Epidemiology
Sinusitis is an indicative inflammation of the paranasal sinuses and nasal mucosa caused by a bacteria or virus. The incidence of acute bacterial pathologies of upper respiratory tract organs is quite high: according to the Centers for Disease Control and Prevention (CDC), the disease is diagnosed in 12.5 percent of adults (30.8 million people) in the US (Rosenfeld et al., 2015). In addition, sinusitis occupies fifth place by the frequency of antibiotic therapy, taking 9 to 21 percent of antibiotic prescriptions, which is often unreasonable due to a lack of examination of bacterial flora. Speaking of the incidence of the identified disease, it should be emphasized that female adults aged 25-64 and children under 15 are the most affected populations. The social significance of the problem of sinusitis is associated with economic damage. The total costs of treating patients reach $ 11 billion per year, as reported by Rosenfeld et al. (2015).
Pathophysioogy
Most often, sinus infections are usually are caused by a virus, while the cases of bacterial origin are less common (“Sinus infection (sinusitis),” 2017). In viral infection of the upper respiratory tract, the edematous mucous membrane of the nasal cavity closes the paranasal sinus, disrupting its drainage. When this occurs, the absorption of oxygen from the sinus into the blood vessels of the mucous membrane is violated. The resulting negative pressure contributes to the release of transudate into the sinus, which serves as a breeding ground for bacteria that penetrate the opening of the sinus or other ways. Among the bacterial pathogens, the most significant are respiratory pathogens – Streptococcus pneumonia and Haemophilus influenza. Rhinovirus leads to the inflammation caused by the virus – swelling of the mucous membrane, plasma extravasation, and hypersecretion of the glands (“Sinus infection (sinusitis)”, 2017). Due to the inflammatory process, the pressure develops in the occluded sinus that is accompanied by painful sensations. In addition to upper respiratory tract infections, allergic rhinitis, prolonged use of vasoconstrictive drops, the curved nasal septum, and other anatomical disorders may be noted.
Symptoms
Sinusitis is marked by the appearance of purulent nasal discharge, often mucopurulent, which can be accompanied by several symptoms: headache, feeling of fullness depending on localization, nasal congestion, and fever (“Sinus infection (sinusitis),” 2017). Also, there can be a swelling of the cheeks or eyelids, toothache, nasal, sore throat, coughing, and loss of the sense of smell.
Physical Assessment and Examination
The diagnosis of sinusitis is based on anamnesis, physical assessment, and laboratory tests. When collecting anamnesis, special attention is to be paid to contact of a patient with acute respiratory viral infections, the span of the disease, self-treatment, and dental pathology. The leading method of the examination is the anterior and posterior rhinoscopy along with endoscopy of the nasal cavity and nasopharynx (Rosenfeld et al., 2015). In the case of sinusitis, anterior rhinoscopy reveals abnormal discharge in the nasal cavity, while pharyngoscopy reveals discharge that flows along the lateral ridges and the posterior pharyngeal wall. It is important to point out the fact that endoscopy of the nasal cavity allows assessing the presence of discharge in the upper nasal passage. During a routine examination of the nasal cavity, pathological discharge on average nasal course indicates a possible lesion in frontal and maxillary sinuses.
Radiography (X-ray) allows reliably establishing the diagnosis of an exudative form of sinusitis or frontal sinusitis. This method also makes it possible to identify the edema of the mucous membrane in the form of a pincushion thickening of the internal contours (Rosenfeld et al., 2015). The advantages of radiography are cost-effectiveness and speed of execution, and its significant drawback is the complexity of visualization of the ethmoidal labyrinth and wedge-shaped sinuses. In case it is suggested that allergy is the cause of sinusitis, environmental allergen assessment should be performed via skin testing or radioallergosorbent assay test (RAST).
In recent decades, radiography is gradually replaced by computed tomography (CT), which offers a detailed assessment of the condition of the nasal cavity. The opportunity to explore the condition of the fistula, which is achieved by layering in sections of different sections of the nasal cavity, is especially useful (Rosenfeld et al., 2015). Such methods as ultrasound scanning and diaphanoscopy are of little importance nowadays. It is advisable to pick up the material for microbiological research via puncture of the affected nasal passage. Sowing requires a certain time, and with direct microscopy, a preliminary result can be obtained faster. To assess the extent of the inflammatory process, a common blood test should be applied. In case of a chronic process, it is obligatory to consult a surgeon and dentist to examine dental caries of the upper jaw.
Evidence-Based Treatment Plan
The goals of treatment for sinusitis are to enhance drainage and suppress infection. Steam inhalations, especially with mucolytic agents, cause narrowing of the nasal vessels and promote drainage (Willihnganz & Clayton, 2016). The topical application of vasoconstrictor drugs is effective but should be used no more than seven days to avoid dependence. It is also possible to use systemic decongestants, yet only in adult patients and with caution since adverse reactions from the sympathetic nervous system are likely.
Glucocorticosteroids may be used to suppress the development of edema of the mucous membrane, restore the functional ability of fistula, and prevent eosinophilic inflammation and degradation of immunoglobulin. Influencing the bacterial factors provoking rhinosinusitis, it is beneficial to indirectly reduce bacterial colonization. Thus, glucocorticosteroid therapy can be considered an important multifactorial component of the treatment of acute sinusitis.
In addition, in some cases, a procedure called puncture of the maxillary sinuses may be required. This eliminates the accumulation of pus in the given place, which greatly facilitates the condition of the patient. Also, pus can be sucked with a special catheter that is used only for purulent sinusitis. The doctor inserts a rubber catheter on which there are two small cylinders: they swell in the nose, and then a specialist uses a syringe to suck all the pus from the nasal cavity. Some medical facilities often carry out the washing of the nose with the help of special equipment.
