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Acute sinusitis

Pathological changes in acute sinusitis occur in the form of catarrhal or purulent inflammation. Exudative phenomena predominate: hyperemia, infiltration and swelling of the mucous membrane. Serous and then purulent exudate appears. The mucous membrane of the paranasal sinuses, which differs in norm by a very insignificant thickness due to a weakly expressed intrinsic layer (tenths of a millimeter), noticeably thickens in acute catarrhal and especially in purulent inflammation. In this case, the anastomosis usually overlaps, which complicates the outflow of inflammatory exudate. The ciliated epithelium in some areas can be rejected, but generally preserved. The own layer of the mucous membrane is infiltrated by lymphocytes, neutrophils, plasmocytes, eosinophils can be found in places. The vessels are dilated, foci of hemorrhage are possible, which, however, is more characteristic of influenza inflammation.

In acute purulent sinusitis, the inflammatory process can spread to the periosteum, causing swelling of the soft tissues of the face in the area of ​​the affected sinus. The necrotic form of inflammation that is possible with the hematogenous spread of the infection (measles, scarlet fever) is currently rare.

In acute sinusitis, general and local symptoms are distinguished. Common symptoms include malaise, weakness, weakness, headache, fever, and a change in hemogram. A headache with sinusitis does not always have a clear localization. However, a more definite topic is also possible, as illustrated in Fig. 2.8.1.

The characteristic symptoms for all sinusitis are: nasal congestion of the corresponding half of the nose (in a bilateral process - both halves), mucous or purulent discharge from the nose, the presence of a purulent path in the middle or upper nasal passage, and a violation of smell. Local symptoms with sinusitis are due to the specifics of the localization process.

Diagnosis of sinusitis is based on the assessment of complaints, medical history, identification of general and local symptoms, radiation diagnostics and methods of instrumental examination (puncture, trepanopuncture and probing of the paranasal sinuses).

Acute ethmoiditis. As you know, the main flow of air during inspiration forms an upward convex arc and is limited by the region of the middle nasal passage. Therefore, in the anatomical and topographic respect, the ethmoid labyrinth is located in the most vulnerable spot of the nose among all other paranasal sinuses. He is the first to be exposed to any adverse environmental factors. Narrow excretory ducts of individual parts of the labyrinth easily overlap with swelling of the mucous membrane, which contributes to the development of the inflammatory process in the cellular structures of the ethmoid bone. The condition of other paranasal sinuses, whose excretory ducts open in the middle and upper nasal passages, cannot but depend on the reactive phenomena developing in the ethmoid labyrinth. Therefore, it will not be an exaggeration to consider the inflammation of any individual paranasal sinus not as isolated sinusitis, but practically as polysynitis, in which the trellis labyrinth necessarily takes part either in whole or in separate parts.

Of the common symptoms observed in acute ethmoiditis, one should point to elevated body temperature and headaches. Locally, the disease manifests itself in a sensation of soreness, localized in the region of the root of the nose and at the inner corner of the eye, aggravated by palpation.

Patients note nasal congestion, profuse mucopurulent and purulent discharge, violation of smell. The latter can manifest itself in the form of hypo- and anosmia and is caused by edema of the olfactory zone (respiratory anosmia). With the defeat of the olfactory nerve, aiosmia is essential.

During anterior rhinoscopy, hyperemia and swelling of the mucous membrane in the region of the middle nasal passage and the middle nasal concha, accumulation of pus in the middle nasal passage are determined. With posterior rhinoscopy, purulent discharge can be detected in the upper nasal passage, since in acute inflammation all groups of cells of the ethmoid labyrinth are affected. In cases where as a result of swelling of the mucous membrane the purulent path is not detected, it is recommended to anemize it and repeat rhinoscopy after a few minutes. In violation of the discharge of pus (closed empyema), the appearance of eye symptoms is possible.

Acute maxillary sinusitis (sinusitis) is one of the most famous diseases of the paranasal sinuses, not only among general practitioners, but also among the general public. At the same time, blue patients are disturbed by a headache localized in the projection area of ​​the maxillary sinus. However, in many cases, its distribution was noted in the forehead, zygomatic bone, temple. It can radiate to the orbital region and to the upper teeth, i.e. almost the entire half of the face is covered with pain.

The reinforcement and the feeling of a “tide” of heaviness in the corresponding half of the face are very characteristic when the head is tilted anteriorly. Headache is associated with secondary trigeminal neuralgia and impaired sinus barofunction as a result of swelling of the mucous membrane and blockage of the anastomosis. Perhaps the appearance of swelling of the cheeks on the affected side.

Palpation in the area of ​​the sinus projection enhances pain. Severe edema of the face, as well as the eyelids, is more characteristic of complicated sinusitis. Patients note nasal congestion and mucous or purulent discharge, as well as liquefaction of smell on the side of inflammation.

