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INTRODUCTION
From the Iirst breath at birth, the rate and depth oI our breathing are unconsciously
matched to our activity, whether studying, sleeping, talking, eating, or exercising. We can
voluntarily stop breathing, but within a Iew seconds we must breathe again. Breathing is a
characteristic oI liIe that, along with the pulse, it is one oI the Iirst things we check to determine
iI an unconscious person is alive.
Breathing is necessary because all living cells oI the body require oxygen and produce
carbon dioxide. The respiratory system allows the exchange oI these gases between the air and
the blood, and the cardiovascular system transports them between the lungs and the cells oI the
body. The capacity to carry out normal activity is reduced without healthy respiratory and
cardiovascular systems.
Respiration includes the Iollowing process: ventilation, or breathing, which is the
movement oI air into and out oI the lungs, exchange oI oxygen and carbon dioxide between the
air in the lungs and the blood, transport oI oxygen and carbon dioxide in the blood; and exchange
oI oxygen and carbon dioxide between the blood and the tissues. The term respiration is also
used in reIerence to cell metabolism.
Respiration is necessary because all living cells oI the body require oxygen and produce
carbon dioxide. Its Iunctions include gas exchange. The respiratory system and the
cardiovascular system work together to supply oxygen to all cells and to remove carbon dioxide.
It also helps in regulation oI the pH. The respiratory system can alter blood pH by changing
blood carbon dioxide levels. It is also responsible in voice production. Air movement past the
vocal Iolds makes sound and speech possible. The sensation oI smell occurs when airborne
molecules are drawn into the nasal cavity which is called olIaction. Another Iunction oI the
respiratory system is protection. The respiratory system provides protection against some micro
organisms by preventing their entry into the body and by removing them Irom the respiratory
surIaces.
NTOMY ND PHYSIOLOGY OF THE
RESPIRTORY SYSTEM
The respiratory system consists oI the external nose, nasal cavity, the pharynx, the larynx,
the trachea, the bronchi, and the lungs. Although air Irequently passes through the oral cavity, it
is considered to be a part oI the digestive system instead oI the respiratory system. The upper
respiratory tract consists oI external nose, nasal cavity, pharynx and associated structures, and
the lower respiratory tract consists oI larynx, trachea, bronchi and the lungs.
Chapter II
Upper irway Infe.tions
&pper airway inIections are the most common cause oI illness and aIIect most people on
occasion. Some inIections are acute, with symptoms that last several days; others are chronic,
with symptoms that last a long time or recur. !atients with these conditions seldom require
hospitalization. However, nurses working in the community settings or long term care Iacilities
may encounter patients who have these inIections. ThereIore, it is important Ior the nurse to
recognize the signs and symptoms and to provide appropriate care.
InIections oI the upper airway are also known as upper respiratory tract inIection (&RIs);
the common cold is the most Irequently occurring example. &RIs occur when micro organism
such as viruses and bacteria are inhaled. There are many causative micro organisms, and people
are susceptible throughout liIe. &RIs is the most common reason Ior seeking health care and Ior
absences Irom school and work.
RHINITIS
Rhinitis is a group oI disorders characterized by inIlammation and irritation oI the
mucous membranes oI the nose. These conditions can have a signiIicant impact on quality oI liIe
and contribute to sinus, ear and sleep problems and learning disorder. Rhinitis oIten coexists with
other respiratory disorders such as asthma. Rhinitis may be acute or chronic; non- allergic or
allergic.
PTHOPHYSIOLOGY
Rhinitis may be caused by variety oI Iactors, including change in temperature or
humidity; odors; inIection; age; systemic disease; use oI over the counter drugs and prescribed
nasal decongestant; and the presence oI a Ioreign body. Allergic rhinitis may occur with
exposure to allergens such as Ioods, medications and particles in the indoor and outdoor
environment. The most common cause oI no allergic rhinitis is common cold. Drug induced
rhinitis may occur with anti hypertensive agent such as ACE inhibitor and beta blockers.
CA&SE
The mucous membrane lining the nasal
passage becomes inIlamed, congested, and
edematous.
The swollen nasal conchae block the sinus
openings and mucus discharged Irom the
nostrils.
CUSE
a. Vasomotor
Idiopathic
Abuse oI nasal decongestant
!sychological stimulation
Irritants
b. Mechanical
Tumor
Deviated septum
Crusting
Hypertrophied turbinates
Foreign body
CSF leak
CLINICL MNIFESTTIONS
O Rhinorrhea (excessive nasal drainage, runny nose)
O Nasal congestion
O Nasal discharge
O Sneezing
O !ruritus oI the nose
O Headache
MEDICL MNGEMENT
O In allergic rhinitis, test may be perIormed to identiIy possible allergens.
O In viral rhinitis, medications are given to relieve symptoms
O !atients with septaldeIormitis or nasal polyps may be reIerred to an ear, nose and throat
specialist.
PHRMCOLOGIC MNGEMENT
O Anti histamines Ior sneezing, pruritus and rhinorrhea
Diphenhydramine (Benadryl)
Chlorpheniramine( Chlor- trimeton)
Brompheniramine
O Second generation anti histamines
Loratadine( Alavert, Claritin)
FexoIenadine (Allegra)
Cetirizine( Zytrec)
NURSING MNGEMENT
O Instruct patient with allergic rhinitis to avoid exposure to allergens.
O !atient education when assisting the patient in the use oI all medication.
O To prevent possible drug interactions, the patient is cautioned to read drug labels
beIore taking OTC medication.
O Saline nasal spray or aerosols may be helpIul in soothing mucous membrane,
soItening crusted secretions and removing irritants.
O To achieve maximal relieI, the patient is instructed to blow the nose beIore
applying any medication to nasal cavity. The patient is taught to keep the head
upright; spray quickly and Iirmly into each nostril away Irom nasal septum and
wait at least 1 minute beIore administering the second spray.
