Sinusitis: Management and Prevention
Sinusitis is infl ammation of the mucous membranes lining one or more of the paranasal sinuses. The various presentations are as folllows:
● acute sinusitis: infection lasting less than 30 days, with complete resolution of symptoms
● subacute infection: lasts from 30 to 90 days, with complete resolution of symptoms
● recurrent acute infection: episodes of acute infection lasting less than 30 days, with resolution of symptoms, which
Recur at intervals of at least 10 days apart
● chronic sinusitis: infl ammation lasting more than 90 days, with persistent upper respiratory symptoms
● acute bacterial sinusitis superimposed on chronic sinusitis:
New symptoms that occur in patients with residual symptoms from prior infection (s). With treatment, the new symptoms resolve but the residual ones do not.
Physical findings and clinical presentation
● patients often give a history of a recent upper respiratory illness with some improvement, then a relapse.
● mucopurulent secretions in the nasal passage
● purulent nasal and postnasal discharge lasting more than 7 to 10 days
● facial tightness, pressure, or pain
● nasal obstruction
● headache
● decreased sense of smell
● purulent pharyngeal secretions, brought up with cough, often worse at night
● erythema, swelling, and tenderness over the infected sinus in a small proportion of patients
● diagnosis cannot be excluded by the absence of such findings.
● these fi ndings are not common, and do not correlate with number of positive sinus aspirates.
● intermittent low-grade fever in about one half of adults with acute bacterial sinusitis
● toothache is a common complaint when the maxillary sinus is involved.
● periorbital cellulitis and excessive tearing with ethmoid sinusitis
● orbital extension of infection: chemosis, proptosis, impaired extraocular movements.
Characteristics of acute sinusitis in children with upper respiratory tract infections:
● persistence of symptoms
● cough
● bad breath
● symptoms of chronic sinusitis (may or may not be present)
● nasal or postnasal discharge
● fever
● facial pain or pressure
● headache
● nosocomial sinusitis is typically seen in patients with nasogastric tubes or nasotracheal intubation.
Cause
● each of the four paranasal sinuses is connected to the nasal cavity by narrow tubes (ostia), 1 to 3 mm in diameter; these drain directly into the nose through the turbinates. The sinuses are lined with a ciliated mucous membrane (mucoperiosteum).
● acute viral infection
● infection with the common cold or infl uenza
● mucosal edema and sinus infl ammation
● decreased drainage of thick secretions, obstruction of the sinus ostia
● subsequent entrapment of bacteria
A. Multiplication of bacteria
B. Secondary bacterial infection
Other predisposing factors
● tumors
● polyps
● foreign bodies
● congenital choanal atresia
● other entities that cause obstruction of sinus drainage
● allergies
● asthma
● dental infections lead to maxillary sinusitis.
● viruses recovered alone or in combination with bacteria (in 16% of cases):
● rhinovirus
● coronavirus
● adenovirus
● parainfluenza virus
● respiratory syncytial virus
● the principal bacterial pathogens in sinusitis are streptococcus pneumoniae, nontypeable haemophilus influenzae, and moraxella catarrhalis.
● in the remainder of cases, fi ndings include streptococcus pyogenes, staphylococcus aureus, alpha-hemolytic streptococci, and mixed anaerobic infections (peptostreptococcus, fusobacterium, bacteroides, prevotella).
Infection is polymicrobial in about one third of cases.
● anaerobic infections seen more often in cases of chronic sinusitis and in cases associated with dental infection; anaerobes are unlikely pathogens in sinusitis in children.
● fungal pathogens are isolated with increasing frequency in immunocompromised patients but remain uncommon
Pathogens in the paranasal sinuses. Fungal pathogens include aspergillus, pseudallescheria, sporothrix, phaeohyphomycoses, zygomycetes.
● nosocomial infections occur in patients with nasogastric tubes, nasotracheal intubation, cystic fi brosis, or those who are immunocompromised.
● s. Aureus
● pseudomonas aeruginosa
● klebsiella pneumoniae
● enterobacter spp.
