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Rhinosinusitis and Its Care Perspective: Review

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 International Journal of of Ayurveda
(A Monthly Scientific Journal of Kiban Research Publications)
www.kibanresearchpublications.com

Review Article

Rhinosinusitis and Its Care Perspective: Review

Pundareekaksha Rao*

Dept. of Shalakya Tantra, Ayurveda College, Coimbatore, India.

*Corresponding Author: Email: dr.pundareeayush@gmail.com

Abstract

Rhinosinusitis is one of the important global health problem defined as inflammation of mucous
membrane of the nose and paranasal sinuses. The term rhinosinusitis is used interchangeably with
sinusitis. Pansinuitis is referred if all sinuses can be infected simultaneously. Rhinosinusitis is seen in
throughout the world having different environmental and socio-economic background but more prevalent
in developing countries. Predisposing factors of rhinosinusitis include upper respiratory infections,
anatomical variations, local irritation, nasal dryness, and immunodeficiency. Purulent rhinorrhea, nasal
blockage, nasal congestion, facial pressure, headache, sneezing, malaise, and fever also may present in
disease process. It is capable of causing irreversible sequel and fatal complications when medical and
surgical interventions are delayed. Inflammation may extend to adjacent areas and cause Adenoiditis,
Laryngitis, Otitis media, Dacryocystitis, Odontogenic sinusitis, Meningitis and Cavernous sinus
thrombosis etc. Symptoms of rhinosinusitis can last well over two weeks with symptomatic treatment
and with minimal intervention. Viral rhinosinusitis usually resolves within seven days without any
intervention.

Keywords: Rhinosinusitis, Sinuses, Pansinusitis, Complications.

Introduction

Rhinosinusitis is an inflammation of the Based on the etiology, rhinosinusitis could

nasal and paranasal sinus mucosa.
According to the According to the duration of
the symptoms, Rhinosinusitis is classified
into two forms, as acute or chronic [1-3].
Acute sinusitis is defined as inflammation
for less than eight weeks in children and 12
weeks in adults [4]. Chronic Rhinosinusitis
in adults is in most guidelines defined as an
inflammation of the nose and the paranasal
sinuses characterised by at least 8-12 weeks
of at least 2 symptoms, like nasal
blockage/obstruction/congestion, nasal
discharge (anterior/posterior nasal drip),
facial pain/pressure and/or reduction or loss
of smell and either endoscopic signs of
disease or relevant CT scan changes [5].
Recurrent rhinosinusitis is 4 or more
episodes of acute sinus infection in one year
with each episode lasting for about a week.
be viral, bacterial, fungal, parasitic, or
mixed. The direct cost of managing acute
and chronic sinusitis exceeds $11 billion per
year, with additional expense from lost
productivity, reduced job effectiveness, and
impaired quality of life [6].
Paranasal sinuses are air filled cavities
present in the skull bones which are
connected to the nose with small apertures
known as ostia. There are four paired
paranasal sinuses, the frontal, maxillary,
ethmoid and sphenoid sinuses.
Ethmoid and maxillary sinuses are present
at birth and fully developed by 3 years. The
development of sphenoidal sinus starts by 3
years and that of frontal sinus by 7 years;
these are fully developed only by adolescence
[7].

