All the epithelial manifestations of the disease are more severe, and secondary bacterial infections cause life-threatening disease of the lower respiratory tract as well as otitis media, conjunctivitis, and sinusitis. The skin rash may be associated with numerous hemorrhages, and there may be extensive intestinal involvement with severe diarrhea, which exacerbates the nutritional deficicncy. The case-fatality rate is commonly 10 and may approach 50 during severe (amines.

Chlamydia pneumoniae

This new chlamydial species (formerly TWAR chlamydiae) causes infections of the respiratory organs in humans that usually run a mild course influenzalike infections, sinusitis, pharyngitis, bronchitis, pneumonias (atypical). Clinically silent infections are frequent. C. pneumoniae is pathogenic in humans only. The pathogen is transmitted by aerosol droplets. These infections are

Douching

They know how to douche, both to see that they are doing it properly and to help them through the first time they do it (Fig. 13.2a, b). This will greatly help compliance. Most patients are advised to douche at least twice daily for 2 weeks and particularly before taking any topical medication (see instruction sheet for the patient on page 285-286). Often patients are advised to douche four times a day in the first week if the mucosa is very unhealthy. In patients with severe polyposis, or those who have had a long history of infective rhinosinusitis, it may take weeks or months for the cilia to recover and protracted douching over this period may be required (Fig. 13.3). In patients who have ciliary dysmotility or cystic fibro-sis, douching is needed in the long term. Some studies have shown that adding antibiotics such as to-

NKT Cells

Chlamydiae are obligate intracellular bacteria with a unique developmental cycle. Two chlamydial species, C. pneumoniae and C. trachomatis, commonly cause human diseases. C. pneumoniae is the causing agent of a wide spectrum of acute and chronic respiratory diseases such as bronchitis, sinusitis, and pneumonia, where as C. trachomatis causes ocular, respiratory, and sexually transmitted diseases. Chlamydial infections are very prevalent worldwide. In particular, up to 70 of healthy human individuals are positive for serum antibodies specific for C. pneumoniae. More recently, C. pneumoniae has been implicated in the pathogenesis of atherosclerosis, Alzheimer's disease, and multiple sclerosis. No vaccine is available for human chla-mydial infections. A clear understanding of the adaptive and innate immune responses to chlamydial infection is critical in the rational development of an effective vaccine to this infection. The differences in T cell cytokine patterns have been correlated...

T3 14 15 16 17 18

It seems likely that immune responses contribute to the respiratory damage, malaise, and fever, which appear at this stage and get steadily worse until the rash appears. Mucosal foci ulcerate on about the eleventh day, to produce the characteristic Koplik's spots in the mouth. By the fourteenth day, just as circulating antibodies become detectable, the characteristic maculopapular rash appears and the fever falls. This skin rash is due in large part to cell-mediated immune responses to viral antigens (type IV hypersensitivity see Chapter 9). Measles decreases the resistance of the respiratory epithelium to secondary bacterial infection, hence pneumonia, sinusitis, or otitis media may supervene. In immunocompromised patients, especially those with impaired cell-mediated immunity, giant cell pneumonia may occur, sometimes several months after the acute infection and often with fatal consequences. Measles also provides the classic example of increased severity of a...

Thiazolidinediones

Adverse reactions associated with the administration of the thiazolidinediones include aggravated diabetes mel-litus, upper respiratory infections, sinusitis, headache, pharyngitis, myalgia, diarrhea, and back pain. When used alone, rosiglitazone and pioglitazone rarely cause hypoglycemia. However, patients receiving these drugs in combination with insulin or other oral hypo-glycemics (eg, the sulfonylureas) are at greater risk for hypoglycemia. A reduction in the dosage of insulin or the sulfonylurea may be required to prevent episodes of hypoglycemia.

Management

Antibiotics are important in the treatment of acute infective sinusitis and should be given for at least seven days after the symptoms have disappeared and often for 14 days altogether. It is important for the antibiotics to be given for this length of time because they do not get into the infected sinus very well. Pain relief is important as acute sinusitis is very painful. To help the drainage of pus from the sinus, a local nasal decongestant can be used. This is one of the few situations where a topical decongestant spray is a good idea, but it should only be used for a limited time (up to seven days they can cause damage if used for longer). Steam inhalations can help to thin the thickened mucus.