● proteus mirabilis
Organisms typically isolated in chronic sinusitis:
● s. Aureus
● s. Pneumoniae
● h. Infl uenzae
● p. Aeruginosa
● anaerobes
Differential diagnosis
● migraine headache
● cluster headache
● dental infection
● trigeminal neuralgia
Workup
● water’s projection: sinus radiograph
● ct scan
● much more sensitive than plain radiographs in detecting acute changes and disease in the sinuses
● recommended for patients requiring surgical intervention, including sinus aspiration; it is a useful adjunct to
Guide therapy:
● transillumination
● used for diagnosis of frontal and maxillary sinusitis
● place transilluminator in the mouth or against cheek to assess maxillary sinuses, and under the medial aspect of the supraorbital ridge to assess frontal sinuses.
● absence of light transmission indicates that sinus is filled with fluid.
● dullness (decreased light transmission) is less helpful in diagnosing infection.
● endoscopy
● used to visualize secretions coming from the ostia of infected sinuses
● culture collection via endoscopy often contaminated by nasal flora; not nearly as good as sinus puncture
● sinus puncture
● gold standard for collecting sinus cultures
● generally reserved for treatment failures, suspected intracranial extension, nosocomial sinusitis.
Treatment Nonpharmacologic therapy
● sinus drainage
● nasal vasoconstrictors, such as phenylephrine nose drops, 0.25% or 0.5%
● topical decongestants should not be used for more than a few days because of the risk of rebound congestion.
● systemic decongestants
● nasal or systemic corticosteroids, such as nasal beclomethasone, short-course oral prednisone
● nasal irrigation, with hypertonic or normal saline (saline may act as a mild vasoconstrictor of nasal blood fl ow)
● use of antihistamines has no proved benefi t, and the drying effect on the mucous membranes may cause crusting,
Which blocks the ostia, thus interfering with sinus drainage.
● analgesics, antipyretics.
Antimicrobial therapy
● most cases of acute sinusitis have a viral cause and will resolve within 2 weeks without antibiotics.
● current treatment recommendations favor symptomatic treatment for those with mild symptoms.
● antibiotics should be reserved for those with moderate to severe symptoms who meet the criteria for diagnosis of
Bacterial sinusitis.
● antibiotic therapy is usually empirical, targeting the common pathogens.
● first-line antibiotics include amoxicillin, tmp-smz.
● second-line antibiotics include clarithromycin, azithromycin, amoxicillin-clavulanate, cefuroxime axetil, loracarbef, ciprofloxacin, levofloxacin.
● for patients with uncomplicated acute sinusitis, the less expensive first-line agents appear to be as effective as the
Costlier second-line agents.
Surgery
● surgical drainage indicated
● if intracranial or orbital complications suspected
● for many cases of frontal and sphenoid sinusitis
● for chronic sinusitis recalcitrant to medical therapy
● surgical débridement imperative for treatment of fungal sinusitis
Have you noticed a gradual and progressive increase in the number of hairs lost when combing or brushing? Perhaps after months or years of vain denial, you have realized that the mirror does not lie, visible thinning has occurred. You're not alone if you're experiencing breakage, increased hair shedding or significant hair loss.
Many women may cover it up with wigs, hair extensions, hats or scarves. Others choose one of the several approved medications or surgical procedures that are available to treat baldness.
Excessive hair loss or balding is mistakenly perceived as strictly something that happens to men although women actually make up to forty percent of American hair loss sufferers. In America, one in four, or over 30 million women will seek solutions and treatment for hair loss annually.
First of all, don't panic! Hair loss or hair shedding is consistent within the hair growth cycle and it is normal to lose some scalp hair each day. The average human scalp has roughly 100,000 to 150,000 individual hairs and the normal hair growth cycle results in the loosening or shedding of about 100 to 150 hairs on a daily basis. New hair growth then emerges from these same previous dormant hair follicles, growing at the average rate of about half an inch per month.
Hair is composed of two separate parts: the follicle and the hair shaft. The follicle lies below the scalp and produces the hair strands that we see growing out of our head. The follicle is alive, however, the hair strand is simply composed of dead cells that have no regenerative ability.
For most people, 90% of our scalp hair is always in a to six-year growth phase (anagen) while the remaining 10% is in a dormant period (telogen), which lasts about three months. When the dormant period ends the hair is shed; these are the worrisome hairs we obsess over in our comb, hairbrush, on our pillow or down the shower drain. Relax, some hair loss is perfectly normal.
Baldness or Alopecia happens when the normal pattern of hair growth is disrupted. The normal pattern of human hair growth is growing, resting, shedding and growing again. If the growth pattern is out of balance, hair does not grow back as readily as it falls out. A family history of androgenetic alopecia increases your risk of balding. Heredity also affects the age at which you begin to lose hair and the development, pattern and extent of your baldness.
What concerns us is not these normally shed hairs, but the noticeable thinning we confront in the mirror. For a woman, thick, vibrant hair is our crowning glory, our vanity visible. A luxuriant full mane epitomizes the beauty of a woman and is integrally woven into our self-image. Our culture strongly identifies femininity with a thick, silky head of hair. Throughout recorded history, images of shining, full bodied hair are associated with female beauty, youth, desirability and good health. Society unfairly identifies dry, lack luster and thinning hair with old age, sickness and poverty.
A dramatic decrease in self-esteem is evident in women when their hair begins to fall out. Hair shedding is not physically painful, however, it often causes severe emotional distress. We obsess over our thin tresses as we battle depression and self-loathing. Women frequently become introverted and withdraw from the world. We avoid intimate contact and make futile attempts to disguise the quality and quantity of our hair.
Hair loss is especially injurious to those who have professions or careers where physical appearance plays a significant role. A young woman is especially vulnerable to the stigma of balding. Not until we are confronted with the loss of our hair do we fully realize how essential hair is to our overall personality.
A woman's hair is at its thickest by age 20. Once we pass 20, however, our hair gradually begins to thin, shedding more than the normal 100-150 hairs a day. With aging, hair strands hold less pigment and become smaller so that what was once the luxuriant and thick hair of our youth becomes thin, fine and lighter in color. For even the elderly woman, significant hair loss can threaten self-image. A woman's sense of sexuality and femininity, as well as her, establish a place in family and society are often undermined by hair loss.
It is hardly surprising when a man starts balding. By the age of thirty-five, about 25 percent of American men will experience some degree of appreciable hair loss and about 75 percent are either bald or have a balding pattern by age 60.
In men, hair loss is often perceived as a sign of virility, a demonstrable sign that his male hormones are functioning at maximum capacity. To project strength and masculinity, men often choose to shave their heads.
Although many men are quite dismayed by a receding hairline, research indicates that the psychological pain of hair loss does not affect men as adversely as it impacts women. What makes coping with hair loss so difficult is the frightening lack of control, the feeling of the inability to do anything to make our hair stop falling out.
Causes Of Hair Loss In Women
As we age, women face a multitude of changes and challenges: wrinkles, a widening waist, cellulite deposits and thickening ankles. It does not seem fair that for many of us hair loss is yet another blow to our self-esteem.
Female pattern baldness or Androgenetic Alopecia is the most common type of hair loss in women and is genetic in nature. This type of female balding is caused by the chemical Dihydrotestosterone or DHT which builds up around the air follicle and over time destroys both the hair shaft and the hair follicle. Pregnancy or the onset of menopause may cause a fluctuation in the production of estrogen. Lacking sufficient estrogen to produce testosterone-blocking enzymes, testosterone is then converted to DHT on the scalp. The result is a shorter hair growth cycle, finer hair and excessive hair loss from shedding and breakage. Some women experience an increase in hair loss several months after delivering a baby.
Genetics aside, there are many other reasons why women lose hair. Surgery, extreme physical or emotional stress, hormonal imbalances, chemotherapy and scalp infections are but a few. Female hair loss can also be triggered by birth control medications, certain prescription drugs or result from the use of harsh chemicals or aggressive styling that can cause permanent damage to the fragile hair follicle. Excessive hair shedding may also be symptomatic of rapid weight loss from dangerous fad-dieting or an eating disorder such as anorexia. The use of street drugs such as cocaine will also exhibit sudden and severe hair shedding.
