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Sinusitis, also known as rhinosinusitis, is
inflammation Inflammation (from la, wikt:en:inflammatio#Latin, inflammatio) is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, damaged cells, or Irritation, irritants, and is a protective response involving im ...
of the
mucous membrane A mucous membrane or mucosa is a membrane that lines various cavities in the body of an organism and covers the surface of internal organs. It consists of one or more layers of epithelial cells overlying a layer of loose connective tissue. It i ...
s that line the sinuses resulting in symptoms that may include thick nasal mucus, a plugged nose, and facial pain. Other signs and symptoms may include
fever Fever, also referred to as pyrexia, is defined as having a temperature above the normal range due to an increase in the body's temperature set point. There is not a single agreed-upon upper limit for normal temperature with sources using val ...
,
headache Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Headaches can occur as a resul ...
s, a poor sense of smell,
sore throat Sore throat, also known as throat pain, is pain or irritation of the throat. Usually, causes of sore throat include * viral infections * group A streptococcal infection (GAS) bacterial infection * pharyngitis (inflammation of the throat) * t ...
, a feeling that phlegm is oozing out from the back of the nose to the throat along with a necessity to clear the throat frequently and frequent attacks of
cough A cough is a sudden expulsion of air through the large breathing passages that can help clear them of fluids, irritants, foreign particles and microbes. As a protective reflex, coughing can be repetitive with the cough reflex following three ph ...
. Generally sinusitis starts off as a common viral infection like common cold. This infection generally subsides within 5 to 7 days. During this time the nasal structures can swell and facilitate the stagnation of fluids in sinuses that leads to acute sinusitis which lasts from 6th day of the infection to 15th day. From the 15th day to 45th day of the infection comes the subacute stage followed by chronic stage. Whenever a chronic stage patient's immunity takes a hit the infection moves to "acute on sinusitis" stage and moves back to chronic when the immunity is up. Sinusitis occurs only in individuals with underlying conditions like
allergies Allergies, also known as allergic diseases, refer a number of conditions caused by the hypersensitivity of the immune system to typically harmless substances in the environment. These diseases include hay fever, food allergies, atopic derm ...
, or structural problems in the nose and in people with lesser immunity against bacteria by birth. Most cases are caused by a viral infection. Recurrent episodes are more likely in persons with
asthma Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, c ...
,
cystic fibrosis Cystic fibrosis (CF) is a rare genetic disorder that affects mostly the lungs, but also the pancreas, liver, kidneys, and intestine. Long-term issues include difficulty breathing and coughing up mucus as a result of frequent lung infections. ...
, and poor immune function. In early stages an ENT doctor confirms sinusitis using nasal endoscopy. Diagnostic imaging is not usually needed in acute stage unless complications are suspected. In chronic cases, confirmatory testing is recommended by either direct visualization or
computed tomography A computed tomography scan (CT scan; formerly called computed axial tomography scan or CAT scan) is a medical imaging technique used to obtain detailed internal images of the body. The personnel that perform CT scans are called radiographers ...
. Some cases may be prevented by hand washing, avoiding smoking, and
immunization Immunization, or immunisation, is the process by which an individual's immune system becomes fortified against an infectious agent (known as the immunogen). When this system is exposed to molecules that are foreign to the body, called ''non-s ...
. Pain killers such as
naproxen Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) used to treat pain, menstrual cramps, inflammatory diseases such as rheumatoid arthritis, gout and fever. It is taken orally. It is available in immediate and delayed release formula ...
,
nasal steroid Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involve ...
s, and nasal irrigation may be used to help with symptoms. Recommended initial treatment for acute sinusitis is watchful waiting. If symptoms do not improve in 7–10 days or get worse, then an
antibiotic An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting pathogenic bacteria, bacterial infections, and antibiotic medications are widely used in the therapy, ...
may be used or changed. In those in whom antibiotics are used, either
amoxicillin Amoxicillin is an antibiotic medication used to treat a number of bacterial infections. These include middle ear infection, strep throat, pneumonia, skin infections, and urinary tract infections among others. It is taken by mouth, or less comm ...
or amoxicillin/clavulanate is recommended first line. Surgery may occasionally be used in people with chronic disease or in someone who is not responding to medicines as per doctor's expectation. Sinusitis is a common condition. It affects between about 10 and 30 percent of people each year in the United States and Europe. Chronic sinusitis affects about 12.5% of people. Treatment of sinusitis in the United States results in more than 11 billion in costs. The unnecessary and ineffective treatment of viral sinusitis with antibiotics is common.