Anterior rhinoscopy allows you to establish hyperemia and swelling of the mucous membrane of the lower and especially the middle turbinate. The presence of serous or purulent discharge (purulent path) in the middle nasal passage is characteristic, which can also be established with posterior rhinoscopy. In cases where the purulent pathway is not detected (with severe swelling of the mucous membrane overlapping the anastomosis), it is also recommended to anemize the middle nasal passage and turn the patient's head to a healthy guard. In this position, the sinus outlet is at the bottom, and pus (if any) appears in the middle nasal passage.

As a result of swelling of the nasal concha, as with ethmoiditis, respiratory hemi- and anosmia are possible. In the case of toxic damage to the olfactory nerve, anosmia can be of an essential nature. In clinical practice, a frequent combination of acute maxillary sinusitis and ethmoiditis has been noted.

Acute frontal sinusitis. For this disease, along with the general symptoms characteristic of a febrile state, there is a severe, sometimes acute, headache localized mainly in the forehead, and a feeling of heaviness in the projection of the affected sinus. Percussion in the same place determines the increase in soreness, and when stroking the skin, a feeling of velvety may appear, which indicates in this case the phenomenon of periostitis. When finger pressure is applied to the area of ​​the medial corner of the eye and to the orbital (thinnest) wall of the frontal sinus, pain almost always increases with acute frontal sinusitis. Often there is edema of the upper eyelid, expressed to one degree or another. Purulent discharge is localized in the very front sections of the middle nasal passage, corresponding to the location of the excretory duct.

Acute frontal sinusitis is almost always combined with acute ethmoiditis (usually the front cells are involved). If at the same time the inflammatory process also captures the maxillary sinus (which is often the case), then in such cases we are dealing with hemisinitis. Acute sphenoiditis is an inflammation of the sphenoid sinus. It is also often combined with inflammation of the ethmoid labyrinth, with posterior cells (posterior ethmoiditis) usually involved. In acute sphenoiditis, patients complain of severe head-splitting headaches, often radiating to the back of the head and orbit. Characteristic is the drainage of purulent mucus along the back wall of the pharynx, which is established by mesopharyngoscopy.
Anterior deep rhinoscopy allows you to see the symptom of the so-called "imaginary infestation" is the closure of the hyperemic mucous membrane of the posterior sections of the middle nasal concha and the nasal septum, which indicates the involvement of the trellised labyrinth cells (usually the posterior ones) in the process.

After anemization and contraction of the mucous membrane in the area of ​​the olfactory fissure, a pus strip is likely to appear. With posterior rhinoscopy, pus accumulation in the nasopharyngeal arch is revealed, the mucous membrane of the nasopharynx and the posterior edge of the vomer is hyperemic and edematous. The violation of smell is characteristic.

The diagnosis of acute sinusitis is established on the basis of complaints, anamnesis, the described symptoms and the results of a radiation examination. An x-ray study currently continues to be a leader among radiation and other non-invasive diagnostic methods.

When X-ray examination, various styling is used, which allows the best way to establish the pathology of a particular paranasal sinus.

Acute sinusitis is characterized by a homogeneous darkening of the sinuses involved in the inflammatory process (Fig. 2.8.2 a). If the picture is taken in the vertical position of the subject, then if there is exudate in the sinus, it is possible to observe the fluid level (Fig. 2.8.2 b).

CT and NMR studies expand the diagnostic capabilities of radiation studies (Fig. 2.8.3 a, b). Thermal imaging and ultrasonic location, as not carrying radiation exposure, are preferable as a preliminary examination at the preclinical (polyclinic) level and allow screening out patients who do not require a more in-depth (radiological) examination.

Diagnostic and at the same time therapeutic methods include puncture and probing of the paranasal sinuses, described in the section "methods for the study of the nose and paranasal sinuses".

Treatment of uncomplicated acute sinusitis is usually conservative. It can be performed on an outpatient basis and in a hospital setting. Polysynuites, as well as sinusitis, accompanied by severe headache, swelling of the soft tissues of the face and the threat of ocular and intracranial complications, should be treated in a hospital.

Treatment of acute sinusitis, as well as other focal infections, consists of a combination of general and local methods. The topical treatment of acute sinusitis is based on the well-known principle “ubi pus ibi evacuo” (if pus is removed). All therapeutic measures that are in line with this principle are aimed at improving the outflow of purulent secretion from the sinuses. The first and simplest of them is the anemization of the mucous membrane of the nasal cavity, which can be done using official vasoconstrictor drugs (naphthyzin, sanatorium, galazolin). A more targeted doctor’s smearing of the mucous membrane in the middle nasal passage with a 3–5% cocaine solution or anesthetic — 2% dicaine solution with 3–4 drops of 0.1% adrenaline solution per 1 ml of the drug is more effective. Anemization of the mucous membrane and a decrease in its volume contributes to the expansion of anastomosis of the sinuses and facilitates the outflow of exudate. Thermal procedures (solux, diathermy, UHF) also contribute to this. However, they should be prescribed subject to a good outflow from the sinuses. The compress did not lose its significance either. A compress correctly applied to the corresponding half of the face improves microcirculation in the area of ​​the inflammatory process, reduces swelling of the soft tissues of the face and mucous membrane of the nasal cavity, restoring patency of the anastomosis and sinus drainage. UHF is poorly tolerated by patients with vascular disorders, including with vegetovascular dystonia. In his capital monograph, "The Corti Organ," Ya.A. Vinnikov and L.S. Titova (1964) reports the studies of C. Bech and G. Plazotta (1956), which established irreversible damage to external hair cells with a local increase in temperature in the cochlea caused by high-frequency current (UHF).

