Chronic Sinusitis - Upper Airway Infections

CHRONIC SINUSITIS

Chronic sinusitis is an inflammation of the sinuses that persists for more than 3 weeks in an adult and 2 weeks in a child. It is es-timated that 32 million people a year develop chronic sinusitis.

Pathophysiology

A narrowing or obstruction in the ostia of the frontal, maxillary, and anterior ethmoid sinuses usually causes chronic sinusitis, pre-venting adequate drainage to the nasal passages. This combined area is known as the osteomeatal complex. Blockage that persists for greater than 3 weeks in an adult may occur because of infec-tion, allergy, or structural abnormalities. This results in stagnant secretions, an ideal medium for infection. The organisms that cause chronic sinusitis are the same as those implicated in acute sinusitis. Immunocompromised patients, however, are at in-creased risk for developing fungal sinusitis. Aspergillus fumigatus is the most common organism associated with fungal sinusitis.

Clinical Manifestations

Clinical manifestations of chronic sinusitis include impaired mu-cociliary clearance and ventilation, cough (because the thick dis-charge constantly drips backward into the nasopharynx), chronic hoarseness, chronic headaches in the periorbital area, and facial pain. These symptoms are generally most pronounced on awak-ening in the morning. Fatigue and nasal stuffiness are also com-mon. In addition, some patients experience a decrease in smell and taste and a fullness in the ears.

Assessment and Diagnostic Findings

A careful history and diagnostic assessment, including a com-puted tomography scan of the sinuses or magnetic resonance imaging (if fungal sinusitis is suspected), are performed to rule out other local or systemic disorders, such as tumor, fistula, and allergy. Nasal endoscopy may be indicated to rule out underlying diseases such as tumors and sinus mycetomas (fungus balls). The fungus ball is usually a brown or greenish-black material with the consistency of peanut butter or cottage cheese.

Complications

Complications of chronic sinusitis, although uncommon, include severe orbital cellulitis, subperiosteal abscess, cavernous sinus thrombosis, meningitis, encephalitis, and ischemic infarction.

Medical Management

Medical management of chronic sinusitis is almost the same as for acute sinusitis. The antimicrobial agents of choice include amoxicillin clavulanate (Augmentin) or ampicillin (Ampicin). Clarithromycin (Biaxin) and third-generation cephalosporins such as cefuroxime axetil (Ceftin), cefpodoxime (Vantin), and cefprozil (Cefzil) have also been effective. Levofloxacin (Lev-aquin), a quinolone, may also be used. The course of treatment may be 3 to 4 weeks. Decongestant agents, antihistamines, saline sprays, and heated mist may also provide some symptom relief.

SURGICAL MANAGEMENT

When standard medical therapy fails, surgery, usually endo-scopic, may be indicated to correct structural deformities that ob-struct the ostia (openings) of the sinus. Excising and cauterizing nasal polyps, correcting a deviated septum, incising and draining the sinuses, aerating the sinuses, and removing tumors are some of the specific procedures performed. When sinusitis is caused by a fungal infection, surgery is required to excise the fungus ball and necrotic tissue and drain the sinuses. Oral and topical cortico steroids are usually prescribed. Antimicrobial agents are admin-istered before and after surgery. Some patients with severe chronic sinusitis obtain relief only by moving to a dry climate.

Nursing Management

Because the patient usually performs care measures for sinusitis at home, nursing management consists mainly of patient teaching.

TEACHING PATIENTS SELF-CARE

The nurse teaches the patient how to promote sinus drainage by increasing the environmental humidity (steam bath, hot shower, and facial sauna), increasing fluid intake, and applying local heat (hot wet packs). The nurse also instructs the patient about the im-portance of following the medication regimen. Instructions on the early signs of a sinus infection are provided and preventive measures are reviewed.