Signs and symptoms

Headache, facial pain, or pressure of a dull, constant, or aching sort over the affected sinuses is common with both acute and chronic stages of sinusitis. This pain is usually localized to the involved sinus and may worsen when the affected person bends over or lies down. Pain often starts on one side of the head and progresses to both sides. Acute sinusitis may be accompanied by a thick
nasal discharge Rhinorrhea, rhinorrhoea, or informally runny nose is the free discharge of a thin mucus fluid from the nose; it is a common condition. It is a common symptom of allergies (hay fever) or certain viral infections, such as the common cold or COVID-1 ...
that is usually green in color, and may contain
pus Pus is an exudate, typically white-yellow, yellow, or yellow-brown, formed at the site of inflammation during bacterial or fungal infection. An accumulation of pus in an enclosed tissue space is known as an abscess, whereas a visible collection ...
or blood. Often, a localized headache or
toothache Toothache, also known as dental pain,Segen JC. (2002). ''McGraw-Hill Concise Dictionary of Modern Medicine''. The McGraw-Hill Companies. is pain in the teeth or their supporting structures, caused by dental diseases or pain referred to the t ...
is present, and these symptoms distinguish a sinus-related headache from other types of headaches, such as tension and
migraine Migraine (, ) is a common neurological disorder characterized by recurrent headaches. Typically, the associated headache affects one side of the head, is pulsating in nature, may be moderate to severe in intensity, and could last from a few ho ...
headaches. Another way to distinguish between toothache and sinusitis is that the pain in sinusitis is usually worsened by tilting the head forward and with the
Valsalva maneuver The Valsalva maneuver is performed by a forceful attempt of exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut while expelling air out as if blowing up a balloon. Variations of the maneuver can ...
. Other symptoms associated with acute rhinosinusitis include cough, fatigue, hyposmia,
anosmia Anosmia, also known as smell blindness, is the loss of the ability to detect one or more smells. Anosmia may be temporary or permanent. It differs from hyposmia, which is a decreased sensitivity to some or all smells. Anosmia can be due to a nu ...
and ear fullness or pressure. Text was copied from this source, which is available under
Creative Commons Attribution 4.0 International License
Sinus infections can also cause middle-ear problems due to the congestion of the nasal passages. This can be demonstrated by dizziness, "a pressurized or heavy head", or vibrating sensations in the head.
Postnasal drip Post-nasal drip (PND), also known as upper airway cough syndrome (UACS), occurs when excessive mucus is produced by the nasal mucosa. The excess mucus accumulates in the back of the nose, and eventually in the throat once it drips down the back of ...
is also a symptom of chronic rhinosinusitis. Halitosis (bad breath) is often stated to be a symptom of chronic rhinosinusitis; however, gold-standard breath analysis techniques have not been applied. Theoretically, several possible mechanisms of both objective and subjective halitosis may be involved. A 2005 review suggested that most "sinus headaches" are migraines. The confusion occurs in part because migraine involves activation of the
trigeminal nerves In neuroanatomy, the trigeminal nerve ( lit. ''triplet'' nerve), also known as the fifth cranial nerve, cranial nerve V, or simply CN V, is a cranial nerve responsible for sensation in the face and motor functions such as biting and chewing; ...
, which innervate both the sinus region and the meninges surrounding the brain. As a result, accurately determining the site from which the pain originates is difficult. People with migraines do not typically have the thick nasal discharge that is a common symptom of a sinus infection. Symptoms of chronic sinusitis may include
nasal congestion Nasal congestion is the blockage of nasal breathing usually due to membranes lining the nose becoming swollen from inflamed blood vessels. Background In about 85% of cases, nasal congestion leads to mouth breathing rather than nasal breathing. ...
, facial pain,
headache Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Headaches can occur as a resul ...
, night-time coughing, an increase in previously minor or controlled asthma symptoms, general malaise, thick green or yellow
discharge Discharge may refer to Expel or let go * Discharge, the act of firing a gun * Discharge, or termination of employment, the end of an employee's duration with an employer * Military discharge, the release of a member of the armed forces from serv ...
, feeling of facial fullness or tightness that may worsen when bending over, dizziness, aching teeth, and bad breath. Often, chronic sinusitis can lead to
anosmia Anosmia, also known as smell blindness, is the loss of the ability to detect one or more smells. Anosmia may be temporary or permanent. It differs from hyposmia, which is a decreased sensitivity to some or all smells. Anosmia can be due to a nu ...
, the loss of the sense of
smell Smell may refer to; * Odor, airborne molecules perceived as a scent or aroma * Sense of smell, the scent also known scientifically as olfaction * "Smells" (''Bottom''), an episode of ''Bottom'' * The Smell, a music venue in Los Angeles, Californ ...
.


By location

The four paired
paranasal sinuses Paranasal sinuses are a group of four paired air-filled spaces that surround the nasal cavity. The maxillary sinuses are located under the eyes; the frontal sinuses are above the eyes; the ethmoidal sinuses are between the eyes and the sph ...
are the frontal, ethmoidal, maxillary, and sphenoidal sinuses. The ethmoidal sinuses are further subdivided into anterior and posterior ethmoid sinuses, the division of which is defined as the basal lamella of the middle nasal concha. In addition to the severity of
disease A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
, discussed below, sinusitis can be classified by the sinus cavity it affects: *
Maxillary Maxillary means "related to the maxilla (upper jaw bone)". Terms containing "maxillary" include: * Maxillary artery *Maxillary nerve In neuroanatomy, the maxillary nerve (V) is one of the three branches or divisions of the trigeminal nerve, ...
– can cause
pain Pain is a distressing feeling often caused by intense or damaging stimuli. The International Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with, or resembling that associated with, ...
or pressure in the maxillary (
cheek The cheeks ( la, buccae) constitute the area of the face below the eyes and between the nose and the left or right ear. "Buccal" means relating to the cheek. In humans, the region is innervated by the buccal nerve. The area between the insi ...
) area (''e.g.,'' toothache, or
headache Headache is the symptom of pain in the face, head, or neck. It can occur as a migraine, tension-type headache, or cluster headache. There is an increased risk of depression in those with severe headaches. Headaches can occur as a resul ...
) (J01.0/J32.0) * Frontal – can cause pain or pressure in the frontal sinus cavity (located above the eyes), headache, particularly in the forehead (J01.1/J32.1) * Ethmoidal – can cause pain or pressure pain between/behind the eyes, the sides of the upper part of the nose (the medial canthi), and headaches (J01.2/J32.2) * Sphenoidal – can cause pain or pressure behind the eyes, but is often
felt Felt is a textile material that is produced by matting, condensing and pressing fibers together. Felt can be made of natural fibers such as wool or animal fur, or from synthetic fibers such as petroleum-based acrylic or acrylonitrile or w ...
in the top of the head, over the mastoid processes, or the back of the head.


