Sinusitis maxillaris


SINUSITIS MAXILLARIS

Description:

Also called as maxillary sinusitis.

The skull contains a number of air-filled spaces called sinuses. They perform the following functions:

    Reduce the weight of the skull.

  • Provide insulation for the skull.

  • Provide resonance for the voice.

Four pairs of sinuses, known as the paranasal air sinuses, connect to the nasal passages (the two airways running through the nose) and are those that are involved in sinusitis. These sinuses are the following:

    Frontal sinuses (behind the forehead).

  1. Maxillary sinuses (behind the cheekbones).

  2. Ethmoid sinuses (between the eyes).

  3. Sphenoid sinuses, (behind the eyes).

Sinusitis: Healthy sinuses are sterile and contain no bacteria. (The nasal passage, on the other hand, normally contains many bacteria that enter through the nostrils.)

Sinusitis is an infection that occurs if one or more of the defense processes or factors are amiss, causing obstruction, and bacterial growth occurs in the paranasal sinuses. Among the many causes of such obstruction or congestion are the common cold, allergies, certain medical conditions, abnormalities in the nasal passage, and change in atmosphere. In any of these cases, sinusitis can develop as follows:

Mucus drainage and airflow are blocked. Secretions build up, encouraging the growth of certain bacteria. The resulting infection, swelling, and inflammation create further blockage, which may cause the sinuses to close up completely.

Forms of Sinusitis: Sinusitis is classified as acute, subacute, or chronic, or recurrent. The classification is based on how long symptoms last:

sinusitis maxillaris

    Acute: Less than 4 weeks.

  • Subacute: 4 - 12 weeks.

  • Chronic: 12 weeks or longer.

  • Recurrent: 3 or more acute episodes in 1 year.

There are four main sinus cavities in the head. They are frontal, ethmoid, sphenoid and maxillary. As the name suggests, maxillary sinus disease occurs when the membrane of the maxillary sinus cavity becomes inflamed. The maxillary sinuses are basically located below the eyes on either side of the nose. The inflammation of the mucous membrane may be due to infection or allergy.

Maxillary sinus disease basically causes tenderness and acute pain in the cheeks. It may also cause swelling of facial muscles. Pain in the upper or back teeth may also occur. This pain increases on bending down.

In adults, the maxillary sinuses are most commonly affected with acute and chronic sinusitis. Most of these cases can be managed with medications alone. For the instances where medical management fails, surgery may be needed to treat chronic maxillary sinusitis.

Symptoms:

Sinus symptoms are very common during a cold or the flu, but in most cases they are due to the effects of the infecting virus and resolve when the infection does. It is important to differentiate between inflamed sinuses associated with cold or flu virus and sinusitis caused by bacteria.

The signs and symptoms that are associated with the diagnosis of sinusitis include one to two of the following:

Nasal congestion and discharge that typically is thick and becomes yellowish to yellow-green, facial pain, pressure, congestion, or fullness (that is also accompanied by other symptoms of sinusitis).

Other symptoms of sinusitis that usually occur in adults include one to two of the following:

Eyes may be red, bulging, or painful if the sinus infection occurs around the eyes, a persistent cough (particularly during the day) ear pain, pressure, or fullness Halitosis (bad breath), dental pain, fatigue. However, many studies have shown that symptoms used to diagnose sinusitis often do not predict prognosis or response to antibiotic treatment.

Sneezing, sore throat, and muscle aches may be present, but they are rarely caused by sinusitis itself. Muscle aches may be caused by fever, sore throat by post-nasal drip, and sneezing from cold or allergies.

Rare complications of sinusitis can produce additional symptoms, which may be severe or even life threatening.

Maxillary sinusitis symptoms include: Altered facial sensation, fever, facial pain, nasal congestion, night-time cough, runny nose, teeth and/or jawbone pain, Sinus pressure below the eyes, and chronic toothache.

Maxillary sinusitis causes:

  • Pain over the cheeks that may travel to the teeth.

  • Hard palate in the mouth sometimes becomes swollen.