Pundareekaksha Rao | Dec. 2016| Vol.1| Issue 1|05-09 5

 Available online at: http://ija.kibanresearchpublications.com/index.php/IJA
The mucus membrane in the nasal cavity
and sinuses is continued and collect pollen,
dust, fungi, and other particulates and
drained along with mucus production.
The “ostiomeatal complex” obstruction could
be due to deviated nasal septum, nasal
polyps, nasopharyngeal angiofibromas etc.
Ostial obstruction generates a negative
pressure in the sinus, which leads to damage
of the lining cilia, and mucus production is
increased. Mucociliary clearance thus gets
compromised. A self-perpetuating cycle is
established, which needs to be interrupted
for optimal outcome [8].
Viruses are most common causes of acute
rhinosinusitis [9]. Within few days, bacterial
invasion and proliferation set in.
Streptococcus pneumonia, Hemophilus
influenzae, Moraxella catarrhalis, beta-
hemolytic Streptococcus pyogenes are usual
pathogens cultured. With chronicity,
polymicrobes supersede [10,11]. These
include staphylococci, alpha-hemolytic
streptococci, anaerobes such as
peptostreptococci, Bacteroides and
Fusobacterium species, pseudomonads, other
gram-negative enteric bacteria, and fungi.
Entry of aerosolized environmental fungi
into sinuses of children with allergic rhinitis
could initiate allergic fungal sinusitis (AFS)
[12].
Whatever the cause of the inciting irritation,
local cells release cytokines that act as
attractants for immune cells. Other
cytokines (especially histamine in an allergic
response) trigger dilation of local venules
and capillaries, providing ease of access for
leukocytes to enter tissue. This allows fluid
to leave the vascular compartment,
accounting for the observed signs of
swelling, redness, and heat. As tissue
swelling blocks osteal drainage, airflow
becomes inadequate, intrasinus pressure
increases [13] and blood flow to the tissues is
significantly reduced [14].
Discussion
Acute rhinosinusitis is more common than
chronic rhinosinusitis. Acute rhinosinusitis
(ARS) is characterized by nasal discharge,
nasal congestion, facial pain, anosmia or
hyposmia. It may be associated fever,
malaise, irritability, headache etc. Clinical
presentation of chronic rhinosinusitis
Pundareekaksha Rao | Dec. 2016| Vol.1| Issue 1|05-09
includes purulent nasal discharge, nasal
obstruction, facial pain, purulent discharge
or edema of the middle meatus, and
decreased smell perception. Triggering
factors of rhinosinusitis include air
pollutants, allergens, cold exposure,
chemical sensitizers, infections etc. ARS may
be classified further by presumed etiology,
based on symptoms and time course, into
acute bacterial rhinosinusitis (ABRS) or
viral rhinosinusitis (VRS) [6].
CRS is usually further categorized based on
the absence or presence of nasal polyps as
CRS without nasal polyps, CRSsNP; or CRS
with nasal polyps, CRSwNP. Although both
are characterized by mucopurulent drainage
and nasal obstruction, CRSsNP is frequently
associated with facial pain/pressure/fullness
whereas CRSwNP is frequently
characterized by hyposmia [5].
Allergic fungal sinusitis (AFS) is a third
subtype of CRS, comprises 5-10% of CRS.
Features of AFS are similar to CRS except
that pain is not common. This inflammation
may extend to adjacent areas and cause
Adenoiditis, Laryngitis, Otitis media,
Dacryocystitis, Odontogenic sinusitis,
Meningitis and Cavernous sinus thrombosis
etc.
Diagnosis
Duration of the clinical features is less than
5 days is generally considered viral
rhinosinusitis. No improvement or
worsening between 5 and 10 days may be
early bacterial disease, and greater than 10
days duration points to a bacterial etiology.
Most viruses peak between 3 and 5 days and
resolve by 7 in adults and 10 days in
children.
Viral rhinosinusitis resolves within seven
days without intervention and bacterial
rhinosinusitis is suggested by maxillary
tooth or facial pain and unilateral maxillary
sinus tenderness.[15\ Purulent nasal
discharge and worsening symptoms after
initial improvement are also reliable clues of
bacterial sinusitis, but are not confirmatory.
Elevated eosinophil counts are also
commonly seen in bacterial sinusitis as well
as AFS [16]. Allergic rhinosinusitis can be
determined from history of allergic
response.Anterior rhinoscopy of allergic
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 Available online at: http://ija.kibanresearchpublications.com/index.php/IJA
rhinitis reveals hypertrophied, red and
inflamed inferior turbinate, nasal polyp, or
pus at middle meatus.
Transillumination permits illumination of
deeper structures for confirmation. Charge-
coupled device camera aid used to capture
