Sinusitis: Causes

Pathogenesis (development of disease)

Acute sinusitis usually develops due to obstruction of the ostia by mucosal swelling, usually referred from the nasal cavity. In rarer cases, sinusitis is caused odontogenically (“originating from the teeth”). The most common causative agents of sinusitis are viruses such as rhinoviruses or (para)influenza viruses, or bacteria such as Streptococcus pneumoniae, Haemophilus influenzae, and various types of streptococci and staphylococci. Adenoviruses can also cause sinusitis. Less commonly, fungi are the cause. An important pathogen in children is Moraxella catarrhalis. In adults, acute sinusitis is caused by Streptococcus pneumoniae or Haemophilus influenzae in more than 60% of cases. Chronic sinusitis may develop from inadequately treated acute sinusitis. In chronic sinusitis, the pathomechanism is insufficient ventilation of the paranasal sinuses. The most common pathogens of chronic sinusitis are Staphylococcus aureus, various Enterobaceriaceae, less frequently Pseudomonas aeruginosa and anaerobes of the oral flora. The leading symptom of chronic rhinosinusitis (CRS) is primary dyskinesia (disturbance of cilia motility/movement). Pathogenetically, inflammatory changes of the sinunasal mucosa seem to underlie all forms of CRS. In CRScNP (CRS with nasal polyps), a Th2-mediated inflammatory process (subpopulation of CD4+ T helper cells) is usually found, whereas in CRSsNP (CRS without nasal polyps), Th1-mediated processes are often found as well.In CRScNP (CRS with nasal polyps), eosinophil-dominated inflammation is also present. Smoking also damages the cilia to a great extent, so that secretion congestion and subsequent inflammation can occur. Sinusitis can also be caused by an allergic reaction (positive allergy test to e.g. house dust mites, grasses, tree pollen). Because sinusitis is usually always preceded by rhinitis (inflammation of the nasal mucosa), the term “sinusitis” is often replaced by “rhinosinusitis.”

Etiology (causes)

Biographic causes

  • Genetic burden:
    • Siblings of CRS children have a 57.5-fold higher risk of the disease compared with children without CRS.
    • First- and second cousins of CRS children had a 9.0- and 2.9-fold increased risk of CRS, respectively.
    • Parents of CRS children had a 5.6-fold increased risk of CRS compared with parents of healthy children.
    • Genetic disorders
      • Kartagener syndrome (synonym: primary ciliary dyskinesia); triad of situs inversus viscerum (mirror-image arrangement of organs), bronchiectasis (synonym: bronchiectasis; permanent irreversible saccular or cylindrical dilatation of the bronchi that may be congenital or acquired; symptoms: Chronic cough with “mouthful expectoration” (large-volume triple-layered sputum: foam, mucus, and pus), fatigue, weight loss, and decreased performance) and aplasia (nonformation) of the paranasal sinuses; symptomatology: rhinitis since birth, purulent secretions; nasal polyps, chronic otitis; vitias; a possible cause of chronic rhinosinusitis (CRS).
      • Cystic fibrosis (ZF) – genetic disease with autosomal recessive inheritance; results in abnormal mucus consistency and subsequently poorer drainage; a possible cause of chronic rhinosinusitis (CRS).
  • Anatomical variants – constrictions in the area of the paranasal sinuses.

Behavioral causes

  • Nutrition
    • Malnutrition and undernutrition – can lead to immunodeficiency (immune deficiency).
    • Micronutrient deficiency (vital substances) – see prevention with micronutrients.
  • Consumption of stimulants
    • Tobacco (smoking) – damages the important cilia (cilia), which are responsible for smooth secretion drainage from the sinuses
    • Alcohol – red wine can cause food allergy, which leads to mucosal oedema (swelling of the mucous membrane due to fluid retention)

Causes due to disease

  • Allergic rhinitis (hay fever) – can cause mucosal edema to close the ostia (drainage openings).
  • Adenoid vegetations (enlargement of the pharyngeal tonsil; age 4-5 years; symptomatology: mouth breathing, snoring, partly typical facies adenoidea: open mouth, hanging lower lip and the often visible tip of the tongue) – a possible cause of chronic rhinosinusitis (CRS).
  • Allergic reactions – positive allergy test to e.g. dust mites, grasses, tree pollen; a possible cause of chronic rhinosinusitis (CRS).
  • Dentogenic (tooth-related) factors – e.g., decayed teeth, mouth-antrum junction – connection between maxillary sinus and oral cavity, overpressed root canal filling material, root debris in maxillary sinus.
  • Gastroesophageal reflux disease (synonyms: GERD, gastroesophageal reflux disease; gastroesophageal reflux disease (GERD); gastroesophageal reflux disease (reflux disease); gastroesophageal reflux; reflux esophagitis; reflux disease; Reflux esophagitis; peptic esophagitis) – inflammatory disease of the esophagus (esophagitis) caused by the pathological reflux (reflux) of acid gastric juice and other gastric contents.
  • Granulomatosis with polyangiitis (GPA), formerly Wegener’s granulomatosis – necrotizing (tissue dying) vasculitis (vascular inflammation) of the small to medium-sized vessels (small vessel vasculitides), which is accompanied by granuloma formation (nodule formation) in the upper respiratory tract (nose, sinuses, middle ear, oropharynx) as well as the lower respiratory tract (lungs)
  • Immunodeficiency, e.g., HIV disease or other immunodeficiency syndromes; a possible cause of chronic rhinosinusitis (CRS)
  • Infections in the respiratory tract are harbingers of sinusitis – e.g. cold, flu, tonsillitis (tonsillitis) – however, only about 0.5 to 10% of these infections are complicated by sinusitis
  • Otitis media (inflammation of the middle ear)
  • Recurrent community-acquired pneumonia (CAP; at least 2 episodes) in children: 71.9% of affected individuals showed chronic rhinosinusitis (CRS) with “postnasal drip” vs. 4.1% in healthy controls
  • Tumors and foreign bodies may be secondary to sinusitis

Medications

  • Antibiotic therapies of nonsinasal infections → risk increase for chronic rhinosinusitis.
  • Α-Sympathomimetic (alpha-sympathomimetic) abuse; a possible cause of chronic rhinosinusitis (CRS).
  • Immunosuppression

Environmental pollution – intoxications (poisonings).

  • Environmental pollution – intoxications (poisonings) can potentially increase the risk

Other causes

  • In ICU patients, nasotracheal tubes (tubes) and feeding tubes may increase the risk of sinusitis
  • Scuba diving and long air travel can trigger barotraumas via changes in atmospheric pressure and may promote sinusitis