Complications

Complications are thought to be rare (1 case per 10,000). The proximity of the brain to the sinuses makes the most dangerous complication of sinusitis, particularly involving the frontal and sphenoid sinuses, infection of the brain by the invasion of anaerobic bacteria through the bones or
blood vessel Blood vessels are the structures of the circulatory system that transport blood throughout the human body. These vessels transport blood cells, nutrients, and oxygen to the tissues of the body. They also take waste and carbon dioxide away from ...
s. Abscesses,
meningitis Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, headache, and neck stiffness. Other symptoms include confusion ...
, and other life-threatening conditions may result. In extreme cases, the patient may experience mild personality changes, headache, altered consciousness, visual problems, seizures,
coma A coma is a deep state of prolonged unconsciousness in which a person cannot be awakened, fails to respond normally to painful stimuli, light, or sound, lacks a normal wake-sleep cycle and does not initiate voluntary actions. Coma patients exhi ...
, and possibly death. Sinus infection can spread through anastomosing veins or by direct extension to close structures. Orbital complications were categorized by Chandler et al. into five stages according to their severity (see table). Contiguous spread to the orbit may result in periorbital
cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of ...
, subperiosteal abscess, orbital cellulitis, and abscess. Orbital cellulitis can complicate acute ethmoiditis if anterior and posterior
ethmoidal vein The ethmoidal veins are the venae comitantes Vena comitans is Latin for accompanying vein. It refers to a vein that is usually paired, with both veins lying on the sides of an artery. They are found in close proximity to arteries so that the p ...
s thrombophlebitis enables the spread of the infection to the lateral or orbital side of the ethmoid labyrinth. Sinusitis may extend to the
central nervous system The central nervous system (CNS) is the part of the nervous system consisting primarily of the brain and spinal cord. The CNS is so named because the brain integrates the received information and coordinates and influences the activity of all p ...
, where it may cause cavernous sinus thrombosis, retrograde
meningitis Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, headache, and neck stiffness. Other symptoms include confusion ...
, and epidural, subdural, and brain abscesses. Orbital symptoms frequently precede intracranial spread of the infection . Other complications include sinobronchitis, maxillary osteomyelitis, and frontal bone osteomyelitis.
Osteomyelitis Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the ...
of the frontal bone often originates from a spreading thrombophlebitis. A periostitis of the frontal sinus causes an osteitis and a periostitis of the outer membrane, which produces a tender, puffy swelling of the forehead. The diagnosis of these complications can be assisted by noting local tenderness and dull pain, and can be confirmed by CT and nuclear
isotope Isotopes are two or more types of atoms that have the same atomic number (number of protons in their nuclei) and position in the periodic table (and hence belong to the same chemical element), and that differ in nucleon numbers ( mass number ...
scanning. The most common microbial causes are anaerobic bacteria and '' S. aureus''. Treatment includes performing surgical drainage and administration of antimicrobial therapy. Surgical
debridement Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy. ...
is rarely required after an extended course of
parenteral A route of administration in pharmacology and toxicology is the way by which a drug, fluid, poison, or other substance is taken into the body. Routes of administration are generally classified by the location at which the substance is applied. ...
antimicrobial therapy. Chronic sinus infections may lead to mouth breathing, which can result in mouth dryness and an increased risk of gingivitis. Decongestants may also cause mouth dryness. If an odontogenic infection involves the maxillary sinus, odontogenic sinusitis (ODS) may ensue. Odontogenic sinusitis can often spread to other sinuses such as the ethmoid, frontal and (less frequently) sphenoid sinus, and even to the contralateral nasal cavity. In rare instances, these infections may involve the
orbit In celestial mechanics, an orbit is the curved trajectory of an object such as the trajectory of a planet around a star, or of a natural satellite around a planet, or of an artificial satellite around an object or position in space such a ...
, causing orbital
cellulitis Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of ...
, which may in turn result in blindness, or determine central nervous system complications such as
meningitis Meningitis is acute or chronic inflammation of the protective membranes covering the brain and spinal cord, collectively called the meninges. The most common symptoms are fever, headache, and neck stiffness. Other symptoms include confusion ...
, subdural empyema,
brain abscess Brain abscess (or cerebral abscess) is an abscess caused by inflammation and collection of infected material, coming from local (ear infection, dental abscess, infection of paranasal sinuses, infection of the mastoid air cells of the temporal b ...
and life-threatening cavernous sinus thrombosis. Infection of the eye socket is a rare complication of ethmoid sinusitis, which may result in the loss of sight and is accompanied by fever and severe illness. Another possible complication is the infection of the bones (
osteomyelitis Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the ...
) of the forehead and other facial bones – Pott's puffy tumor.


