Anatomical background
Humans have 4 sinuses, the maxillary sinuses, the frontal sinuses, the ethmoid sinuses, and the sphenoid sinuses. They are connected to the nasal cavity by 1-3 mm narrow bony openings called ostia and are lined with a thin respiratory epithelium with goblet cells and seromucous glands. The ciliated hairs provide clearance of mucus into the nasal cavity. Sinusitis primarily affects the maxillary sinuses.
Symptoms
Acute infectious rhinosinusitis is usually preceded by a cold with symptoms such as sore throat, runny nose, and inflammation of the nasal mucosa. The disease manifests itself in congestion, secretion congestion and purulent discharge. In addition, there is headache and sinus pain when bending forward and unilateral pain in the area of the frontal sinuses (forehead, jaw bone, between the eyes, toothache). Other possible symptoms include fever, postnasal drip, cough, fatigue, disturbances in the sense of smell, bad breath, nasal polyps, feeling of congestion and illness. In children, the clinical picture is less specific. Although symptoms improve in most patients after 7-10 days, they may persist for several weeks. The condition is termed acute in the first 3 weeks, subacute in weeks 4-12, and chronic after 12 weeks. Possible complications include rare spread of bacterial pathogens to surrounding tissues (orbit, skin, bone, meninges, brain), development of frequently recurring sinusitis (acute recurrent rhinosinusitis), or chronic sinusitis.
Causes
The cause of the symptoms is inflammation of the nasal and sinus mucosa. The cilia are inhibited and the mucosa forms more mucus. This leads to swelling and congestion. The narrow connections between the sinus and nasal cavity become misaligned, causing a buildup of secretions in the sinuses. Sinusitis is most often caused by viruses as a complication of a cold. Pathogens are often rhinoviruses, but other viruses such as parainfluenza viruses, coronaviruses, RSV, adenoviruses and enteroviruses are also possible triggers. Bacterial rhinosinusitis, e.g. with , , or , is considered rare (according to the literature only 0.2 to 2% of cases!) and occurs only delayed as a complication with longer disease duration. More rarely, infectious sinusitis may also be caused by fungi, especially by and , . Fungal infection is potentially dangerous and must be adequately treated.
Diagnosis
Diagnosis is made on the basis of history, clinical presentation, and duration of illness. Other causes must be excluded, such as allergic diseases (hay fever, allergic rhinitis), nasal polyps, rhinitis medicamentosa, toothache, headache, trigeminal neuralgia, cystic fibrosis, foreign bodies, tumors, chemical and traumatic causes. If the course is complicated or chronic, other diagnostic methods may be used, including imaging, endoscopy, and pathogen detection by a specialist. Bacterial infection may be suspected if symptoms persist for more than 7-10 days, continue to worsen after 5-7 days, or severe discomfort occurs. In contrast, the color of nasal secretions does not indicate the cause of the infection.
Nonpharmacologic treatment
Recommended nonmedicinal measures include heat, such as in the form of warm compresses (e.g., cold-hot pack) or red light, adequate hydration, increasing humidity, and elevating the head end of the bed. Smoking should be avoided if possible. Surgical intervention may be indicated if complications arise.
Drug treatment
Acute sinusitis heals on its own within two weeks in the majority of patients, and drug therapy is not absolutely necessary (except, in some cases, for bacterial infections and fungal infections). Treatment is primarily aimed at alleviating the symptoms. There are numerous medicines on the market – cold remedies are among the best-selling drugs. Their effectiveness is largely insufficiently documented scientifically. Pain relievers:
- Such as acetaminophen or ibuprofen are effective against the pain, increased temperature, and feeling of illness. The appropriate precautions must be observed.
Inhalations:
- With steam, medicinal drugs (eg chamomile, thyme) or essential oils (eg eucalyptus oil, thyme oil, rosemary oil, menthol, cineol, camphor) relieve the symptoms symptomatically and can contribute to the dissolution of mucus.
- The use of essential oils is controversial because they may paralyze the cilia of the mucous membrane. Their use is sometimes contraindicated in infants and young children. Essential oils can also be applied in the form of cold balms, cold baths or as nasal ointments.
In phytotherapy:
- Is common, among other things, taking capsules with essential oils (eg Myrtol, eucalyptus oil) or medicinal drugs, such as gentian root, cowslip flowers, sorrel herb, elderflower and verbena. The anti-inflammatory bromelain from pineapple is also taken.
Nasal rinses or moisturizing nasal sprays:
- With saline solution, Emser salt or sea water remove mucus, bacteria and encrustations in the nose and moisturize the dry mucous membrane.
Decongestant nasal sprays:
- With active ingredients such as xylometazoline or oxymetazoline can decongest the mucosa and facilitate breathing. They should not be used for more than 5-7 days in a row, as they may cause rhinitis medicamentosa. They are often ineffective in acute sinusitis.
- Oral vasoconstrictive agents such as phenylephrine and antihistamines such as chlorphenamine should not be used in our view because of the possible adverse effects.
Expectorants:
- Such as acetylcysteine, carbocisteine, ambroxol or bromhexine may be able to liquefy the mucus and thus promote its removal. An attempt at treatment is possible.
Antibiotics:
- E.g. amoxicillin, are only indicated if a bacterial infection has been proven or seems likely due to the clinical symptoms after a long period of illness. For the exact criteria, please refer to the literature. It is well known that too many antibiotics are prescribed unnecessarily for this indication due to misconceptions. Treatment may cause adverse effects such as diarrhea, skin rashes, candidamycosis and, in women, vaginal thrush.
Glucocorticoid nasal sprays:
- Can reduce mucosal inflammation. Most are not approved for this indication. Mometasone is approved in many countries for symptomatic treatment of “uncomplicated acute rhinosinusitis,” but OTC preparations are not. Oral glucocorticoids may cause more adverse effects. Glucocorticoids are considered first-line agents for nasal polyps, which can also occur in the setting of sinusitis.
Micronutrients:
