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Joseph B. Jacobs,M.D.
NYU Langone Medical Center

New York Office

345 East 37th St., Suite 306

New York, NY 10016

Ph / (646) 754-1203

Fx / (646) 754-1222

SINUSITIS

ACUTE SINUSITIS

ostiomeatal_complex.jpgSinusitis is an inflammation, thickening, and swelling of the normal tissue called mucosa, which lines all the sinuses. This same type of tissue lines all the passages of your nose as well as the small channels which connect the nose and sinuses. These channels, or ostiomeatal complex, which is pictured above with the gray shading, can become blocked by swollen tissue. The causes of such swelling may relate to allergy, viruses, bacteria, or fungus. In addition, due to the individual characteristics of our sinuses and these channels which connect our sinuses to our nose, certain structural conditions, such as a deviated nasal septum, may be responsible for recurrent or persistent sinus complaints. [See diagram of deviated nasal septum blocking sinuses below under causes of sinusitis] This combination of swelling and inflammation is now often called Rhinosinusitis (Nose-Sinuses) rather than Sinusitis since the nose and sinuses are often simultaneously involved. Either 1 or more sinuses on either the right, left or both sides can be involved. If this swelling results in blockage of mucous drainage and air flow, an increase in the volume of bacteria can occur, Acute Bacterial Rhinosinusitis may result.


RECURRENT ACUTE BACTERIAL SINUSITIS

Recurrent Acute Bacterial Sinusitis, 3 or more episodes of acute sinusitis each year, should be thoroughly evaluated. The reasoning behind such advice is the possibility that a structural condition or persistent swelling of the membrane within the nose, sinuses or their channels may exist.nasal_endoscopy.jpg  A thorough endoscopic evaluation of the nose (pictured right) as well as a radiologic examination consisting of a Cat Scan or CT [pictured below] is required to provide a specific diagnosis.

                                                       
                                                                 

                                                                                                 Nasal/ Sinus Endoscopy

 

Routine x-rays are no longer used for this purpose since the information obtained is not adequate to visualize the complex anatomy of the region or to identify localized areas of swelling which may be blocking mucous drainage and air flow. Treatment of Recurrent Acute Bacterial Rhinosinusitis may require longer courses of medicine such as antibiotics, decongestant pills or nose sprays. Sometimes testing and more specific treatment for allergy is helpful. If a localized structural condition is present, or tissue inflammation or swelling is identified surgery may be appropriate. This is discussed under Chronic Rhinosinusitis.



CHRONIC RHINOSINUSITIS

Chronic Rhinosinusitis is a persistent inflammation and swelling of the membrane and tissue lining the nose, sinuses and their connecting or osteomeatal channels. The definition of a chronic nasal and sinus disorder is a combination of symptoms, discussed below, persisting more than 12 weeks. Nasal symptoms occur due to tissue swelling within our nose while sinus symptoms occur due to blockage of the osteomeatal channels which will block air flow and mucous drainage. Chronic Rhinosinusitis can improve briefly, however it often does not go away completely even with many different medications and longer periods of treatment. Therefore, this "blockage" tends to be permanent and causes symptoms to persist and linger.
In fact, these symptoms may be less obvious to an individual than those that occur with acute Rhinosinusitis. However, they can impact on our quality of life significantly. We may be unable to breathe well through our nose which is often more blocked at night. This leads to constant mouth breathing which may be associated with poor sleep, lethargy, malaise and irritability. There may be a continuous nasal discharge which is thick and discolored often running down the back of the nose to the throat, "post nasal drip." There may be swelling around the eyes. Loss of smell may occur and could be persistent. Clearing of the throat, cough and ear stuffiness is often present constantly or intermittently. The diagnosis of Chronic Rhinosinusitis is made by a combination of history and symptoms, an endoscopic examination of the nasal cavity and by a CT scan.

CAUSES OF RHINOSINUSITIS

Rhinosinusitis can occur due to structural problems and narrow passageways which result from the variable development of our nose and sinuses. A deviated nasal septum, pictured below with the arrow and telescopic view, is one such problem. In addition, there are structural problems that can result from the variable size and shape of the channels or osteomeatal pathways of the sinuses. This blockage can result in poor function. Allergies, such as dust, pollen as well as environmental irritants such as smoke and chemicals can result in constant tissue swelling and create blockages and rhinosinusitis. Allergy testing is sometimes suggested and if warranted, allergy injections and/or allergy medications such as antihistamines and medicated nose sprays can be prescribed. All such products attempt to control the swollen tissue and improve function.
 
deviated_blocking.jpg
Deviated Nasal Septum Blocking Sinus Passage

More recently, fungus has been found in the mucous of many patients with Chronic Rhinosinusitis and may be a factor in the overall allergic process. Fungi are organisms that do not require light and can therefore live in damp and dark places. The nose and sinuses are therefore natural places to find fungi. Fungi may be able to cause an allergic reaction due to their presence. We do not believe this is a true infection and therefore medications for fungal infections are not generally prescribed. In addition, such medication can have significant side effects. In some instances we do prescribe antifungal or other washes for the nose and sinuses. For additional information please review www.sinuspharmacy.com, www.aslrx.com and www.neilmed.com. Often these products are not effective until the nose and sinus cavities have been surgically opened in cases of Chronic Rhinosinusitis.

All of the above factors will eventually cause thickening of the nasal and sinus lining tissue. If this process persists the thickening can become permanent. Eventually despite our best efforts with treatment this continuous swelling can create polyps. Polyps are no more than rounded groups of very swollen sinus tissue and their presence does not suggest that your sinus problem is more serious.

ct_scan.gif
CT Scan on left of screen demonstrates normal sinuses filled with air which appears black.
CT Scan image on right of screen demonstrates Sinus Blockage. Gray area is swollen tissue.

In general, it is believed that a combination of factors are involved in the development of nose and sinus problems as well as our genes and family history. Symptoms begin to appear when the thickened tissue causes blockage of function. Treatment is often prescribed by the patient’s regular physician or specialist and improvement tends to take place. If the attack is acute, short term, the swelling and symptoms disappear completely. However, if the problem has lingered or the tissue remains swollen the symptoms do not disappear. More medication is generally given. Over time there is less improvement with each course of medication and finally a combination of swollen somewhat scarred tissue causes various degrees of constant blockage, hence Chronic Rhinosinusitis. Any structural problem that exists such as a deviated nasal septum will add to the symptoms and generally there would be less improvement with medication.
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Copyright © 2005 Dr. Joseph B. Jacobs