In recent years, the range of physiotherapeutic agents has expanded. There are new devices for microwave therapy, for example, (Luch-2), which allow not only to increase tissue heating, but also to localize precisely dosed energy to a limited area, which reduces the risk of unwanted side effects. These requirements are also met by new methods such as laser therapy, magneto and magnetolaser therapy.

Puncture of the maxillary sinuses, despite the known dangers (Temkina I.Ya., 1963), continues to be one of the most common methods of conservative treatment and is used both in inpatient and in outpatient practice. Other methods of conservative treatment - trepanopuncture of the frontal sinuses, puncture of the ethmoid labyrinth, puncture and probing of the sphenoid sinus - are more complex manipulations and are carried out in stationary conditions.

If necessary, repeated punctures of the paranasal sinuses resort to permanent drains, which are thin polyethylene or fluoroplastic tubes that are inserted into the sinus for the entire period of treatment, saving the patient from unpleasant manipulations.

Through the introduced drainage tube, sinus is systematically washed with an isotonic or furatsillinovy ​​(1: 5000) solution and other drugs (usually antibiotics) are administered.

The introduction of medicinal solutions into the paranasal sinuses is possible by the so-called method. "moving" along the Proetz. With this method, a vacuum is created in the nasal cavity using surgical suction. It allows you to remove pathological contents from the sinuses, and after infusion of medicinal solutions into the nasal cavity, the latter rush into the opened sinuses.

A more successful non-puncture method for the treatment of inflammatory diseases of the paranasal sinuses, especially with polysynitis, is carried out using the JAMIC sinus catheter (Markov G.I., Kozlov V.S., 1990; Kozlov BC, 1997). This device allows you to create a controlled pressure in the nasal cavity and paranasal sinuses and thereby evacuate pathological exudate from the sinuses, followed by the introduction of medicinal solutions into them through the opened anastomoses.

As a general treatment for patients with acute sinusitis, analgesics, antipyretic, antihistamines and antibacterial drugs are prescribed.

Currently, due to the known adverse side effects of antibiotics (dysbiosis, development of fungal flora, allergization, inhibition of antibody production), there is a tendency to narrow the indications for their use. However, if necessary, penicillin 500,000 units 4-6 times a day can be prescribed, as well as other antibiotics that have a wider spectrum of action (zeporin, keflin, kefzol, etc.). The purpose of antibiotics should be adjusted in accordance with the sensitivity of the microflora obtained from the focus of inflammation. Sulfanilamide preparations (sulfadimethoxine, sulfalene, biseptol, etc.) are prescribed both independently and in combination with antibiotics. Given the likelihood of anaerobic flora, especially in acute sinusitis with a pronounced clinical form, antibiotic therapy is recommended to be strengthened with drugs that have an etiotropic effect on anaerobic infection (trichopolum, metragil).

With odontogenic maxillary sinusitis, appropriate carious teeth should be removed. In this case, an unwanted opening of the maxillary sinus is possible. The formed channel connecting the sinus with the oral cavity can close on its own or after repeated lubrication with iodine tincture. Otherwise, they resort to plastic closure of the fistula by moving the flap cut from the soft tissues of the gums, which is a difficult operation, most successfully performed by maxillofacial surgeons.
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Acute sinusitis

  1. Chronic sinusitis
    Chronic sinusitis usually occurs as a result of repeated and insufficiently cured acute sinusitis. A combination of adverse factors of a general and local nature, such as decreased body reactivity, impaired drainage and sinus aeration, caused by anatomical abnormalities and pathological processes in the nasal cavity, is also significant in their development.
  2. Chronic sphenoid sinusitis. U-32.3
    {foto19} Treatment outcome: Clinical criteria for improving the patient's condition: 1. Normalization of temperature. 2. Normalization of laboratory parameters. 3. Improving the clinical symptoms of the disease (pain, difficulty breathing, discharge from
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    {foto30} Treatment outcome: Clinical criteria for improving the patient's condition: 1. Normalization of temperature. 2. Normalization of laboratory parameters. 3. Improving the clinical symptoms of the disease (pain, difficulty breathing, discharge from
  4. Chronic frontogenic sinusitis. U-32.1
    {foto31} Treatment outcome: Clinical criteria for improving the patient's condition: 1. Normalization of temperature. 2. Normalization of laboratory parameters. 3. Improving the clinical symptoms of the disease (pain, difficulty breathing, discharge from
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