Rhinosinusitis

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Abstract

■ Inflammation causes changes in the nasal and sinus mucosa.
■ Edema occurs and this is followed by a transudate. The effect of edema is that it causes obstruction of the ostia of the sinuses, thereby causing impairment in the drainage of secretions.
■ The quality of the mucus changes.
■ Inflammation causes the cilia to become paralyzed. This may be temporary or sustained, depending upon the severity of damage.
■ The outcome of all these changes is that mucus collects within the sinuses and stasis occurs.
■ Initially, the secretions are sterile. They can soon get contaminated with bacteria by nose-blowing, which forces the bacteria into the sinuses from the nasal cavity.
■ This results in an acute bacterial infection within the sinuses.
■ This can resolve either spontaneously or with the aid of medication. If it does not resolve it can result in chronic disease.
■ The criteria for the diagnosis of acute (presumed bacterial) rhinosinusitis include having symptoms that persist for 10 days up to a maximum of 24 days.
■ Fever should be present. Symptoms for diagnosis should include anterior and/or posterior nasal discharge, nasal obstruction, and facial pain.
■ Objective documentation should include a nasal airway examination for purulent discharge and radiographic evidence of acute rhinosinusitis.
■ Both nasal endoscopy and CT are objective measures that can increase the accuracy of the chronic rhinosinusitis (CRS) diagnosis.
■ Nasal endoscopic observation of pus, polyps or other disease can help confirm a diagnosis of CRS.
■ For areas that cannot be observed with nasal endoscopy, CT can be useful in helping to diagnose disease.
■ The use of combining symptoms, findings on nasal endoscopy, and the findings on CT scans can reliably and accurately diagnose and treat CRS.
■ Newer instruments and powered tools are now available making mucosal preservation possible.
■ Areas in the healing sinus cavity that demonstrate polypoid mucosa are most likely the areas that will demonstrate persistent inflammation. This is likely due to an osteitis reaction.
■ Aggressive postoperative debridement of devitalized bone in these areas will result in improved epithelialization of the sinus cavity. Simultaneously, equally aggressive management of infection and inflammation is needed.
■ Long-term antibiotics and long-term application of topical steroids are appropriate for the management of these conditions.
■ Literature is accumulating in support of the use of topical steroids, which are given preoperatively as well as postoperatively.
■ Details of endoscopic sinus surgery are provided elsewhere in this textbook.
■ It has been found that a definite relationship exists among allergy, bronchial asthma, and RS.
■ The allergic component must be treated appropriately if the management of RS is to be successful.
■ Similarly, successful sinus surgery results in a better ability to control bronchial asthma.