VIRL RHINITIS
The common cold, also called viral rhinitis, is one oI the most common inIectious
diseases in humans. The inIection is usually mild and improves without treatment. Because oI
the large number oI people who get the common cold, this illness results in nearly 26 million
days oI missed school and 23 million days oI absence Irom work every year in the &nited States.
The average American has one to three colds per year.
The common cold is an upper respiratory inIection that is caused by several Iamilies oI
viruses. Within these virus Iamilies, more than 200 speciIic viruses that can cause the common
cold have been identiIied. The virus Iamily that causes the most colds is called rhinovirus.
Rhinoviruses cause up to 40 percent oI colds, and this virus Iamily has at least 100 distinct virus
types in its group. Other important upper respiratory virus Iamilies are named coronavirus,
adenovirus and respiratory syncytial virus. Since so many viruses can cause cold symptoms,
development oI a vaccine Ior the common cold has not been possible.
Rhinoviruses cause most colds in the early Iall and spring. Other viruses tend to cause
winter colds and their symptoms can be more debilitating. There is no evidence that going out in
cold or rainy weather makes you more likely to catch a cold.
CLINICL MNIFESTTIONS
O Nasal congestion
O Rhinorrhea
O Sneezing
O Tearing watery eyes
O Scratchy or sore throat
O eneral malaise
O Low grade Iever
O Chills
O Headache
O Muscle ache
TRETMENTS
Although medical therapies can improve the symptoms oI the common cold, they do not
prevent, cure or shorten the illness. Drink enough Iluids, get plenty oI rest, and treat your
symptoms to keep yourselI as comIortable as possible. argling warm salt water can soothe a
sore throat. Inhaling steam may improve nasal congestion temporarily. Over-the-counter cold
remedies that contain a decongestant will help to dry secretions and relieve congestion. These
remedies may also relieve cough, iI the cough is triggered by mucus in the throat. Antihistamines
may improve the symptoms oI runny nose and watery eyes, but they should be used with care
because over-the-counter versions cause sedation. Over-the-counter cough suppressants do not
have a proven beneIit, but some people Ieel that they are helpIul. It is important to keep in mind
that antibiotics do not cure the common cold or shorten the length oI time that symptoms last.
Vitamin C, zinc and echinacea (a Irequently used herbal therapy) have been widely rumored to
decrease the likelihood oI developing the common cold and to shorten symptoms, but no
conclusive research has demonstrated that this is true.
NURSING MNGEMENT
Hand washing remains the most eIIective measure to prevent transmission oI organisms.
The nurse teaches the patient how to break the chain oI inIection with appropriate hand washing
or hand hygiene and the use oI tissue to prevent the spread oI virus with coughing and sneezing.
CUTE PHRYNGITIS
Acute pharyngitis is a sudden painIul inIlammation oI the pharynx, the back portion oI the throat
that includes the posterior third oI the tongue, soIt palate, and tonsils. It is commonly reIerred to
as a sore throat. Viral pharyngitis spreads easily in the droplets oI coughs and sneezes and
unclean hands that have been exposed to the contaminated Iluids.
PTHOPHYSIOLOGY
Viral inIection causes most cases oI acute pharyngitis. Responsible viruses include the
adenovirus, inIluenza virus, Epstein-Barr virus, and herpes simplex virus. Bacterial inIection
accounts Ior the remainder oI cases. Ten percent oI adults with pharyngitis have group A beta-
hemolytic streptococcus, which is commonly reIerred to as group A streptococcus (AS) or
streptococcal pharyngitis. When AS causes acute pharyngitis the body responds by triggering
an inIlammatory response in the pharynx. Resulting to pain, Iever, vasodilation, edema, and
tissue damage, maniIested by redness and swelling in the tonsillar pillars, uvula and soIt palate.
Other bacterial organisms implicated in acute pharyngitis include Mycoplasma pneumonia,
Neisseria gonorrhea and H. inIluenza type B.
CLINICL MNIFESTTIONS
O Fiery-red pharyngeal membrane and tonsils
O Lymphoid Iollicles that are swollen and Ilecked with white-purple exudates
O Enlarged and tender cervical lymph nodes
O Fever
O Malaise
O Sore throat
O Heaache
O Myalgia
Occasionally, patients with AS pharyngitis may exhibit:
O Vomiting
O Anorexia
O Scarlatina-Iorm rash with urticaria (known as scarlet Iever)
DIGNOSTIC FINDINGS
O The most dependable method to determine the cause is trough swab specimens obtained
Irom posterior pharynx and tonsils.
O Rapid streptococcal antigen test newer and more rapid diagnostic test. However, its
accuracy varies widely depending on the person perIorming the test.
MEDICL MNGEMENT
O II the cause s bacterial, penicillin is usually the treatment oI choice. !enicillin V
potassium given Ior 5 days is the regimen oI choice.
O Erythromycin may also be given
O Cephalosporins and macrolides (clarithromycin and azithromycin) may be used iI there is
any allergy or resistance to penicillin and erythromycin.
O Analgesics may also be prescribed to relieve severe sore throats.
O Some patients may Iind salt-water gargling to be soothing. In severe cases, gargles with
benzocaine may relieve symptoms.
O Liquid or soIt diet is provided during the acute stage oI the disease.
O Cool beverages, warm liquids and Ilavored Irozen desserts may also be soothing.
NURSING MNGEMENT
O Initiation and correct administration oI prescribed antibiotic therapy.
O Instruct patient to seek medical assistance iI dyspnea, drooling, inability to swallow, and
inability to Iully open the mouth occur.
O Instruct patient to have bed rest during the Iebrile stage oI illness and to rest Irequently
once up and about.
O Instruct patient to dispose used tissues properly to prevent spread oI inIection.
O Examine skin once or twice daily because acute pharyngitis may lead to some other
communicable disease (e.g. rubella)
O Ice collar to relieve severe sore throats.
