Introduction to Vijay K. Anand, MD, FACS

Review Curriculum Vitae (CV) and Biography of Vijay K. Anand, MD, FACS

Introduction to Sinusitis

Sinusitis is the most common chronic condition diagnosed in the United States affecting an estimated 14% of the population. The direct medical costs of sinusitis amount to billions of dollars annually. Indirectly, the costs of treating sinusitis are greatly magnified by the staggering amount of lost hours of productivity at work and school. Current methods of cost analysis indicate that sinusitis usurps nearly 1% or the entire Gross National Product.

Physicians routinely use the term rhinosinusitis ('rhino' = nose; sinus = air-filled cavity behind the upper facial bones) or simply 'sinusitis' to refer to an inflammation of the paranasal sinuses. Sinusitis may involve both the mucous membranes of the nasal cavity and the 4 sinus pairs - frontal, ethmoid, maxillary and sphenoid paranasal sinuses. The mucous secretions found in the nasal passages of a sinusitis sufferer are directly related to the ongoing pathologic changes in both the surrounding bone and tissue.

Signs and Symptoms

Each one of the four pairs of sinuses has an opening for mucous drainage. When this natural mucous drainage process is obstructed, chronic sinus inflammation will occur. We all know sinusitis best by any of the recognizable symptoms it produces, either singly or in complex combinations. The major and minor symptoms or factors of sinusitis include:

Major Factors

Thick colored post nasal drainage or
discharge becoming yellowish to yellow-green
Congested nasal passages
Sneezing
Reduction or loss of sense of smell
Facial pain
Facial pressure or fullness
Fever - only with additional symptoms
Pus in the nose upon physical exam

Minor Factors

Fever
Fatigue
Headache
Hoarseness (Pharyngitis)
Bad breath (halitosis)
Persistent Cough
Dental Pain
Irritability
Clicking in ears
Ear Pain
Stuffiness or blockage felt in ears

Sinusitis is classified into the clinical categories listed below:

Acute Sinusitis(duration less than 4 weeks)

Acute sinusitis is sudden in onset and lasts up to 4 weeks. The symptoms resolve completely and, once the disease has been treated, antibiotics are no longer needed. A strong history consistent with acute sinusitis includes two or more major factors or one major and two minor factors. However, the finding of nasal purulence is a strong indicator of an accurate diagnosis. A suggestive history for which acute sinusitis should be included in the differential diagnosis includes one major factor or two or more minor factors. In the absence of other nasal factors, fever or pain alone does not constitute a strong history.

Severe, prolonged, or worsening infections may be associated with a nonviral element. Factors suggesting acute bacterial sinusitis are the worsening of symptoms after 5 days, the persistence of symptoms for more than 10 days, or the presence of symptoms out of proportion to those typically associated with a viral (upper respiratory) infection.

Recurrent Acute Sinusitis(more than 4 episodes per year)

Recurrent acute sinusitis is defined by symptoms and physical findings consistent with acute sinusitis, with these symptoms and findings worsening after 5 days or persisting as long as 10 days. However, each episode lasts 7 to 10 days or more and may last up to 4 weeks. Furthermore, as many as 4 episodes occur in 1 year. Between episodes, symptoms are absent without current antibiotic therapy. The diagnostic criteria for recurrent acute sinusitis are otherwise identical to those for acute sinusitis.

Large Image-Guided views (click for larger picture):

Subacute Sinusitis(duration greater than 4 weeks and less than 12 weeks)

Subacute sinusitis represents a continuum of the natural progression of acute sinusitis that has not resolved. This condition is diagnosed after a 4-week duration of acute sinusitis, and it lasts up to 12 weeks. Subacute sinusitis is not known to represent a discrete histopathologic entity, but it may warrant therapy different from that for either acute sinusitis or chronic sinusitis. Patients with subacute sinusitis may or may not have been treated for the acute phase, and the symptoms are less severe than in acute sinusitis. Thus, unlike in acute sinusitis, fever would not be considered a major factor. The clinical factors required for the diagnosis of subacute adult sinusitis are the same for those for chronic sinusitis. Subacute sinusitis usually resolves completely after an effective medical regimen.

Chronic Sinusitis(duration greater than 12 weeks)

Chronic sinusitis is sinusitis lasting as long as 12 weeks. The diagnosis of chronic sinusitis is confirmed by the major and minor clinical factors complex described previously with or without findings on the physical examination. A strong history consistent with chronic sinusitis includes the presence of two or more major factors or one major and two minor factors. A history suggesting that chronic sinusitis should be considered in the differential diagnosis includes two or more minor factors or one major factor. Facial pain does not constitute a strong history in the absence of other nasal factors. Cultures may be of particular value in identifying resistant microbial flora.

Acute Exacerbation of Chronic Sinusitis

Acute exacerbation of chronic adult Sinusitis represents a sudden worsening of the baseline chronic Sinusitis with either worsening or new symptoms. Typically, the acute (not chronic) symptoms resolve completely between occurrences. Due to the underlying chronic nature of this condition, bacterial flora may represent resistant or atypical strains. Thus, image-guided culture may be particularly helpful in directing antimicrobial therapy.

Large Image-Guided views (click for larger picture):