  • Symptoms are worse when head is upright

Causes and Risk factors:

Bacteria are the most common direct cause of acute sinusitis. (Other organisms might be the infecting cause in less common cases.) The ability of bacteria or other organisms to infect the sinuses, however, must first be set up by conditions that create a favorable environment in the sinus cavities. Sinusitis is most often an acute condition, which is self-limiting and treatable. In some cases, however, the inflammation in the sinuses is lasting, or is chronic do begin with. The causes for such chronic sinusitis cases are sometimes unclear.

Upper Respiratory Infections: The typical process leading to acute sinusitis starts with a flu or cold virus. Over 85% of people with colds have inflamed sinuses. These inflammations are typically brief and mild, however, and only between 0.5 - 10% of people with colds develop true sinusitis. Instead, colds and flu set the stage by causing inflammation and congestion in the nasal passages (called rhinitis), leading to obstruction in the sinuses. This creates a hospitable environment for bacterial growth, which is the direct cause of sinus infection. In fact, rhinitis is the precursor to sinusitis in so many cases that expert groups now refer to most cases of sinusitis as rhinosinusitis.

Rhinosinusitis tends to involve the following sinuses:

The maxillary sinuses (behind the cheekbones) are the most common sites. The ethmoid sinuses (between the eyes) are the second most common sites affected by colds. The frontal (behind the forehead) and sphenoid (behind the eyes) sinuses are involved in about a third of cold-related cases. Nearly everyone with colds has inflamed sinuses. These inflammations are typically brief and mild, however, and most people with colds do not develop true sinusitis.

Inflammatory Response, Allergies, and Asthma: The absence of bacterial organisms as factor in many cases suggests that some instances of chronic sinusitis may be due to a continuing inflammatory condition. Many of the immune factors observed in people with chronic sinusitis resemble those that appear in allergic rhinitis, suggesting that sinusitis in some individuals is due to an allergic response.

Allergies, asthma, and sinusitis often overlap. Those with allergic rhinitis (so-called hay fever and rose fever) often have symptoms of sinusitis, and true sinusitis can develop as a result of the mucus blockage it causes. A causal association, however, has not been proved, and many experts believe allergies themselves rarely predispose to sinusitis. People with chronic sinusitis may also have an allergic reaction to fungal organisms.

Abnormalities of the Nasal Passage: Abnormalities in the nasal passage can cause blockage and thereby increase the risk for chronic sinusitis. Some abnormalities include:

    Polyps (small benign growths) in the nasal passage block mucus drainage and restrict airflow. Polyps themselves may be consequences of previous sinus infections that caused overgrowth of the nasal membrane. Enlarged adenoids can lead to sinusitis.

  • Adenoids are masses of tissue located high on the posterior wall of the pharynx. They are made up of lymphatic tissue, which trap and destroy pathogens in the air that enter the nasopharynx.

  • Cleft palate Tumors Deviated septum (a common structural abnormality in which the septum, the center section of the nose, is shifted to one side, usually the left) Click the icon to see an image of a deviated septum.

The Role of Bacteria: The role of bacteria or other infectious organisms is complicated in chronic sinusitis. They may have a direct, or an indirect, role. In some patients, infectious organisms play no role at all. For example, one study reported the following for patients with chronic sinusitis who had not responded to antibiotics:

30% had no evidence of bacteria in their passageways. 20% had bacteria unrelated to infection. The bacteria most commonly implicated in sinusitis include:

Streptococcus pneumoniae: This bacterium is found in 20 - 45% of adults and children with sinusitis. H. influenzae (a common bacterium associated with many upper respiratory infections). This bacterium colonizes nearly half of all children by age 2, and causes about 25% of sinusitis cases in this group. Studies have reported the presence of this bacterium in up to a third of adult sinusitis patients. Moraxella catarrhalis. Over 75% of all children harbor this bacterium, which causes about 25% of sinusitis cases. Other possible bacterial culprits include:

Other streptococcal strains Staphylococcus aureus P. aeruginosa, Klebsiella pneumoniae, Proteus mirabilis, Enterobacter species, and Escherichia coli Fusobacterium nucleatum and Prevotella intermedia).

Risk Factors

Sinusitis is one of the most common diseases in the United States, affecting about 1 in 7 adults each year. About 31 million Americans are diagnosed with sinusitis each year.