O !roper mouth care to prevent the development oI Iissures oI the lips and oral
inIlammation when bacterial inIection is present.
CHRONIC PHRYNGITIS
It is a persistent inIlammation oI the pharynx. It is common in adults who work in dusty
surroundings, use their voice to excess, suIIer Irom chronic cough or habitually use alcohol or
tobacco.
3 types:
O Hypertrophic: characterized by general thickening and congestion oI the pharyngeal
mucous membrane.
O Atrophic: !robably a late sign oI the Iirst type ( the membrane is thin, whitish, glistening,
and at times wrinkled)
O Chronic granular (clergyman`s sore throat): Characterized by numerous swollen lymph
Iollicles on the pharyngeal wall.
CLINICL MNIFESTTION
O Constant sense oI irritation or Iullness in the throat
O Mucus that collects in the throat and can be expelled by coughing
O DiIIiculty swallowing
MEDICL MNGEMENT
Treatment oI chronic pharyngitis is based on relieving symptoms, avoiding exposure to irritants,
and correcting any upper respiratory, pulmonary, gastrointestinal or cardiac condition that might
be responsible Ior a chronic cough.
O Nasal congestion may be relieved by short-term use oI nasal sprays or medications
containing ephedrine sulIate or phenylephrine HCl
O For adults with chronic pharyngitis tonsillectomy is an eIIective option.
NURSING MNGEMENT
O Instruct patient to avoid contact with others until the Iever subsides to prevent the spread
oI inIection.
O Instruct to avoid alcohol, tobacco, secondhand smoke, and exposure to cold or
environmental or occupational pollutants.
O Instruct patient to wear disposable mask to minimize exposure to pollutants.
O Encourage patient to drink plenty oI water
O argling with warm saline solution may relieve throat discomIort.
O Lozenges keep the throat moistened.
PERITONSILLR BSCESS
Peritonsillar abscess also called 6:insy is the most common major suppurative complication Ior
sore throat. This collection oI purulent exudate between the tonsillar capsule and the surrounding
tissues, including the soIt palate may develop aIter an acute tonsillar inIection those progresses
to a local cellulitis and abscess.
The most common causative organism is Cro:5 A Beta-Hemolytic Stre5tococci (CABHS).
CLINICL MNIFESTTIONS
O Severe sore throat
O Fever
O Trismus (inability to open the mouth)
O Drooling
O DiIIiculty oI swallowing the saliva because oI pain
O !atient`s breath smells rancid
O Raspy voice
O Odynophagia (severe sensation oI burning, squeezing pain while swallowing)
O Dysphagia (diIIiculty in swallowing)
O Otalgia (pain in the ear)
O Enlarged cervical lymph nodes
SSESSMENT and DIGNOSTIC FINDINGS
O Intraoral ultrasound
O Transcutaneous cervical ultrasound
MEDICL MNGEMENT
` Antimicrobial agents and corticosteroid thera5y are used Ior treatment oI peritonsillar abscess.
Antibiotics(usually 5enicillin are extremely eIIective in controlling the inIection and iI they are
prescribed early in the course oI the disease, the abscess may resolve without needing to be
incised.
SURGICL MNGEMENT
Treatment choices include:
Aeedle as5iration- may be preIerred over a more extensive procedure due to high
eIIicacy, low cost and patient tolerance.
- the mucus membrane over the swelling is Iirst sprayed with topical anesthetic
and then injected with a local anesthetic.
Incision and drainage :nder local or general anesthesia
- patient is in sitting position to make it easier to expectorate the blood and pus
that accumulate in the pharynx.
- it is also eIIective but more painIul than needle aspiration
rainage of the abscess with sim:ltaneo:s tonsillectomy
- there is a risk oI hemorrhage
NURSING MNGEMENT
The nurse encourage the use oI prescribed topical anesthetic agents and assists with throat
irrigations or the Irequent use oI mouthwashes or gargles with the use oI saline or alkaline
solutions at a temperature oI 40.6 C to 43.3 C.
argle gently at intervals oI 1 to 2 hrs Ior 24 to 36 hours..
Liquids that are cool are usually tolerated. Adequate Iluids must be provided to treat
dehydration and prevent its reoccurrence.
Encourage Ior continuation oI good oral hygiene.
CUTE SINUSITIS
Acute sinusitis (acute rhinosinusitis) causes the cavities around your nasal passages (sinuses) to
become inIlamed and swollen. This interIeres with drainage and causes mucus to build up.
With acute sinusitis, it may be diIIicult to breathe through your nose. The area around your eyes
and Iace may Ieel swollen, and you may have throbbing Iacial pain or a headache.
Acute sinusitis is most oIten caused by the common cold. Other triggers include bacteria,
allergies and Iungal inIections. Treatment oI acute sinusitis depends on the cause. In most cases,
home remedies are all that's needed. However, persistent sinusitis can lead to serious inIections
and other complications.
Acute sinusitis symptoms oIten include:
O Drainage oI a thick, yellow or greenish discharge Irom the nose or down the back oI the throat
O Nasal obstruction or congestion, causing diIIiculty breathing through your nose
O !ain, tenderness, swelling and pressure around your eyes, cheeks, nose or Iorehead
O Aching in your upper jaw and teeth
O Reduced sense oI smell and taste
O Cough, which may be worse at night
Other signs and symptoms can include:
O Ear pain
O Headache
O Sore throat
O Bad breath (halitosis)
O Fatigue
O Fever
When to see a do.tor
II you have mild symptoms oI sinusitis, try selI-care.
