Allergic Rhinitis & Sinus Infections:Sinusitis/Rhinosinusitis

Concepts Behind Sinus Infections: Sinusitis/ Rhinosinusitis

What is Sinusitis/ Rhinosinusitis?

• inflammation of the sinus/ swelling of the tissues lining the sinus
• Instead of air, filled with fluid and germs (bacteria, virus, fungi)
• resulting in symptoms
  • Think nasal Mucus
  • Plugged Nose
  • Pain in face
  • Fever/ Headaches/ Poor sense of smell, sore throat, cough

What are the types and Classifications of Sinusitis/ Rhinosinusitis?

• Acute rhinosinusitis (ARS)
  • Cold-like symptoms (runny, stuffy nose and facial pain) that start suddenly lasting 10-14 days.
  • A new infection that may last up to four weeks and can be subdivided symptomatically into severe and non-severe. Some use definitions up to 12 weeks
• Subacute rhinosinusitis
  • An infection and sinus inflammation that lasts between four and 12 weeks, and represents a transition between acute and chronic infection
• Chronic rhinosinusitis (CRS) – When the inflammation signs and symptoms last for more than 12 weeks.
• Recurrent acute rhinosinusitis – Four or more separate episodes of acute sinusitis that occur within one year

What Causes Sinusitis/ Rhinosinusitis?

• Infection
  • Common Cold
  • Other Viral Infections: Usually caused by viruses
  • Bacterial Infection: If symptoms last more than 10 days or worsens after starting to improve
• Allergies
  • Allergic rhynitis (Swelling of lining of nose)
• Air Pollution
• Structural Problems in nose
  • Nasal Polyps (Small growths in lining of nose)
  • Deviated septum (Shift in nasal cavity)

Who are more likely to get Sinusitis?

• More likely in people with
  • swelling inside the nose from a common cold
  • Blocked drainage ducts
  • Narrowed drainage ducts
    • Structural differences or those with nasal polyps
  • asthma
  • cystic fibrosis
  • Infectious Conditions
    • poor immune function
    • suppressed immune system e.g. medications
  • Children
    • Allergies
    • Illness from other kids
    • ?Bottle drinking while lying on back?
    • smoke in environment
  • Adults with Risk Factors
    • Infections
    • Smoking

Where does Sinusitis/ Rhinosinusitis Occur?

• Maxillary – can cause pain or pressure in the maxillary (cheek) area (e.g., toothache,[13] or headache)
• Frontal – can cause pain or pressure in the frontal sinus cavity (located above eyes), headache, particularly in the forehead
• Ethmoidal (anterior or posterior) – can cause pain or pressure pain between/behind the eyes, the sides of the upper part of the nose (the medial canthi), and headaches
• Sphenoidal – can cause pain or pressure behind the eyes, but often refers to the skull vertex (top of the head), over the mastoid processes, or the back of the head.

Symptoms of Sinusitis

• Symptoms of Acute Sinusitis
  • Main Symptoms
    • Facial pain or pressure
    • Nasal stuffiness
    • Nasal discharge
    • Loss of smell
    • Cough or congestion
  • Other Symptoms
    • Fever
    • Bad breath
    • Fatigue
    • Dental pain
  • Itwo or more symptoms or thick, green, or yellow nasal discharge.
• Symptoms of Chronic Sinusitis
  • Symptoms for 8 weeks or more:
    • A feeling of congestion or fullness in your face
    • A nasal obstruction or blockage
    • Pus in the nasal cavity
    • Fever
    • Nasal discharge or discolored postnasal drainage
  • Other Symptoms
    • Headaches
    • Bad breath
    • Fatigue
    • Dental pain

Tests for Chronic Rhinosinusitis

• Physical Examination
  • Press sinuses for tenderness
  • tap teeth for inflamed paranasal sinus
• X-rays for complications
• Direct Visualisation
• Computed tomography
• Referral to otolaryngologist

Treating Sinusitis/ Rhinosinusitis

• Prevention
  • Handwashing
  • Avoid Smoking
  • Immunization
• Help with Symptoms and Treatment
  • Rest and drinking enough water to thin the mucus
  • Breathing low-temperature steam/Moist
  • Vapouriser
  • Warm Compress
  • Gargling
  • Pain Killers: Naproxen
  • Decongest Nasal Sprays: oxymetazoline
  • Nasal irrigation
  • Nasal Steroids and Corticosteroids
  • Saline Nose drops
• For Acute Symptoms
  • Watchful waiting: If does not improve in 7-1 0 days then should use an antibiotic
    • e.g. amoxicillin, amoxicillin/clavulanate
    • Fluoroquinolones and macrolide antibiotic such as clarithromycin or tetracycline like doxycycline
• For Chronic Disease:
  • Surgery may be used
    • Maxilliary antral washout: Puncturing sinus and flushing with saline to clear mucus
    • Functional Endoscopic Sinus Surgery (FESS)
    • Use of Drug-eluting stents e.g. propel mometasone furoate implant
    • Balloon sinuplasty
    • Caldwell-Luc radical antrostomy
• For Allergies
  • Antihistamine
  • From Fungus: Antifungal medication
• Immune Deficiency
  • Immunoglobulin

Concepts Behind Allergic Rhinitis/ Hay fever

What is Allergic rhinitis/ Hay fever?