Young Children and Sinusitis: Before the immune system matures, all infants are susceptible to respiratory infections, with a possible frequency of one cold every 1 - 2 months. Young children are prone to colds and may have 8 - 12 bouts every year. Smaller nasal and sinus passages also make children more vulnerable to upper respiratory tract infections than older children and adults. Ear infections such as otitis media are also associated with sinusitis. Nevertheless, true sinusitis is very rare in children under 9 years of age. Some experts believe it is greatly over-diagnosed in this population.

The Elderly and Sinusitis: The elderly are at specific risk for sinusitis. Their nasal passages tend to dry out with age. In addition, the cartilage supporting the nasal passages weakens, causing airflow changes. They also have diminished cough and gag reflexes and faltering immune systems and are at greater risk for serious respiratory infections than are young and middle-aged adults.

People with Asthma or Allergies: People with asthma or allergies are at higher risk for non-infectious inflammation in the sinuses. The risk for sinusitis is higher in patients with severe asthma. People with a combination of polyps in the nose, asthma, and sensitivity to aspirin (called Samter's, or ASA, triad) are at very high risk for chronic or recurrent acute sinusitis.

Changes in Atmospheric Pressure: People who experience changes in atmospheric pressure, such as while flying, climbing to high altitudes, or swimming, risk sinus blockage and therefore an increased chance of developing sinusitis. (Swimming increases the risk for sinusitis for other reasons, as well.)

Cigarette Smoke and Other Air Pollutants: Air pollution from industrial chemicals, cigarette smoke, or other pollutants can damage the cilia responsible for moving mucus through the sinuses. Whether air pollution is an important cause of sinusitis and, if so, which pollutants are critical factors is still not clear. Cigarette smoke, for example, poses a small but increased risk for sinusitis in adults. Second-hand smoke does not appear to have any significant effect on adult sinuses, although it does seem to pose a risk for sinusitis in children.

Diagnosis:

Patients should see a doctor if they have sinusitis symptoms that do not clear up within a few days, are severe, or are accompanied by high fever or acute illness. However, only one-half to two-thirds of patients with such symptoms actually have sinusitis. Some experts complain that too many patients are diagnosed with true sinusitis and given unnecessary antibiotics when their symptoms would actually resolve easily in days with over-the-counter medications or no drugs at all. Others believe that true sinusitis is often mistakenly diagnosed as an allergy and not treated, which could lead to serious illness.

The first goal in diagnosing sinusitis is to rule out other possible causes of symptoms, and then determine:

    The site where the infection has occurred.

  • Whether the condition is acute or chronic.

  • The organism causing the infection (if possible).

Medical History: The patient should describe all symptoms such as nasal discharge and specific pain in the face and head, including eye and tooth pain.After assessing symptoms, the doctor should take a thorough medical history of the patient.

Physical Examination: The doctor will press the forehead and cheekbones to check for tenderness and check for other signs of sinusitis, including yellow to yellow-green nasal discharge. The doctor will also check the inside of the nasal passages using a device with a bright light to check the mucus and look for any structural abnormalities.

In some cases, tests may be used to detect that presence of immune factors in sinus tissues that would suggest persistent inflammation. Such findings would strongly suggest a chronic or allergic condition.

Imaging Techniques:

Computer Tomography: Computed tomography (CT) scanning is the best method for viewing the paranasal sinuses. There is little relationship, however, between symptoms in most patients and findings of abnormalities on a CT scan. CT scans are recommended for acute sinusitis only if there is a severe infection, complications, or a high risk for complications. CT scans are useful for diagnosing chronic or recurrent acute sinusitis and for surgeons as a guide during surgery. They show inflammation and swelling and the extent of the infection, including in deeply hidden air chambers missed by x-rays and nasal endoscopy. Often, they can detect the presence of fungal infections.

X-Rays: Until the availability of endoscopy and CT scans, x-rays were commonly used. They are not as accurate, however, in identifying abnormalities in the sinuses. For example, more than one x-ray is needed for diagnosing frontal and sphenoid sinusitis. X-rays do not detect ethmoid sinusitis at all. This area can be the primary site of an infection that has spread to the maxillary or frontal sinuses.

Magnetic Resonance Imaging: Magnetic resonance imaging (MRI) is not as effective as CT in defining the paranasal anatomy and therefore is not typically used to image the sinuses for suspected sinusitis. MRI is also more expensive than CT. However, it can help rule out fungal sinusitis and may help differentiate between inflammatory disease, malignant tumors, and complications within the skull. It may also be useful for showing soft tissue involvement.