Conta.t yo:r do.tor iI you have any oI the Iollowing:
O Symptoms that don't improve within a Iew days or symptoms that get worse
O A persistent Iever
O A history oI recurrent or chronic sinusitis
See a do.tor i22ediately iI you have signs or symptoms that may indicate a serious inIection:
O !ain or swelling around your eyes
O Swollen Iorehead
O Severe headache
O ConIusion
O Double vision or other vision changes
O StiII neck
O Shortness oI breath
Causes:
When you have sinusitis, the mucous membranes oI your nose, sinuses and throat (upper
respiratory tract) become inIlamed. Swelling obstructs the sinus openings and prevents mucus
Irom draining normally, causing Iacial pain and other sinusitis symptoms.
Blocked sinuses create a moist environment that makes it easier Ior inIection to take hold.
Sinuses that become inIected and can't drain become pus Iilled, leading to symptoms such as
thick, yellow or greenish discharge and other symptoms oI inIection.
Acute sinusitis can be caused by:
O Viral infe.tion. Most cases oI acute sinusitis are caused by the common cold.
O Ba.terial infe.tion. When an upper respiratory tract inIection persists longer than seven to 10
days, it's more likely to be caused by a bacterial inIection than by a viral inIection.
O F:ngal infe.tion. You're at increased risk oI a Iungal inIection iI you have sinus abnormalities
or a weakened immune system.
Some health conditions can increase your risk oI getting a sinus inIection that causes sinusitis, or
can increase your risk oI getting sinusitis that isn't caused by an underlying inIection. These
conditions include:
O llergies s:.h as hay fever. InIlammation that occurs with allergies may block your sinuses.
O Nasal polyps or t:2ors. These tissue growths may block the nasal passages or sinuses.
O Deviated nasal sept:2. A crooked septum the wall between the nostrils may restrict or
block sinus passages.
O Tooth infe.tion. A small number oI cases oI acute sinusitis are caused by an inIected tooth.
O Enlarged or infe.ted adenoids in .hildren. Adenoids are located in the upper back part oI the
throat.
O Other 2edi.al .onditions. The complications oI cystic Iibrosis, gastroesophageal reIlux disease
(ERD) or immune system disorders may result in blocked sinuses or an increased risk oI
inIection.
Ris fa.tors
You may be at increased risk oI getting sinusitis iI you have:
O Hay fever or another allergi. .ondition that aIIects your sinuses
O nasal passage a-nor2ality, such as a deviated nasal septum, nasal polyps or tumors
O 2edi.al .ondition such as cystic Iibrosis, gastroesophageal reIlux disease (ERD), or an
immune system disorder such as immunoglobulin or antibody deIiciency
O Reg:lar expos:re to poll:tants such as cigarette smoke
Co2pli.ations
Acute sinusitis complications include:
O sth2a flare-:ps. Acute sinusitis can trigger an asthma attack.
O Chroni. sin:sitis. Acute sinusitis may be a Ilare-up oI a long-term problem known as chronic
sinusitis. Chronic sinusitis is sinusitis that lasts longer than 12 weeks.
O Meningitis. This occurs when inIection spreads to the lining oI the brain.
O Vision pro-le2s. II inIection spreads to your eye socket, it can cause reduced vision or even
blindness. This is a medical emergency that requires immediate treatment to prevent potentially
permanent damage.
O Ear infe.tion. Acute sinusitis may occur along with an ear inIection.
Tests and diagnosis
O Physi.al exa2. To look Ior the cause oI your symptoms, your doctor will Ieel Ior tenderness in
your nose or throat. Your doctor may use a tool to hold your nose open and apply medication
that constricts blood vessels in your nasal passages. This makes it easier to see inside your nasal
passages. Your doctor will then shine a light into your nasal passages to look Ior inIlammation or
Iluid. This visual inspection will also help rule out physical conditions that trigger sinusitis, such
as nasal polyps or other abnormalities.
O Nasal endos.opy. A thin, Ilexible tube (endoscope) with a Iiber-optic light inserted through your
nose allows your doctor to visually inspect the inside oI your sinuses.
O I2aging st:dies. Images taken using computerized tomography (CT) or magnetic resonance
imaging (MRI) can show details oI your sinuses and nasal area. These may identiIy a deep
inIlammation or physical obstruction that's diIIicult to detect using an endoscope.
O Nasal and sin:s .:lt:res. Laboratory tests are generally unnecessary Ior diagnosing acute
sinusitis. However, in cases in which the condition Iails to respond to treatment or is progressing,
tissue cultures may help pinpoint the cause, such as identiIying a bacterial cause.
O llergy testing. II your doctor suspects that the condition may be brought on by allergies, an
allergy skin test may be recommended. A skin test is saIe and quick, and can help pinpoint the
allergen that's responsible Ior your nasal Ilare-ups.
Treat2ents and dr:gs
Most cases oI acute sinusitis don't need treatment because they are caused by viruses that cause
the common cold. SelI-care techniques are usually the only treatment needed to speed recovery
and ease symptoms.
Treat2ents to relieve sy2pto2s
O Saline nasal spray, which you spray into your nose several times a day to rinse your nasal
passages.
O Nasal .orti.osteroids. These nasal sprays help prevent and treat inIlammation. Examples
include Iluticasone (Flonase), mometasone (Nasonex), budesonide (Rhinocort Aqua),
triamcinolone (Nasacort AQ) and beclomethasone (Beconase AQ).
O De.ongestants. These medications are available in over-the-counter (OTC) and prescription
liquids, tablets and nasal sprays. OTC oral decongestants include SudaIed, ActiIed and Drixoral.
Nasal sprays include phenylephrine (Neo-Synephrine, others) and oxymetazoline (AIrin, others).
These medications are generally taken Ior only a Iew days at most. Otherwise they can cause the
return oI more severe congestion (rebound congestion).
O Over-the-.o:nter pain relievers such as aspirin, acetaminophen (Tylenol, others) or ibuproIen
(Advil, Motrin, others). Aspirin has been linked with Reye's syndrome, so use caution when
giving aspirin to children or teenagers. Though aspirin is approved Ior use in children older than
age 2, children and teenagers recovering Irom chickenpox or Ilu-like symptoms should never
take aspirin. Talk to your doctor iI you have concerns.
nti-ioti.s
Antibiotics usually aren't needed to treat acute sinusitis.