• A type of inflammation in the nose
• when immune system overreacts to allergens in the air
• Symptoms similar to common cold
  • runny or stuffy nose
  • sneezing
  • red, itchy and watery eyes
  • swelling around the eyes
  • fluid from nose is usually clear
  • Symptoms onset within minutes following exposure and can affect sleep, ability to work and ability to concentrate at school. Lasts more than 2 weeks and do not include fever
• Also often complications with asthma, allergic conjunctivitis, atopic dermatitis
• (DOES NOT RESULT IN FEVER)

What are the Types and Classifications of Allergic rhinitis?

• Seasonal Vs Perennial
  • Seasonal allergic rhinitis:
    • occurs in particular during pollen seasons
    • It does not usually develop until after 6 years of age.
  • Perennial allergic rhinitis
    • occurs throughout the year
    • commonly seen in younger children.[26]
• Allergic rhinitis may also be classified as Mild-Intermittent, Moderate-Severe intermittent, Mild-Persistent, and Moderate-Severe Persistent. Intermittent is when the symptoms occur <4 days per week or <4 consecutive weeks. Persistent is when symptoms occur >4 days/week and >4 consecutive weeks. The symptoms are considered mild with normal sleep, no impairment of daily activities, no impairment of work or school, and if symptoms are not troublesome. Severe symptoms result in sleep disturbance, impairment of daily activities, and impairment of school or work.

What triggers Allergic rhinitis?

• environmental allergens such as pet hair, dust or mold
• Pollen of Seasonal plants (during haying season)
  • Trees - such as pine (Pinus), birch (Betula), alder (Alnus), cedar, hazel (Corylus), hornbeam (Carpinus), horse chestnut (Aesculus), willow (Salix), poplar (Populus), plane (Platanus), linden/lime (Tilia), and olive (Olea).
    • In northern latitudes: 15–20% of people with hay fever sensitive to birch pollen grains. A major antigen in these is a protein called Bet V I.
    • Mediterranean regions: Olive pollen
    • Japan: sugi (Cryptomeria japonica) and hinoki (Chamaecyparis obtusa) tree pollen.
    • NOTE: Allergy friendly" trees include: ash (female only), red maple, yellow poplar, dogwood, magnolia, double-flowered cherry, fir, spruce, and flowering plum.
  • Grasses (Family Poaceae):
    • An estimated 90% of people with hay fever are allergic to grass pollen
    • ryegrass (Lolium sp.) and timothy (Phleum pratense).
  • Weeds
    • ragweed (Ambrosia), plantain (Plantago), nettle/parietaria (Urticaceae), mugwort (Artemisia Vulgaris), Fat hen (Chenopodium), and sorrel/dock (Rumex)Inherited genetics
• environmental exposures

Tests and diagnostics for Allergic rhinitis

• medical history in combination with skin prick test or blood tests for allergen-specific IgE antibodies (But sometimes falsely positive)
• Allergy Testing
  • Skin Test
    • Patch Test
  • Intradermal
    • Skin-Prick test
    • Dissolve suspected allergen in water and dropped onto lower eyelid
  • RAST blood
  • Peripheral eosinophilia

Symptoms of Allergic Rhinitis

• rhinorrhea (Excess nasal secretion)
• Itching
• Sneezing fits
• nasal congestion and obstruction
• Physical Characteristics
  • conjuctival swelling
  • erythema
  • eyelid swelling
  • lower eyelid venous stasis (Allergic shiners rings under eyes
  • Swollen nasal turbinates
  • middle ear effusion
• Behavioural signs
  • wiping or rubbing nose with palm in upward motion (nasal salute, allergic salute) resulting in crease running across nose and possible physical deformity
• Cross-Reactivity
  • allergy to birch pollen also has reaction to skin of apples or potatoes

Treating Allergic rhinitis

• exposure to animals in early life can reduce developing allergies to them later in life
• Medication: Not sufficient or associated with side effects
  • nasal steroids
  • antihistamines: diphenhydramine
  • cromolyn sodium
  • leukotriene receptor antagonists: montelukast
• Allergen immunotheraphy: Exposure to larger and larger amounts of allergen as injections under the skin or tablet under the tongue ofr 3-5 years

References

• https://en.wikipedia.org/wiki/Sinusitis
• http://www.webmd.com/allergies/sinusitis-and-sinus-infection