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Additions and corrections to Sinusitis:

Chronic sinusitis Chronic sinusitis is a complicated spectrum of diseases that share chronic inflammation of the sinuses in common. It is divided into cases with polyps and cases without, and the former is sometimes called chronic hyperplastic sinusitis. The causes are poorly understood[3] and may include allergy, environmental factors such as dust or pollution, bacterial infection, or fungus (either allergic, infective, or reactive). Non allergic factors such as [rhinitis] can also cause chronic sinus problems. Abnormally narrow sinus passages (such as a [septum]), which can impede drainage from the sinus cavities could also be a factor. A combination of anaerobic and aerobic bacteria are observed, including [aureus] and coagulase-negative [[1]]. Typically antibiotics provide only a temporary benefit, possibly because of the presence of antibiotic-resistant biofilms.

Biofilms are complex aggregates of extracellular matrix and inter-dependent microorganisms from multiple species, many of which may be difficult or impossible to isolate using standard clinical laboratory techniques. Bacteria found in biofilms may show increased antibiotic resistance when compared to free-living bacteria of the same species. It has been hypothesized that biofilm-type infections may account for many cases of antibiotic-refractory chronic sinusitis.[9][10][11] A recent study found that biofilms were present on the mucosa of 3/4 of patients undergoing surgery for chronic sinusitis.[12] In addition, the presence of bacterial biofilms has been correlated to significantly worse pre-operative CT scores and post-operative surgical outcomes [1, 2], suggesting that patients will chronic sinusitis will not become healthy until the disease-causing biofilm is removed. Surgery using powered irrigation has been suggested as a method of removing bacterial biofilms from these patients[1, 3, 4]

A more recent, and still debated, development in chronic sinusitis is the role that [[2]] may play. Fungus can be found in the nasal cavities and sinuses of most patients with sinusitis, but can also be found in healthy people as well. It remains unclear if fungus is a definite factor in the development of chronic sinusitis. Trials of antifungal treatments have had mixed results.[3]

Attempts have been made to provide a more consistent nomenclature 6 for subtypes of chronic sinusitis. Many patients have demonstrated the presence of eosinophils in the mucous lining of the nose and paranasal sinuses. As such the name eosinophilic mucin rhinosinusitis (EMRS) has come into being. Cases of EMRS may be related to an allergic response, but allergy is often not documentable, resulting in further subcategorization of allergic and non-allergic EMRS.

Symptoms Symptoms of sinusitis include: nasal congestion; facial pain; headache; fever; general malaise; thick green or yellow discharge; vertigo or lightheadedness; blurred vision, feeling of facial 'fullness' or 'tightness' which worsens on bending over; aching teeth, and halitosis. Very rarely, chronic sinusitis can lead to anosmia, the inability to smell or detect odors.[citation needed] In a small number of cases, chronic maxillary sinusitis can also be brought on by the spreading of bacteria from a dental infection.

Chronic sinusitis

Medical approaches Patients with chronic sinusitis are often given “maximal medical therapy” before being operated on. As with acute sinusitis, this therapy can include, but is not limited to treatment with steroids and the use of antibiotics. Nasal irrigation may also help with symptoms of chronic sinusitis.[17] [18][19] There are a number of devices available for nasal irrigation both at home as well as powered irrigation in the operating room. Based on the recent theories on the role that fungus may play in the development of chronic sinusitis, antifungal treatments have also been trialed, but have had mixed results.

Surgical treatment For chronic or recurring sinusitis, referral to an [[3]] may be indicated for more specialist assessment and treatment, which may include nasal surgery. However, for most patients the surgical approach is not superior to appropriate medical treatment. Surgery should only be considered for those patients who do not experience sufficient relief from optimal medication.[20][21]

A number of surgical approaches can be used to access the sinuses and these have generally shifted from external/extranasal approaches to intranasal [[4]] ones. A relatively recent advance in the treatment of sinusitis is a type of surgery called functional endoscopic sinus surgery [[5]], whereby normal clearance from the sinuses is restored by removing the anatomical and pathological obstructive variations that predispose to sinusitis. The benefit of FESS is its ability to allow for a more targeted approach to the affected sinuses, reducing tissue disruption, and minimizing post-operative complications.[22]

Another recently developed treatment is balloon sinuplasty. This method, similar to balloon angioplasty used to "unclog" arteries of the heart, utilizes balloons in an attempt to expand the openings of the sinuses in a less invasive manner. Its final role in the treatment of sinus disease is still under debate.

For persistent symptoms and disease in patients who have failed medical and the functional endoscopic approach, older techniques can be used to address the maxillary sinus such as the [radical antrostomy] (e.g. incision in the upper [[6]], opening in the anterior wall of the antrum, removal of the entire diseased [sinus mucosa] and drainage is allowed into inferior or middle meatus by creating a large window in the lateral nasal wall.)[23]

1. Psaltis, A.J., et al., The effect of bacterial biofilms on post-sinus surgical outcomes. Am J Rhinol, 2008. 22(1): p. 1-6. 2. Bendouah, Z., et al., Biofilm formation by Staphylococcus aureus and Pseudomonas aeruginosa is associated with an unfavorable evolution after surgery for chronic sinusitis and nasal polyposis. Otolaryngol Head Neck Surg, 2006. 134(6): p. 991-6. 3. Healy, D.Y., et al., Biofilms with fungi in chronic rhinosinusitis. Otolaryngol Head Neck Surg, 2008. 138(5): p. 641-7. 4. Desrosiers, M., M. Myntti, and G. James, Methods for removing bacterial biofilms: in vitro study using clinical chronic rhinosinusitis specimens. Am J Rhinol, 2007. 21(5): p. 527-32.