O Antibiotics won't help when acute sinusitis is caused by a viral or Iungal inIection.
O Most cases oI bacterial sinusitis improve without antibiotics.
O Antibiotic treatment is generally needed only iI you have a bacterial inIection, especially iI the
inIection is severe, recurrent or persistent.
Antibiotics used to treat acute sinusitis caused by a bacterial inIection include amoxicillin
(Amoxil, Trimox, others), doxycycline (Doryx, Monodox, others) or the combination drug
trimethoprim-sulIamethoxazole (Bactrim, Septra, others). II the inIection doesn't go away or iI
the sinusitis comes back, your doctor may try a diIIerent antibiotic.
II your doctor does prescribe antibiotics, it's critical to take the entire course oI medication.
enerally, this means you'll need to take them Ior 10 to 14 days even aIter your symptoms get
better. II you stop taking them early, your symptoms may come back.
ntif:ngal 2edi.ations
Rarely, acute sinusitis is caused by a Iungal inIection, which can be treated with antiIungal
medication. The dose oI medication as well as how long you'll need to take it depends on
the severity oI your inIection and how quickly your symptoms improve.
I22:notherapy
II allergies are contributing to your sinusitis, allergy shots (immunotherapy) that help reduce the
body's reaction to speciIic allergens may help treat your symptoms.
Prevention
Take these steps to help reduce your risk oI getting acute sinusitis:
O void :pper respiratory infe.tions. Minimize contact with people who have colds. Wash your
hands Irequently with soap and water, especially beIore your meals.
O Caref:lly 2anage yo:r allergies. Work with your doctor to keep symptoms under control.
O void .igarette s2oe and poll:ted air. Tobacco smoke and other pollutants can irritate and
inIlame your lungs and nasal passages.
O Use a h:2idifier. II the air in your home is dry, such as it is iI you have Iorced-air heat, adding
moisture to the air may help prevent sinusitis. Be sure the humidiIier stays clean and Iree oI mold
with regular, thorough cleaning.
Pathophysiology
Failure oI normal mucus transport and decreasedsinusventilation are the major Iactors
contributing to the development oIsinusitis. Obstruction oI the sinus ostia occurs with mucosal
edema or any anatomic abnormality that interIeres with drainage. Bacterial
andviralinIectionsalso impair themucustransport system. The Irequency oI ciliary beats
(normally 700 per minute) decreases to less than 300 per minute during periods oI inIection.
InIlammation causes 30 percent oI the ciliated columnar cells to undergo metaplastic changes
to mucus-secreting goblet cells. The obstruction and decreased transport results in stagnation oI
secretions, decreased pH and lowered oxygen tension within the sinus, creating an excellent
culture medium Ior bacteria.
A number oI Iactors can contribute to the development oI sinusitis.The most common cause of
acute bacterial sinusitis is a viralupperrespiratoryinfection.&p to 0.5 percent oI upper
respiratory inIections in adults develop into documented sinusitis.Children experience six to
eight colds per year, and approximately 5 to 10 percent of these infections are complicated by
sinusitis.
Allergicrhinitishas also been considered a contributing Iactor to sinusitis; however, no causal
relationship has been proven, and it is now believed to be a rare initiating Iactor.Iatrogenic
factors include mechanical ventilation, nasogastric tubes, nasal packing and dental
procedures. !regnancy, hormone changes associated with puberty, and senile rhinorrhea may
be contributing Iactors.Anatomic variations include tonsillar and adenoid hypertrophy,
deviated septum, nasal polyps and cleft palate. Smoking and intranasal cocaine use also
predispose to sinusitis.
Computed tomographic (CT) scanning in humans has shown that most uncomplicated colds are
associated with some radiographic Iindings oI sinus involvement, the great majority oI which
do not progress to Ilorid sinusitis. Experimentally-produced rhinovirus inIections can generate
abnormalities oI the sinuses (as detected by MR imaging) accompanied by increased nasal
secretion but without any evidence Ior bacterial involvement.Thus, prophylactic antibiotics for
colds are never indicated, although they are frequently administered.
Viral &RI most common cause.
Nasotracheal or nasogastric tubes can predispose to sinusitis.
!rophylacticantibiotic not indicated.
The bacteria responsible Ior sinusitis vary with the clinical setting:
O The major causes oI typical acute bacterial sinusitis include Streptococcus pneumoniae,
HaemophilusinIluenzae, Streptococcus pyogenes, and (less oIten) Staphylococcus
aureus.
O !atients withchronicsinusitisare more likely to be inIected with obligate anaerobes which
are part oI the usual mouth Ilora.
O Nosocomial sinusitis involves bacteria and Iungi that enter the sinus aIter becoming part
oI the patient's respiratory tract Ilora. This includes methicillin-resistant S. aureus
(MRSA), various gram-negative bacilli (such as Escherichia coli
and!seudomonasaeruginosa), and yeasts such as Candida albicans.
CHRONIC SINUSITIS
Chronic sinusitis is a common condition in which the cavities around nasal passages
(sinuses) become inIlamed and swollen. Chronic sinusitis lasts 12 weeks or longer despite
treatment attempts.
Also known as chronic rhinosinusitis, this condition interIeres with drainage and causes
mucus to build up. II you have chronic sinusitis, it may be diIIicult to breathe through your nose.
The area around your eyes and Iace may Ieel swollen, and you may have throbbing Iacial pain or
a headache.
Chronic sinusitis may be caused by an inIection, but it can also be caused by growths in
the sinuses (nasal polyps) or by a deviated nasal septum. Chronic sinusitis most commonly
aIIects young and middle-aged adults, but it also can aIIect children.