Sinus Puncture and Bacterial Culture: Sinus puncture with bacterial culture is the gold standard for diagnosing a bacterial sinus infection. It is invasive, however, and is performed only when antibiotics have not worked. Sinus puncture involves using a needle to withdraw a small amount of fluid from the sinuses. It requires a local anesthetic and is performed by a specialist. The fluid is then cultured to determine what type of bacteria is causing sinusitis.

Treatment:

Medical Therapy: Medical therapy is the first-line treatment of chronic sinusitis. It should consist of a 3- to 6-week course of oral antibiotics (eg, fluoroquinolone or macrolide, a broad-spectrum penicillin class drug with beta lactamase inhibitor), steroids, and nasal saline irrigations. If significant intranasal edema is observed on endoscopic examination, a course of oral steroids (7-28 d, depending on severity) may serve as a useful adjunct therapy. Consider a short course of decongestant to provide symptomatic relief for patients with symptoms of significant nasal congestion. High doses of guaifenesin (600 mg PO bid) may also be beneficial as a mucolytic for patients with tenacious nasal secretions.

Culture-directed antibiotics may be used based on endoscopically obtained cultures of middle meatus mucopurulence, if empiric antibiotics have already failed.

Surgical Therapy: Surgery is reserved for patients with confirmed chronic sinusitis, as documented by findings on history, physical examination findings, and CT findings, who have not responded to medical therapy.

Three main surgical options are available: (1) endoscopic uncinectomy with or without maxillary antrostomy, (2) Caldwell-Luc procedure, and (3) inferior antrostomy (naso-antral window).

Today, endoscopic maxillary antrostomy and uncinectomy are the standard for treatment of refractory chronic maxillary sinusitis. The Caldwell-Luc and inferior antrostomy approaches are reserved for rare circumstances (an example may be a case of severe allergic fungal sinusitis where standard antrostomy alone does not allow complete extirpation of fungal concretions or complete drainage).

Additionally, further FESS with mucosal sparing techniques may be performed if additional disease is present within the ethmoid, sphenoid, and frontal sinuses.

Consent should be obtained prior to any surgical procedure. This should include a thorough discussion of possible risks such as orbital injury, blindness, nasolacrimal duct injury, epiphora, epistaxis, cerebrospinal fluid leak, meningitis and brain abscess, and of course persistent rhinosinusitis.

A preoperative antibiotic course may be administered in the weeks prior to surgery if an active infection is present. A preoperative steroid course may be administered if significant edema or polyps are observed on examination.

Medicine and medications:

Many people take medications to reduce mild pain and fever. Adults most often choose aspirin, ibuprofen (Advil), or acetaminophen (Tylenol).

The following are recommendations for children:

Acetaminophen (Tylenol) or ibuprofen (usually Advil or Motrin) is the pain reliever of choice in children. Most pediatricians advise such medications for children who run fevers over 101° F. Aspirin and aspirin-containing products are virtually never recommended for children or adolescents. Reye syndrome, a very serious condition, has been associated with aspirin use in children who have flu symptoms or chicken pox.

Oral Decongestants: Pseudoephedrine and phenylephrine are the only decongestants taken by mouth that are currently available over-the-counter (OTC) in the United States. It decreases the volume of mucus in the nose, as well as within the Eustachian tubes. Many brands of OTC oral decongestants are available. A common brand is Sudafed. Oral decongestants such as Sudafed can also be helpful for relieving cough associated with postnasal drip.

Side Effects of Decongestants: Decongestants have certain adverse effects, which are more apt to occur in oral than nasal decongestants, including: Agitation and nervousness, drowsiness (particularly with decongestants taken by mouth and in combination with alcohol), changes in heart rate and blood pressure.

Antihistamines: Older antihistamines, such as diphenhydramine (Benadryl), are helpful in relieving cough when used alone or in combination with a decongestant.