Symptoms

Acute sinusitis causes pain over the affected sinus, usually the cheek, or on one side of the forehead, a blocked nose and or a discharge, feeling unwell, and a temperature. Facial pain alone without any nasal symptoms is rarely due to sinus disease and is often caused by other types of pain such as midfacial segment pain, tension-type headaches, migraine, dental pain, or trigeminal neuralgia. Sinusitis is chronic when the symptoms have persisted for longer than three months. The features are mainly of nasal congestion, and there is a mucky nasal discharge that is often painless in a patient who feels quite well.

Imaging Findings

Fungus Ball Maxillary Sinus

In eosinophilic fungal rhinosinusitis, the CT density and MR paramagnetic characteristics of fungal material, as well as progressive dehydration of eo- sinophilic mucin, produce signal patterns similar to fungus ball (Fig. 6.20). The differentiation is based on localization of the disease - isolated and unilateral in 94 of fungus balls, diffuse and scattered in 95 of eosinophilic fungal rhinosinusitis - and association with nasal polyposis, which is more common in eo-sinophilic fungal rhinosinusitis (Dhong et al. 2000). Bone changes in both fungus balls and eosino-philic fungal rhinosinusitis follow the same model exhibited by chronic rhinosinusitis and nasal pol-yposis. Mechanical pressure and osteoclastic activ Fig. 6.20a,b. Nasal polyposis, eosinophilic fungal rhinosinusitis. Ethmoid, nasal fossae, and maxillary sinuses are completely filled by polypoid material exhibiting scattered areas of spontaneous hyperdensity. Extensive bone remodeling and dehiscence at the level of the...

Ostiomeatal Unit

Concha Bullosa And Inflammation

Frontal bone osteomyelitis secondary to acute right frontal sinusitis due to frontal recess blockage (arrows) Fig. 6.5a,b. Complicated acute rhinosinusitis. Axial CT after contrast administration. (a) Fluid material occupies both maxillary sinuses (a level is observed on the right) and a left concha bullosa (asterisks). The more cranial scan (b) shows an air-fluid collection within the anterior cranial fossa, bordered by thick and enhancing dura (arrows) epidural abscess. The absence of macroscopic defects of posterior frontal sinus wall suggests intracranial spread of infection through small veins perforating the diploe of frontal bone Fig. 6.5a,b. Complicated acute rhinosinusitis. Axial CT after contrast administration. (a) Fluid material occupies both maxillary sinuses (a level is observed on the right) and a left concha bullosa (asterisks). The more cranial scan (b) shows an air-fluid collection within the anterior cranial fossa, bordered by thick and enhancing dura...

Placental Villi

Sacrococcygeal Teratoma Type

Situs inversus is a condition in which transposition of the viscera in the thorax and abdomen occurs. Despite this organ reversal, other structural abnormalities occur only slightly more frequently in these individuals. Approximately 20 of patients with complete situs inversus also have bronchiectasis and chronic sinusitis because of abnormal cilia (Kartagener syndrome). Interestingly, cilia are normally present on the ventral surface of the primitive node and may be involved in left-right patterning during gastrulation. Other conditions of abnormal sidedness are known as laterality sequences. Patients with these conditions do not have complete situs inversus but appear to be predominantly bilaterally left sided or right sided. The spleen reflects the differences those with left-sided bilaterality have polysplenia, and those with right-sided bilaterality have asplenia or hypoplastic spleen. Patients with laterality sequences also are likely to have other malformations, especially...

Nasal Septum Cocaine

Cocaine Lesions

85 and 68 of patients suffering from sinusitis and rhinitis, respectively. The most common complaints are epistaxis, crusting, and nasal obstruction. Nasal mucosa appears covered by crusts, with superficial hemorrhages. Especially in advanced stages and or in the presence of an aggressive form of the disease, it is possible to identify necrosis and resorption of the septal cartilage, turbinates, and lateral bony walls of the nasal cavities mucosa is even more friable and inclined to hemorrhage (Fig. 6.23). Patients with an extensive septal perforation may present a typical deformity of the nasal pyramid called saddle nose . When the granuloma-tous process directly involves the lacrimal pathway or the presence of abundant scar tissue obstructs the nasolacrimal duct, chronic dacryocystitis with epiphora may be observed.