Sy2pto2s
Chronic sinusitis and acute sinusitis have similar signs and symptoms, but acute sinusitis is a
temporary inIection oI the sinuses oIten associated with a cold. At least two oI the Iollowing
signs and symptoms must be present Ior a diagnosis oI chronic sinusitis:
O Drainage oI a thick, yellow or greenish discharge Irom the nose or down the back oI the throat
O Nasal obstruction or congestion, causing diIIiculty breathing through your nose
O !ain, tenderness and swelling around your eyes, cheeks, nose or Iorehead
O Reduced sense oI smell and taste
Other signs and symptoms can include:
O Ear pain
O Aching in your upper jaw and teeth
O Cough, which may be worse at night
O Sore throat
O Bad breath (halitosis)
O Fatigue or irritability
O Nausea
The signs and symptoms oI chronic sinusitis are similar to acute sinusitis, except they last longer
and oIten cause more signiIicant Iatigue. Fever isn't a common sign oI chronic sinusitis, as it
may be with acute sinusitis.
When to see a do.tor
You may have several episodes oI acute sinusitis, lasting less than Iour weeks, beIore developing
chronic sinusitis. You may be reIerred to an allergist or an ear, nose and throat specialist Ior
evaluation and treatment.
See a do.tor i22ediately if you have symptoms that may be a sign oI a serious inIection:
O !ain or swelling around your eyes
O A swollen Iorehead
O Severe headache
O ConIusion
O Double vision or other vision changes
O StiII neck
O Shortness oI breath
Ca:ses:
Common causes oI chronic sinusitis include:
O Nasal polyps or t:2ors. These tissue growths may block the nasal passages or sinuses.
O llergi. rea.tions. Allergic triggers include Iungal inIection oI the sinuses.
O Deviated nasal sept:2. A crooked septum the wall between the nostrils may restrict or
block sinus passages.
O Tra:2a to the fa.e. A Iractured or broken Iacial bone may cause obstruction oI the sinus
passages.
O Other 2edi.al .onditions. The complications oI cystic Iibrosis, gastroesophageal reIlux, or HIV
and other immune system-related diseases may result in nasal blockage.
O Respiratory tra.t infe.tions. InIections in your respiratory tract most commonly, colds
can inIlame and thicken your sinus membranes, blocking mucus drainage and creating conditions
ripe Ior growth oI bacteria. These inIections can be viral, bacterial or Iungal in nature.
O llergies s:.h as hay fever. InIlammation that occurs with allergies may block your sinuses.
O I22:ne syste2 .ells. With certain health conditions, immune cells called eosinophils can cause
sinus inIlammation.
Ris fa.tors
You're at increased risk oI getting chronic or recurrent sinusitis iI you have:
O nasal passage a-nor2ality, such as a deviated nasal septum or nasal polyps
O spirin sensitivity that causes respiratory symptoms
O 2edi.al .ondition, such as cystic Iibrosis or chronic obstructive pulmonary disease (CO!D)
O n i22:ne syste2 disorder, such as HIV/AIDS or cystic Iibrosis
O Hay fever or another allergi. .ondition that aIIects your sinuses
O sth2a about 1 in 5 people with chronic sinusitis have asthma
O Reg:lar expos:re to poll:tants such as cigarette smoke
Co2pli.ations
Chronic sinusitis complications include:
O sth2a flare-:ps. Chronic sinusitis can trigger an asthma attack.
O Meningitis, an inIection that causes inIlammation oI the membranes and Iluid surrounding your
brain and spinal cord.
O Vision pro-le2s. II inIection spreads to your eye socket, it can cause reduced vision or even
blindness that can be permanent.
O ne:rys2s or -lood .lots. InIection can cause problems in the veins surrounding the sinuses,
interIering with blood supply to your brain and putting you at risk oI a stroke.
Tests and diagnosis
To look Ior the cause oI your symptoms, your doctor will Ieel Ior tenderness in your nose or
throat. To make it easier to see inside your nasal passages, he or she may:
O &se a tool to hold your nose open
O Apply medication that constricts blood vessels in your nasal passages
O Shine a light into your nasal passages to look Ior inIlammation or Iluid
This visual inspection will also help rule out physical conditions that trigger sinusitis, such as
nasal polyps or other abnormalities.
Your doctor also may use several other methods to help screen Ior chronic sinusitis:
O Nasal endos.opy. A thin, Ilexible tube (endoscope) with a Iiber-optic light inserted through your
nose allows your doctor to visually inspect the inside oI your sinuses. This also is known as
rhinoscopy.
O I2aging st:dies. Images taken using computerized tomography (CT) or magnetic resonance
imaging (MRI) can show details oI your sinuses and nasal area. These may identiIy a deep
inIlammation or physical obstruction that's diIIicult to detect using an endoscope.
O Nasal and sin:s .:lt:res. Cultures are generally unnecessary Ior diagnosing chronic sinusitis.
However, in cases in which the condition Iails to respond to treatment or is progressing, tissue
cultures may help pinpoint the cause, such as identiIying a bacterial or Iungal pathogen.
O n allergy test. II your doctor suspects that the condition may be brought on by allergies, an
allergy skin test may be recommended. A skin test is saIe and quick and can help pinpoint the
allergen that's responsible Ior your nasal Ilare-ups.
Treat2ents and dr:gs
The goal oI treating chronic sinusitis is to:
O Reduce sinus inIlammation
O eep your nasal passages draining
O Eliminate the underlying cause
O Reduce the number oI sinusitis Ilare-ups you have
Treat2ents to relieve sy2pto2s
O Saline nasal spray, which you spray into your nose several times a day to rinse your nasal
passages.
O Nasal .orti.osteroids. These nasal sprays help prevent and treat inIlammation. Examples
include Iluticasone (Flonase), budesonide (Rhinocort Aqua), triamcinolone (Nasacort AQ),
mometasone (Nasonex) and beclomethasone (Beconase AQ).
