Chronic sinusitis begins and ends with damage to the mucosal lining of the sinuses. There are several disease processes that have the potential to cause damage to an individual’s mucosal lining. These include allergic rhinitis, mold infestation/infection, gastrointestinal reflux, and immunological disorders. It should also be remembered that with each case, risk factors may be single or multiple depending on the individual. If these risk factors are addressed and managed, the likelihood of reducing the patient’s sinus symptoms is greatly increased.
Another item that needs to be discussed when talking about chronic sinusitis is adequate drainage. If there is an obstruction, which impedes drainage, secretions accumulate. This accumulation inhibits the natural mechanisms of the sinuses to clear pathogens that now have the potential to cause bacterial infections. Therefore, surgery along with the medical management of the above mentioned risk factors is important for helping patients who suffer with chronic rhinosinusitis (CRS).
Allergic rhinitis (AR) is one of the most common illnesses associated with CRS. Allergens enter the sinuses through the nasal passages and set off a cascade of inflammatory reactions which damages the mucosa. Bacteria that normally colonizes the sinus cavities are now able the penetrate beneath the mucosal layer, which when intact is an excellent barrier against bacterial infections. Allergy testing allows the clinician to identify offending allergens to the individual patient and subsequent allergy immunotherapy helps the patient to minimize the effects of the allergens. This is accomplished by having the patient develop tolerance to the allergen by introducing increasing concentrations of the allergen over a period of time.
Allergic Fungal Sinusitis
A special subset of allergic rhinitis is Allergic Fungal Sinusitis (AFS). Though it shares many of the same traits as allergic rhinitis there are some distinct differences. One of the most significant is that most patients do not have a positive skin test to molds which are ubiquitous to the environment. However, like other allergens AFS causing inflammatory damage to the mucosal lining of the sinuses and causes secondary bacterial infections. In a recent article from the American Journal of Rhinology and Allergy, it describes that symptoms of patient with AFS can range from mild to severe and depending on the severity of the disease will dictate the appropriate way to manage the disease.
Gastro- Esophageal Reflux Disease or (GERD) is a major contributor to CRS. If the Lower Esophageal Sphincter (LES) doesn’t function properly, gastric secretions are able to travel back up the esophagus and damage structures such as the vocal cords, bronchioles, and sinus cavities. Just as it is with AR and AFS, the disruption of the mucosal integrity of the sinus cavity leads to bacterial infections. In many cases, bacteria associated with gastrointestinal tract are found in the sinus cavities making it highly suggestive that the underlying cause for the patient’s CRS is reflux in origin. Treating the underlying reflux helps avoid the recurrent use of antibiotics.
Another risk factor for CRS is immunologic disorders which can be both inherent and acquired. One such inherent disorder is Common Variable Immunodeficiency which can be present in childhood. However, in many instances, the full expression of the disease many not be recognized until the third or fourth decade of life. Unfortunately CVID is not well recognized and in many instances undiagnosed until later on in life. Lately, our practice has identified several patients that developed immunodeficiencies after chemotherapy for treatment of an underlying malignancy. Treating CVID with gamma globulin therapy greatly reduces the incidence of sinus infections in those that have this underlying problem.
In conclusion, it takes experienced clinicians who understand how multiple disease processes can collectively cause CRS and can identify the underlying risk factors in each individual patient to effectively treat this condition by customizing a treatment plan that is based on the patient and not on some standardized protocol.
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