Penicillins: Amoxicillin (Amoxil, Polymox, Trimox, Wymox, or any generic formulation) has been the most widely prescribed antibiotic for acute sinusitis. This penicillin is both inexpensive and at one time was highly effective against the S. pneumoniae bacteria. Unfortunately, bacterial resistance to amoxicillin has increased significantly, both among S. pneumoniae and H. influenzae, and penicillin is no longer as reliable as it once was.

Amoxicillin-clavulanate (Augmentin) is a type of penicillin that works against a wide spectrum of bacteria. An extended release form has been approved for treating adults with sinusitis infections that have become resistant to penicillin.

Many people have a history of an allergic reaction to penicillin, but some evidence is suggesting that the allergy may not recur in a significant number of adults. Skin tests are available that could determine if some people previously allergic could use these important antibiotics.

Cephalosporins: They are often classed by generation:

First generation includes cephalexin (Keflex), cefadroxil (Duricef, Ultracef), and cephradine (Velosef). Second generation include cefaclor (Ceclor), cefuroxime (Ceftin), cefprozil (Cefzil), and loracarbef (Lorabid). Third generation include cefpodoxime (Vantin), cefdinir (Omnicef) cefditoren (Sprectracef), cefixime (Suprax), and ceftibuten (Cedex). Ceftriaxone (Rocephin) is an injected cephalosporin. These are effective against a wide range of bacteria. Cephalosporins are usually safe for patients with mild penicillin allergies (rash), but should be avoided in patients with high-grade penicllin allergies (hives, airway swelling, collapse).

Macrolides and Azalides: Macrolides are a class of antibiotics that are divided into different sub-groups. Azalides are one of those sub-groups. This type of antibiotic is often used to treat mild-to-moderate bacterial sinusitis in patients who are allergic to penicillin. Some of the most common macrolids/azalides are azithromycin (Zithromax), clarithromycin (Biaxin), and roxithromycin (Rulid). An extended-release form of azithromycin (Zmax) was approved in 2005 as a single dose treatment for mild-to-moderate acute bacterial sinusitis. These antibiotics are also effective against many strains of S. pneumoniae and M. catarrhalis, but macrolide-resistance rates doubled between 1995 - 1999 as the number of children treated with the antibiotics increased. Erythromycin is not effective against H. influenzae.

Macrolides have anti-inflammatory actions, which may have benefits for some patients with chronic sinusitis. Investigators are studying long-term low-dose macrolide treatments, which are not intended to eliminate bacteria, but to reduce inflammation. Studies suggest that this approach may be effective without increasing the risk for bacterial resistance.

Trimethoprim-Sulfamethoxazole: Trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra) is another first-line antibiotic for sinusitis. It is less expensive than amoxicillin and particularly useful for patients with mild sinusitis who are allergic to penicillin. It is no longer effective, however, against certain streptococcal strains. It should not be used in patients whose infections occurred after dental work or in patients allergic to sulfa drugs. Allergic reactions can be very serious.

Fluoroquinolones (Quinolones). Fluoroquinolones (also simply called quinolones) interfere with the bacteria's genetic material so they cannot reproduce. Newer generation fluoroquinolones, which include levofloxacin (Levaquin), sparfloxacin (Zagam), gatifloxacin (Tequin), and moxifloxacin (Avelox), are currently the most effective antibiotics against the common bacteria that cause sinusitis. They are recommended for adults with moderate sinusitis who have already been treated with antibiotics within 6 weeks or who are allergic to beta-lactam antibiotics.

Lincosamides: Lincosamides prevent bacteria from reproducing. The most common lincosamide is clindamycin (Cleocin). This antibiotic is useful against many S. pneumoniae bacteria but not against H. influenzae.

Tetracyclines: Tetracyclines inhibit bacterial growth. They include doxycycline, tetracycline, and minocycline. They can be effective against S. pneumoniae and M. catarrhalis, but bacteria that are resistant to penicillin are also often resistant to doxycycline. Tetracyclines have unique side effects among antibiotics, including skin reactions to sunlight, possible burning in the throat, and tooth discoloration. They should not be used by children or pregnant women.

Scientists are investigating whether antifungal drugs may help treat chronic sinusitis. One such drug, Amphotericin B (SinuNase), is currently in Phase III trials for patients who have had sinus surgery but are still experiencing recurrent sinusitis.

DISCLAIMER: This information should not substitute for seeking responsible, professional medical care.

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