Causes


Acute

Acute sinusitis is usually precipitated by an earlier upper respiratory tract infection, generally of
viral Viral means "relating to viruses" (small infectious agents). Viral may also refer to: Viral behavior, or virality Memetic behavior likened that of a virus, for example: * Viral marketing, the use of existing social networks to spread a marke ...
origin, mostly caused by
rhinovirus The rhinovirus (from the grc, ῥίς, rhis "nose", , romanized: "of the nose", and the la, vīrus) is the most common viral infectious agent in humans and is the predominant cause of the common cold. Rhinovirus infection proliferates in te ...
es (with RVA and RVC giving more severe infection than RVB), coronaviruses, and influenza viruses, others caused by adenoviruses, human parainfluenza viruses, human respiratory syncytial virus, enteroviruses other than rhinoviruses, and
metapneumovirus ''Metapneumovirus'' is a genus of viruses in the family ''Pneumoviridae''. The genus contains two species: * Avian metapneumovirus (aMPV) * Human metapneumovirus ''Human metapneumovirus'' (HMPV) is a negative-sense single-stranded RNA virus o ...
. If the infection is of bacterial origin, the most common three causative agents are ''
Streptococcus pneumoniae ''Streptococcus pneumoniae'', or pneumococcus, is a Gram-positive, spherical bacteria, alpha-hemolytic (under aerobic conditions) or beta-hemolytic (under anaerobic conditions), aerotolerant anaerobic member of the genus Streptococcus. They a ...
(38%)'', ''
Haemophilus influenzae ''Haemophilus influenzae'' (formerly called Pfeiffer's bacillus or ''Bacillus influenzae'') is a Gram-negative, non-motile, coccobacillary, facultatively anaerobic, capnophilic pathogenic bacterium of the family Pasteurellaceae. The bacte ...
(36%)'', and ''
Moraxella catarrhalis ''Moraxella catarrhalis'' is a fastidious, nonmotile, Gram-negative, aerobic, oxidase-positive diplococcus that can cause infections of the respiratory system, middle ear, eye, central nervous system, and joints of humans. It causes the i ...
(16%)''. Until recently, ''H. influenzae'' was the most common bacterial agent to cause sinus infections. However, introduction of the ''H. influenzae'' type B (Hib) vaccine has dramatically decreased these infections and now non-typable ''H. influenzae'' (NTHI) is predominantly seen in clinics. Other sinusitis-causing
bacterial Bacteria (; singular: bacterium) are ubiquitous, mostly free-living organisms often consisting of one biological cell. They constitute a large domain of prokaryotic microorganisms. Typically a few micrometres in length, bacteria were among ...
pathogen In biology, a pathogen ( el, πάθος, "suffering", "passion" and , "producer of") in the oldest and broadest sense, is any organism or agent that can produce disease. A pathogen may also be referred to as an infectious agent, or simply a ger ...
s include '' S. aureus'' and other
streptococci ''Streptococcus'' is a genus of gram-positive ' (plural ) or spherical bacteria that belongs to the family Streptococcaceae, within the order Lactobacillales (lactic acid bacteria), in the phylum Bacillota. Cell division in streptococci ...
species In biology, a species is the basic unit of Taxonomy (biology), classification and a taxonomic rank of an organism, as well as a unit of biodiversity. A species is often defined as the largest group of organisms in which any two individuals of ...
, anaerobic bacteria and, less commonly,
Gram-negative Gram-negative bacteria are bacteria that do not retain the crystal violet stain used in the Gram staining method of bacterial differentiation. They are characterized by their cell envelopes, which are composed of a thin peptidoglycan cell wa ...
bacteria. Viral sinusitis typically lasts for 7 to 10 days. Acute episodes of sinusitis can also result from
fungal A fungus ( : fungi or funguses) is any member of the group of eukaryotic organisms that includes microorganisms such as yeasts and molds, as well as the more familiar mushrooms. These organisms are classified as a kingdom, separately from ...
invasion. These infections are typically seen in people with
diabetes Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level (hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ...
or other immune deficiencies (such as AIDS or
transplant Transplant or Transplantation may refer to: Sciences *Transplanting a plant from one location to another *Organ transplantation, moving an organ from one body to another *Transplant thought experiment, an experiment s