O Oral or inje.ted .orti.osteroids. These medications are used to relieve inIlammation Irom
severe sinusitis, especially iI you also have nasal polyps. Examples include prednisone and
methylprednisolone. Oral corticosteroids can cause serious side eIIects when used long term, so
they're used only to treat severe asthma symptoms.
O De.ongestants. These medications are available in over-the-counter (OTC) and prescription
liquids, tablets and nasal sprays. Examples oI OTC oral decongestants include SudaIed and
ActiIed. An example oI an OTC nasal spray is oxymetazoline (AIrin). These medications are
generally taken Ior a Iew days at most; otherwise they can cause the return oI more severe
congestion (rebound congestion).
O Over-the-.o:nter pain relievers such as aspirin, acetaminophen (Tylenol, others) or ibuproIen
(Advil, Motrin, others). Because oI the risk oI Reye's syndrome a potentially liIe-threatening
illness never give aspirin to anyone younger than age 18.
O spirin desensitization treat2ent iI you have reactions to aspirin that cause sinusitis. However,
this treatment can have serious complications such as intestinal bleeding or severe asthma
attacks.
nti-ioti.s
Antibiotics are sometimes necessary Ior sinusitis iI you have a bacterial inIection. However,
chronic sinusitis is usually caused by something other than bacteria, so antibiotics usually won't
help.
Antibiotics used to treat chronic sinusitis caused by a bacterial inIection include amoxicillin
(Amoxil, others), doxycycline (Doryx, Monodox, others) or the combination drug trimethoprim-
sulIamethoxazole (Bactrim, Septra, others). II the inIection doesn't subside or iI the sinusitis
comes back, your doctor may try a diIIerent antibiotic.
II your doctor does prescribe antibiotics, it's critical to take the entire course oI medication.
enerally, this means you'll need to take them Ior 10 to 14 days or even longer even aIter
your symptoms get better. II you stop taking them early, your symptoms may come back.
I22:notherapy
II allergies are contributing to your sinusitis, allergy shots (immunotherapy) that help reduce the
body's reaction to speciIic allergens may help treat the condition.
S:rgery
In cases that continue to resist treatment or medication, endoscopic sinus surgery may be an
option. For this procedure, the doctor uses an endoscope, a thin, Ilexible tube with an attached
light, to explore your sinus passages. Then, depending on the source oI obstruction, the doctor
may use various instruments to remove tissue or shave away a polyp that's causing nasal
blockage. Enlarging a narrow sinus opening also may be an option to promote drainage.
Prevention
Take these steps to reduce your risk oI getting chronic sinusitis:
O void :pper respiratory infe.tions. Minimize contact with people who have colds. Wash your
hands Irequently with soap and water, especially beIore your meals.
O Caref:lly 2anage yo:r allergies. Work with your doctor to keep symptoms under control.
O void .igarette s2oe and poll:ted air. Tobacco smoke and air contaminants can irritate and
inIlame your lungs and nasal passages.
O Use a h:2idifier. II the air in your home is dry, such as it is iI you have Iorced hot air heat,
adding moisture to the air may help prevent sinusitis. Be sure the humidiIier stays clean and Iree
oI mold with regular, thorough cleaning.
Pathophysiology
The sinuses are normally sterile under physiologic conditions. Secretions produced in the sinuses
Ilow by ciliary action through the ostia and drain into the nasal cavity. In the healthy individual,
Ilow oI sinus secretions is always unidirectional (ie, toward the ostia), which prevents back
contamination oI the sinuses. In most individuals, the maxillary sinus has a single ostium (2.5
mm in diameter, 5 mm
2
in cross-sectional area) serving as the only outIlow tract Ior drainage.
This slender conduit sits high on the medial wall oI the sinus cavity in a nondependent position.
Most likely, the edema oI the mucosa at these 1- to 3-mm openings becomes congested by some
means (eg, allergy, viruses, chemical irritation) that causes obstruction oI the outIlow tract stasis
oI secretions with negative pressure, leading to inIection by bacteria.
Retained mucus, when inIected, leads to sinusitis. Another mechanism hypothesizes that because
the sinuses are continuous with the nasal cavity, colonized bacteria in the nasopharynx may
contaminate the otherwise sterile sinuses. These bacteria are usually removed by
mucociliaryclearance; thus, iI mucociliary clearance is altered, bacteria may be inoculated and
inIection may occur, leading to sinusitis. Data are available that support the Iact that healthy
sinuses are colonized. The bacterial Ilora oI noninIlamed sinuses were studied Ior aerobic and
anaerobic bacteria in 12 adults who underwent corrective surgery Ior septal deviation. Organisms
were recovered Irom all aspirates, with an average oI 4 isolates per sinus aspirate. The
predominant anaerobic isolates werePrevotella, Porphyromonas,
Fusobacterium and Peptostreptococcusspecies. The most common aerobic bacteria were S
pyogenes, S aureus, S pneumonia, and H influen:ae. In another study, specimens were processed
Ior aerobic bacteria only, and Staphylococcus species and alpha-hemolytic streptococci were
isolated.
Organisms were recovered in 20 oI maxillary sinuses oI patients who underwent
surgical repositioning oI the maxilla.
In contrast, another report oI aspirates oI 12 volunteers with no sinus disease showed no bacterial
growth.Jiang et al evaluated the bacteriology oI maxillary sinuses with normal endoscopic
Iindings.
Organisms were recovered Irom 14 (47) oI 30 swab specimens and 7 (41) oI 17 oI
mucosal specimens. ordts et al reported the microbiology oI the middle meatus in normal
adults and children.This study noted in 52 patients that 75 had bacterial isolates present, most
commonly coagulase-negative staphylococci (CNS) (35), Corynebacterium species (23),
and S aureus (8) in adults. Low numbers oI these species were present. In children, the most
common organisms were H influen:ae (40), M catarrhalis (34), and S pneumoniae(50), a
marked diIIerence Irom Iindings in adults. Nonhemolytic streptococci and Moraxella species
were absent in adults.