Infections

Sagittal Pituitary Mri

Acute bacterial infection of the sella turcica is a rare event (153-161). Whereas in many instances the pathogenesis of pituitary infection is not apparent, those instances in which an etiology has been established suggest that pituitary abscess arises in two clinical settings. The first is the result of secondary extension from a preexisting anatomically contiguous purulent focus. Acute sphenoid sinusitis, osteomyelitis of the sphenoid bone, mastoiditis, cavernous sinus thrombophlebitis, peritonsillar abscess, purulent otitis media, and bacterial meningitis have all been implicated as the primary infectious source. The other principal pathogenetic mechanism relates to generalized sepsis and hematogenous dissemination from a variety of distant septic foci (pneumonia, osteomyelitis, endocarditis, retroperitoneal abscess, tooth abscess). Isolated pituitary abscesses are extremely rare. More commonly (although still extremely unusual) abscesses have been reported in association with...

What Is Htv Disease

Retained Uncinate Process

Sphenoethmoid recess pattern is rather rare, consisting of sphenoid sinusitis and (not infrequently) posterior ethmoiditis, secondary to sphenoethmoid recess obstruction. Obliteration of the recess and inflammatory mucosal thickenings within sphenoid and posterior ethmoid are better depicted with axial CT (Fig. 6.11).

Simmend Disease

Cousin JN, Har-El G, Li J (2000) Is there a correlation between radiographic and histologic findings in chronic sinusitis Journal of Otolaryngology 29(3) 170-173. Ferguson BJ (2000) Eosinophilic mucin rhinosinusitis a distinct clinicopathological entity. Laryngoscope 110 799-813. Gliklich RE, Metson R (1995) The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryn-gology - Head and Neck Surgery Laryngoscope 105 387-390. Goldwyn BG, Sakr W, Marks SC (1995) Histopathologic analysis of chronic sinusitis. American Journal of Rhinology 9 2730. Ikeda K, Tanno N, Tamura G, Suzuki HI, Oshima T, Shimomura A, Nakabayashi S, Takasaka T (1999) Endoscopic sinus surgery improves pulmonary function in patients with asthma associated with chronic sinusitis. Annals of Otology, Rhinology and Laryngology 108 355-359. Jones NS (1999 a) Current concepts in the management of pae-diatric rhinosinusitis. Journal of Laryngology and Otology 113 1-9. Jones NS (2004) Midfacial...

Conclusion

Holzapfel L, ChastangC, Demingeon G, Bohe J, PirallaB,CoupryA (1999) A randomized study assessing the systematic search for maxillary sinusitis in nasotracheally mechanically ventilated patients. Influence of nosocomial maxillary sinusitis on the occurrence of ventilator-associated pneumonia. Am J Respir Crit Care Med 159 695-701

Orbital Infections

Preseptal cellulitis represents a superficial cellulitis of the eyelid skin and subcutaneous tissue. This infection can arise from one of three sources paranasal sinus infections, direct extension from a localized infection of the eyelid or adjacent tissues (i.e., acute dacryocystitis or hordeola), and periorbital trauma (i.e., infected cuts or Localized lid infections and sinus infections should be promptly treated to prevent preseptal cellulitis from developing. Patients present with dull aching pain, eyelid swelling and erythema, decreased vision, proptosis, conjunctival swelling and injection, and ocular motility disturbances. In addition, the patients frequently have constitutional symptoms of fever and malaise. Paranasal sinus infections constitute the most common source of orbital cellulitis, with ethmoid sinusitis being the principal source. Other important sources include dacryocystitis, dental abscess, and trauma, as well as risk factors such as systemic debilitation....

Cranial Meningocele

Retentioncyst Sinus

However, the presence of a high signal on T2 images within paranasal sinuses or mastoid cells or adjacent to the skull base may be due to thickened mucosa, mastoiditis or rhinosinusitis, and not necessarily to CSF accumulation. Therefore, a CSF fistula may be suspected whenever the high signal of the fistulous tract appears to be in direct continuity with the intracranial subarachnoid space. This point is relevant, as high signal intensities on T2 sequences are shown in up to 25 of patients examined by MR for non-sinonasal diseases (Moser et al. 1991).

Indications for MRI

Cribriform Plate

The prevalence of incidental changes on MRI is so great that the technique is of little use in the diagnosis of rhinosinusitis (Cooke and Hadley, 1991). A comparison between a T2-weighted image (fluid bright), a T1-weighted image (fluid dark), and aT1-weighted image with nonionic contrast provides useful information about soft-tissue lesions (Fig. 7.8a-c). This is particularly helpful in defining the boundary of pathology in relation to the dura, orbital apex, or optic nerve.