When To Contact A Medical Professional
Reacting intensely to the physical state of our thinning hair may seem like excessive vanity, but it is not. Baldness is not usually caused by disease but is more commonly related to heredity, aging and hormone function. However, changes in hair appearance, texture and growth patterns may indicate serious health concerns. Hair is one of the first areas, along with skin and nails, to reflect nutritional deficiencies, hormonal imbalance and illness. It is wise to pay attention.
Women's hair seems to be particularly sensitive to underlying medical conditions so it is important that women with undiagnosed hair loss be properly evaluated by a physician. If your thinning hair is a result of a medical condition, your doctor will treat these ailments and as a result, you may experience significant growth of new hair.
Once you and your doctor have identified the cause of your hair loss you may be referred to a hair specialist or implant surgeon to learn about the treatment options available such as or hair transplant procedures to promote growth or hide the loss. For some types of alopecia, hair may resume normal growth without any treatment.
A healthy balanced diet, regular exercise, hydration and rest can go a long way towards preventing hair loss and maximizing the potential of your hair growth cycle.
Although medical research is on going, the following have proved beneficial in growing and maintaining a healthy head of hair.
Nutrition
Poor nutrition is often an underlying cause of hair loss as the hair is a reliable indicator of nutritional well being. Discuss with your health care provider your diet, all medications and any supplements you may be taking. Dull hair color or dry and brittle hair may be indicators of a deficiency in essential fats in the diet, oily hair may be a sign of a B vitamin deficiency.
Recent medical studies have found that a high percentage of women with thinning hair are deficient in iron and the amino acid lysine. It is difficult to obtain sufficient lysine through diet alone. Lysine is important in the transport of iron and necessary to support hair growth. Lysine is found in eggs and red meat so vegetarians need to be aware of this potential shortfall in their diets.
The amino acids L-Cysteine and L-Methionine are believed to improve hair texture, quality, and growth.
Low-fat foods that rank high in protein, low in carbohydrates, can play a vital role in sustaining healthy hair growth and aid in preventing hair loss. Important essential fatty acids for maintaining hair health are found in walnuts, sunflower seeds, sardines, spinach, soy and canola oil. Omega 3 and Omega 6 Oils protect the heart as well as your hair so include salmon in your diet on a regular basis.
Herbal Remedies Offer Hope For Hair Loss
Discuss with your nutritional advisor or medical professional the benefits of herbs. The following natural plant derivatives have properties to encourage a healthy head of hair.
Hair Care
Always choose organic natural products to avoid the chemicals and toxins found in many hair care products. Harsh chemicals may strip the natural oils from your hair and lead to breakage and poor hair growth. Dye, hair straightening and permanent solutions are highly destructive to the hair shaft and follicle as well as the delicate sebum balance of the scalp.
Be gentle with your hair. Allow hair to dry naturally rather than using a hairdryer. A natural bristle brush is helpful in preventing damage. Do not style until completely dry. Wet hair is weak hair so handle with care. Avoid or break any bad habits you may have that pull or twist the hair. Try not to constantly run your fingers through your hair, tug at the hair and avoid hair clips or rubber bands that pull at and break off the hair. Minimize the usage of mousse, gels and hair sprays. These products dry and weigh down the hair shaft and dull the natural luster of your hair.
Avoid salt and chlorinated water when swimming. If exposed, always wash the hair with cool water and organic gentle shampoo and apply a mild conditioner. Sun worshipers should make sure that hair care products have sunscreen properties to protect hair from the damaging effects of UV rays. Remember to wear a hat to prevent sunburn of the scalp.
Healthy Lifestyle
Hair loss is traumatic, however, our hair is only part of who we are. I remind myself to keep my obsession with my hair loss in perspective and be happy with all the other areas of my life that are going right and in balance. Focus on the positive, eat well, rest well and be at peace with who you are. Remember, that for some, hair grows back as mysteriously as it disappeared.
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