The antibacterial therapy is indicated for moderate and acute sinusitis based on the estimated leading bacterial pathogen. In mild forms, antibiotics are recommended only in cases of recurrent upper respiratory tract infection and clinical symptoms that exceed 5-7 days (Russell & Bekeny, 2014). The antibacterial therapy is prescribed to patients with severe concomitant somatic pathology, for example, diabetes, and immunocompromised patients during 10-14 days. If the pathogen is not identified, antibiotics that are effective against the most common pathogens are Streptococcus pneumoniae and Haemophilus influenza. Therefore, the first-line drug is Amoxicillin, and the second-line is erythromycin or sulfamethoxazole (Willihnganz & Clayton, 2016).
With the ineffectiveness of ampicillin during the first 72 hours, one can assume the presence of strains of microorganisms that produce β-lactamase. In such cases, high-dose amoxicillin-clavulanate or a respiratory fluoroquinolone, such as levofloxacin or moxifloxacin, can be prescribed (Russell & Bekeny, 2014). Other available antibiotics are likely to be ineffective for sinusitis due to their low ability to improve the quality outcomes of the treatment and more side effects compared to Amoxicillin. In chronic sinusitis, the selection of antibacterial agents is carried out, taking into account the drugs that a patient received earlier.
The non-pharmacological methods of treatment include using drops for washing the nose on the basis of seawater. Saline solutions clean the mucous membrane and moisturize it. These drugs do not contain any medicinal ingredients and, therefore, do not have contraindications and side effects: they can be prescribed to children as well as pregnant and breastfeeding women. In case the identified measures proved to be ineffective, surgery may be prescribed by an otolaryngologist to address anatomical defects.
Patient Education
The patients need to be explained that sinusitis treatment required a comprehensive approach, in which their contribution plays a great role. It is the responsibility of health care professionals to make sure that patients understand their diagnosis and prescribed medication intake ways and dosage. Systematic drug consumption should be prioritized as the main method to recover as soon as possible (Rosenfeld et al., 2015). The patients are to be taught simple rules, following which they will be able to increase the effectiveness of the therapy: drinking enough liquid, rest, horizontal position with a raised head during sleep time, and avoiding contacts with irritants or allergens. It is recommended to regularly reorganize chronic foci of infection in the body. At the same time, the role of nutrition and lifestyles should also be mentioned to strengthen the immune system. As another preventive measure for sinusitis, it is recommended to lead a healthy lifestyle: eliminate harmful habits, walk and sleep more, and eat properly.
Prevention is an integral part of patient education as it allows reducing the number of morbidity via awareness increase. The preventive measures consist of the treatment of the underlying diseases, such as influenza, acute cold, scarlet fever, and other infectious diseases. The elimination of predisposing factors, including the deviation of the nasal septum, atresia, and synechia in the nasal cavity, also matter (Rosenfeld et al., 2015). It should be explained to patients that concomitant allergic rhinitis can significantly affect the course of the disease, increasing the time of rehabilitation. Good hand hygiene, quitting smoking along with secondhand smoke, and timely immunizations are the key ways to prevent sinusitis development. The use of a humidifier and avoiding close contact with people who have respiratory infections are also helpful to avoid the given health issue. Another important measure for the prevention of sinusitis refers to the timely treatment of rhinitis and elimination of cold symptoms, which frequency is complicated by sinusitis. In some cases, the disease develops on the background of infections in the oral cavity, for example, due to deep caries. Accordingly, regular visits to the dentist are likely to prevent the development of complications.
Follow-Up
In case the duration of symptoms is more than ten days, it is critical to schedule a follow-up appointment with the assigned healthcare specialist with the aim of re-evaluating the patient’s condition. The practitioner should interview the patient about the drugs he or she used, including their dosage and any related issues. It should be clear to patients that it make take several times before they feel some health improvements. Therefore, there is no need to address the health professional after 2-3 days of medication usage. Most importantly, an ear-nose-throat (ENT)-the doctor should be contacted as a follow-up measure if the symptoms remain severe or become complicated.
Evaluation of Treatment Plan
The assessment of the results of the treatment prescribed by the doctor may differ depending on the type of sinusitis diagnosed. For the episodic onset of the disease, the effectiveness is determined by the complete recovery, when all the symptoms are eliminated, as it can be revealed during the patient observation and laboratory tests. In its turn, the acute sinusitis treatment may be considered successful if the respiratory condition of the patient is enhanced to some extent after several days of the therapy, and the symptoms disappear within four weeks (Rosenfeld, 2016). Consequently, chronic sinusitis implies the presence of polyps, defective nasal structure, or some other states that are difficult to correct. For such patients, it is important to monitor treatment progress based on their sensations. If the recurrence of the disease is relatively low, the treatment may be regarded as effective in chronic cases.
References
Rosenfeld, R. M. (2016). Acute sinusitis in adults. New England Journal of Medicine, 375(10), 962-970.
Rosenfeld, R. M., Piccirillo, J. F., Chandrasekhar, S. S., Brook, I., Ashok Kumar, K., Kramper, M.,… Walsh, S. A. (2015). Clinical practice guideline (update): Adult sinusitis. Otolaryngology–Head and Neck Surgery, 152(2), 1-39.
Russell, P. T., & Bekeny, J. R. (2014). Oral antibiotics and the management of chronic sinusitis: What do we know?. Current Opinion in Otolaryngology & Head and Neck Surgery, 22(1), 22-26.
Sinus infection (sinusitis). (2017). Web.
Willihnganz, M., & Clayton, B. D. (2016). Basic pharmacology for nurse (12th ed.). St. Louis, MO: Elsevier Health Sciences.