The pathophysiology oI rhinosinusitis is related to 3 Iactors:
O Obstruction oI sinus drainage pathways (sinus ostia)
O Ciliary impairment
O Altered mucus quantity and quality
O-str:.tion of sin:s drainage
Obstruction oI the natural sinus ostia prevents normal mucus drainage. The ostia can be blocked
by mucosal swelling or local causes (eg, trauma, rhinitis), as well as by certain inIlammation-
associated systemic disorders and immune disorders. Systemic diseases that result in decreased
mucociliary clearance, including cystic Iibrosis, respiratory allergies, and primary ciliary
dyskinesia (artagener syndrome), can be predisposing Iactors Ior acute sinusitis in rare cases.
!atients with immunodeIiciencies (eg, agammaglobulinemia, combined variable
immunodeIiciency, and immunodeIiciency with reduced immunoglobulin |Ig( and
immunoglobulin A |IgA(bearing cells) are also at increased risk oI developing acute sinusitis.
Mechanical obstruction because oI nasal polyps, Ioreign bodies, deviated septa, or tumors can
also lead to ostial blockage. In particular, anatomical variations that narrow the ostiomeatal
complex, including septal deviation, paradoxical middle turbinates, and Haller cells, make this
area more sensitive to obstruction Irom mucosal inIlammation. &sually, the margins oI the
edematous mucosa have a scalloped appearance, but in severe cases, mucus may completely Iill
a sinus, making it diIIicult to distinguish an allergic process Irom inIectious sinusitis.
Characteristically, all oI the paranasal sinuses are aIIected and the adjacent nasal turbinates are
swollen. Air-Iluid levels and bone erosion are not Ieatures oI uncomplicated allergic sinusitis;
however, swollen mucosa in a poorly draining sinus is more susceptible to secondary bacterial
inIection.
Hypoxia within the obstructed sinus is thought to cause ciliary dysIunction and alterations in
mucus production, Iurther impairing the normal mechanism Ior mucus clearance.
I2paired .iliary f:n.tion
Contrary to earlier models oI sinus physiology, the drainage patterns oI the paranasal sinuses
depend not on gravity but on the mucociliary transport mechanism. The metachronous
coordination oI the ciliated columnar epithelial cells propels the sinus contents toward the natural
sinus ostia. Any disruption oI the ciliary Iunction results in Iluid accumulation within the sinus.
!oor ciliary Iunction can result Irom the loss oI ciliated epithelial cells; high airIlow; viral,
bacterial, or environmental ciliotoxins; inIlammatory mediators; contact between 2 mucosal
surIaces; scars; and artagener syndrome.
Ciliary action can be aIIected by genetic Iactors, such as artagener syndrome. artagener
syndrome is associated with immobile cilia and hence the retention oI secretions and
predisposition to sinus inIection. Ciliary Iunction is also reduced in the presence oI low pH,
anoxia, cigarette smoke, chemical toxins, dehydration, and drugs (eg, anticholinergic
medications and antihistamines).
Exposure to bacterial toxins can also reduce ciliary Iunction. Approximately 10 oI cases oI
acute sinusitis result Irom direct inoculation oI the sinus with a large amount oI bacteria. Dental
abscesses or procedures that result in communication between the oral cavity and sinus can
produce sinusitis by this mechanism. Additionally, ciliary action can be aIIected aIter certain
viral inIections.
Several other Iactors can lead to impaired ciliary Iunction. Cold air is said to stun the ciliary
epithelium, leading to impaired ciliary movement and retention oI secretions in the sinus
cavities. On the contrary, inhaling dry air desiccates the sinus mucous coat, leading to reduced
secretions. Any mass lesion with the nasal air passages and sinuses, such as polyps, Ioreign
bodies, tumors, and mucosal swelling Irom rhinitis, may block the ostia and predispose to
retained secretions and subsequent inIection. Facial trauma or large inoculations Irom swimming
can produce sinusitis as well. Drinking alcohol can also cause nasal and sinus mucosa to swell
and cause impairment oI mucous drainage.
ltered q:ality and q:antity of 2:.:s
Sinonasal secretions play an important role in the pathophysiology oI rhinosinusitis. The mucous
blanket that lines the paranasal sinuses contains mucoglycoproteins, immunoglobulins, and
inIlammatory cells. It consists oI 2 layers: (1) an inner serous layer (ie, sol phase) in which cilia
recover Irom their active beat and (2) an outer, more viscous layer (ie, gel phase), which is
transported by the ciliary beat. !roper balance between the inner sol phase and outer gel phase is
oI critical importance Ior normal mucociliary clearance.
II the composition oI mucus is changed, so that the mucus produced is more viscous (eg, as in
cystic Iibrosis), transport toward the ostia considerably slows, and the gel layer becomes
demonstrably thicker. This results in a collection oI thick mucus that is retained in the sinus Ior
varying periods. In the presence oI a lack oI secretions or a loss oI humidity at the surIace that
cannot be compensated Ior by mucous glands or goblet cells, the mucus becomes increasingly
viscous, and the sol phase may become extremely thin, thus allowing the gel phase to have
intense contact with the cilia and impede their action. Overproduction oI mucus can overwhelm
the mucociliary clearance system, resulting in retained secretions within the sinuses.
.:te sin:sitis in the intensive .are setting
Acute sinusitis in the intensive care population is a distinct entity, occurring in 18-32 oI
patients with prolonged periods oI intubation, and is usually diagnosed during the evaluation oI
unexplained Iever. Cases in which the cause is obstruction are usually evident and can include
the presence oI prolonged nasogastric or nasotracheal intubation. Moreover, patients in an
intensive care setting are generally debilitated, predisposing them to septic complications,
including sinusitis. Finally, sinusitis in intensive care settings is associated with nasal catheter
placement.