and record images for diagnosis of sinusitis.
This technique has been found to be a safe,
reliable, low cost, and simple [17].
CT and MRI are the best methods to detect
pathology in the sinuses. CT is useful for
detecting pathology like sinus collections,
mucosal changes, growths, and bone
changes. Fluid levels in the sinus can be
detected with the X-ray. Blood tests
performed to assess the severity of infection,
includes complete blood count, C-reactive
protein (CRP) and erythrocyte
sedimentation rate (ESR), blood cultures etc.
A positive nasal smear may be helpful in
indicating the aetiology of disease [18,19]
MRI preferred or orbital and intracranial
extensions or in AFS. Tests for allergy,
immunodeficiency, cystic fibrosis, and
immotile cilia syndrome assist to detect
associated conditions [20-22] In AFS, total
serum Ig E and skin or in vitro tests for
fungi and common allergens are usually
positive [23,24].
Management
Symptoms of rhinosinusitis can last well
over two weeks with symptomatic treatment
and with minimal intervention. 90% of acute
rhinosinusitis cases resolved completely
with medical treatment. Viral rhinosinusitis
usually resolves within seven days without
any intervention [15].
An acute attack of rhinosinusitis is usually
treated with instillation of topical
decongestants, saline nasal drops, Nasal
saline irrigations, and nasal steroids. Steam
inhalation and adequate water intake have
been found to be useful. The saline
irrigations assist to mechanically clear
secretions, minimize bacterial and allergen
burden, and improve mucociliary function
[25].
Antihistamines are beneficial in those with
associated nasal allergy. Antibiotics are
usually not warranted. Antibiotics give
improvement in children having severe
Pundareekaksha Rao | Dec. 2016| Vol.1| Issue 1|05-09
acute sinusitis, toxic features, suspected
complications, or persistence of symptoms
[26]. Antibiotics are specifically not
recommended in mild/moderate disease
during first week of infection due to risk of
adverse effects, antibiotic resistance, and
cost [27]. There is a substantial evidence of
bacterial colonization in CRS, antibiotics
still play a major role for occurrences of
acute exacerbation [1,28].
Oral corticosteroids are commonly given in
CRS for 2-4 weeks to blunt the inflammatory
response [29]. Decongestants and
antihistamines often provide beneficial
symptomatic relief. Saline nasal irrigation is
also useful as adjuvant therapy in CRS
[30,31]. In AFS, surgical cleansing, anti-
fungal medicines, steroids, and
immunotherapy are used [32] Anti-IgE
therapy has been found to provide clinical
benefit in patients with seasonal allergic
rhinitis [33,34]. Immunotherapy is valuable
for children with known allergens that
cannot be avoided and where conservative
therapy has not been advantageous.
Surgical Management
Surgical interventions are recommended
when rhinosinusitis is associated with
anatomic aberrations and maximal medical
therapy fails. Functional endoscopic sinus
surgery (FESS) is done via a flexible
endoscope and is beneficial for management
of chronic sinusitis. FESS can remove the
thick tenacious secretions, debris, and mucin
in allergic fungal sinusitis which are
otherwise difficult without open surgical
methods. Detergent, 1% solution in normal
saline of Johnson and Johnson baby
shampoo, topical antibiotics such as
gentamycin/tobramycin or antifungal drugs,
and tea or sinufresh could be used during
surgery to irrigate the sinus and improve
outcomes [35-38].
Other more invasive surgical techniques for
maxillary sinusitis include antral washout,
natural ostotomy, intranasal inferior meatal
antrostomy (INA, nasoantral window),
middle meatal antrostomy, Caldwell-Luc’s
operation (intraoral maxillary antrostomy),
and uncinectomy (with or without endoscope
and with or without maxillary antrostomy).
All of these operations have their own
indications, limitations, and problems.[39-
41].
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 Available online at: http://ija.kibanresearchpublications.com/index.php/IJA
In balloon sinuplasty, ostia are dilated with
the help of balloons. It could be tried before
FESS for those who fail to respond to
medical treatment and have minimal
anatomic findings on CT scan [42].
Adenoidectomy is usually the first surgical
intervention considered for children with
CRS. Intravenous antibiotics, antimicrobial
therapy, Nasal decongestants, Steroids and
nasal saline irrigation may be required in
complications.
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Conclusions
Rhinosinusitis can be diagnosed easily on
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