Infratemporal Fossa

Infratemporal Fossa

Cortical destruction is detected at CT as a break of the mineralized bone through its whole thickness, whereas on MR a defect of the continuous hypoin-tense thickness of the cortex, replaced by solid tissue, implies invasion also of the periosteum (Maroldi et al. 1996). It can be observed in aggressive inflammatory lesions (both non-invasive and invasive fungal rhinosinusitis), some benign, but aggressive, neo

Acute Otitis Media

Because otitis media is a complication of URI, it has a peak incidence in the winter when colds are most likely to occur. Unlike sinusitis, which is more likely to affect adults, otitis media is predominantly a disease of younger children, with a peak incidence between 6 and 36 mo of age (51). Otitis media occurs with varying frequency in children. In a large population study, it was found that during the first 3 yr of life about a third of children never had otitis media, another third had one or two episodes, and the remaining third had three or more episodes. Suppurative otitis media is most often caused by the same organisms that result in sinusitis. Studies of middle ear aspirates suggest that Streptococcus pneumoniae is the most common bacterial cause of otitis media and is found in about 40 of effusions. H. influenzae accounts for approx another 20 . B. catarrhalis and Staphylococcus aureus each make up fewer than 10 of cases. In neonates, Gram-negative species also should be...

Types Of Infections

Aspergillus species can cause superficial infections, involving skin or the upper respiratory tract. For example, Aspergillus sinusitis is a serious problem in bone marrow stem cell recipients, patients with hematologic malignancies, and individuals with HIV infection. Invasive disease can occur in immunocompromised patients and is a harbinger of poor prognosis correction of the underlying disease process is critical to survival. Involvement of the lung, CNS, GI tract, and multiple other organs can occur. Histopathologic evaluation will reveal fungal invasion of blood vessels with thrombosis and infarction of involved tissues. These mold infections occur almost exclusively in severely immunocompromised patients. Risk factors include cytotoxic chemotherapy, prolonged antibiotic therapy, organ transplantation, and HIV infection. Infection can present as noninvasive infection, especially of the skin, or as deep infection with pneumonia, sinusitis, or dissemination. Fusarium species may...

Complications

The complications of sinusitis are rare because of the use of antibiotics. As the sinuses surround the eye on three sides, inflammation and infection can spread to the eye socket. Swelling around the eye, the eye protruding, decreased vision, or a reduced range of eye movements with pain all require urgent consultation to prevent any permanent eye damage.

Allergy Tests

Skin Prick Test Chart

Fig. 8.5 If a patient has nonresponsive or temporarily infective rhinosinusitis and bronchiectasis, perform a saccharin test while their mucosa is as healthy as you can get it. Fig. 8.5 If a patient has nonresponsive or temporarily infective rhinosinusitis and bronchiectasis, perform a saccharin test while their mucosa is as healthy as you can get it. As the upper and lower respiratory tract are in continuity, it is worth having a peak flow meter (and in children a height-peak flow chart) to check for possible asthma. It is pertinent to remember that 16 of those with rhinosinusitis have asthma and that 80 of asthmatics have rhinosinusitis. Cytology of the nasal mucosa has not been standardized, and what is termed eosinophilia varies from study to study. It is said that those with eosinophils will respond better to topical nasal steroids, but it is simpler to do a trial of medical treatment than do nasal cytology, particularly as this is the clinical strategy that will be used whatever...

Immunotherapy

The use of immunotherapy in grass pollen allergic rhinitis has been proven in the short- and long-term (Durham et al., 1999). However, if there is cross-reactivity to a range of inhaled allergens, then im-munotherapy directed at one allergen is less effective. Similarly, the evidence to support allergen avoidance is mixed. The results of house dust mite desensitiza-tion have been equivocal. Fungal immunotherapy following surgery for allergic fungal sinusitis has helped prevent recurrence and it has been postulated that this may help patients with eosinophilic mucin rhi-nosinusitis (Ferguson, 2000). The benefits of allergen avoidance are contentious. When there is a marked single allergen, for example, to house dust mite, then going to great lengths to avoid this allergen has been shown to help. However, it is debatable how well these studies can be extrapolated into day-to-day practice, and whether patients are ready to comply with these measures. It appears that half-measures to...

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