Rhinitis and sinusitis are problems that primary-care physicians frequently encounter. Although these disorders are not life threatening, they can result in considerable discomfort and decrease the patient's quality of life. Nasal and sinus symptoms are the leading cause of restrictive activity and loss of productivity at work, home, and school. The treatment of rhinitis and sinusitis is costly, and these disorders can also complicate other medical illnesses, which can become more difficult to treat. Upper airway symptoms can be a manifestation of a systemic disease. The medications used to treat nasal obstruction cost about $5 billion annually, and surgical intervention is estimated to cost approximately $ 60 billions annually. These figures do not include the expense of diagnostic tests and office visits or the lost productivity at work and school (1). Herein this review article discusses the clinical management of these disorders, diagnostic tools, distinguishing characteristics of these conditions and available pharmacological and non-pharmacological treatment.
The common cold is a frequent, recurrent, acute upper respiratory tract infection affecting every age and race. It is a benign, self-limiting viral infection. The symptoms are stuffy and/or runny nose, sneezing, cough, sore throat, and sometimes, mild fever with generalized aches and pains. Although not a serious condition, colds have a substantial impact on time lost from work and school, general practitioner consultations and money spent on drugs - both prescription and over-the-counter (2).
The etiological agents are viral. More than 200 different viruses are known to cause the symptoms of the common cold. The most frequent viruses associated with respiratory infections are human rhinoviruses (HRV). Although the majority of HRV infections are mild and self-limited, HRV is an important cause of respiratory disease across all age groups. Recent studies have established the importance of HRV in predisposing to or causing otitis media, sinusitis and exacerbations of asthma, as well as other lower respiratory tract disorders. Among elderly people, infants and immunocompromised hosts HRV infections are often associated with lower respiratory tract morbidity and rarely mortality. However, the high incidence of HRV infections and their frequent association with upper and lower respiratory tract complications highlight the need for more effective means of prevention and treatment.
Other viruses responsible for more severe illnesses cause approximately 10 to 15 percent of adult colds include: Coronaviruses, adenoviruses, coxsackieviruses, echoviruses, orthomyxoviruses (including influenza A and B viruses), paramyxoviruses (including several parainfluenza viruses), respiratory syncytial virus and enteroviruses (3).
Viruses cause infection by overcoming the body's complex defense system: The body's first line of defense is mucus, produced by the membranes in the nose and throat. Mucus traps the material we inhale: pollen, dust, bacteria and viruses. When a virus penetrates the mucus and enters a cell, it commandeers the protein-making machinery to manufacture new viruses, which, in turn, attack surrounding cells.
Cold symptoms are probably the result of the body's immune response to the viral invasion. Virus-infected cells in the nose send out signals that recruit specialized white blood cells to the site of the infection. In turn, these cells emit a range of immune system chemicals known as kinins (pro-inflammatory chemokines and cytokines). These chemicals probably lead to the symptoms of the common cold by causing swelling and inflammation of the nasal membranes, leakage of proteins and fluid from capillaries and lymph vessels, and the increased production of mucus. This results in sneezing, nasal congestion and swelling of the sinus membranes that result in obstruction of nasal breathing. Post- nasal drip is the likely cause of the irritating cough typical of colds. The mild fever and aches reflect a generalized response to the viral infection.
Symptoms of the common cold usually begin two to three days after infection. Fever is usually slight but can climb to 102o F in infants and young children. Cold symptoms can last from 2 to 14 days, but two-thirds of people recover in a week. If symptoms occur often or last much longer than two weeks, they may be the result of an allergy rather than a cold.
Colds occasionally can lead to secondary bacterial infections of the middle ear or sinuses. High fever, significantly swollen glands including the tonsils, severe facial pain, and a cough that produces mucus, may indicate a complication or more serious illness requiring a doctor's attention.
The common cold is further complicated in those with a history of chronic respiratory disorder such as asthma, chronic bronchitis, and respiratory complications associated with smoking. Experimental rhinovirus infections in patients with asthma demonstrate features of exacerbation, such as lower airway symptoms, variable airways obstruction, and bronchial hyper-responsiveness. It has been proved by studies that these same viruses have been found to initiate the same inflammatory processes as seen and characterized in the asthmatic patient. This has clear implications for therapy of asthmatic patients (4).
New therapeutic interventions for upper respiratory tract infections need to be developed based on the increasing patho-physiological knowledge about the role of viruses and the antiviral immune response in common respiratory infection (5).
The flu is similar to cold in that the patient may feel sore throat, muscle aches, runny nose, cough, headache, and fever - except the flu comes on much more aggressively and suddenly. If there is a fever, it will usually be higher and last longer with the flu than with a cold. The flu is a very common illness. Attack rates in children range from 10% to 40% a year. Children are more susceptible than adults. Morbidity occurs in adults 75 years and older, but rarely in the very young. Concurrent illness in elderly adults is potentially dangerous. Both sexes are equally susceptible.
There are three different types of flu:
|•||Type A: the most common.|
|•||Type B: like Type A, it occurs every year. Influenza B outbreaks are generally less extensive and are associated with less severe disease than those associated with the influenza A virus.|
|•||Type C: it spreads rapidly through a population. It tends to occur every two to three years.|
Types A and B change slightly from year to year and is considered a mutating illnesses. The vaccines developed during the fall of one year don't work the next year.
The flu virus can survive for up to three days on its own, outside the body and can be transmitted by air or through human contact. Once contracted, the virus incubates for 18 to 72 hours.
It typically comes on aggressively, with a fever of 102°F to 106° F. Because the root of the virus is seated at the mucous membranes of the upper respiratory system, distress symptoms are usually felt from this area and can include the following:
|•||Achy muscles, frontal headache, and watery, irritated eyes.|
Though flu symptoms generally run for about three to four days, one may continue to feel tired and run down for up to several weeks later.
The flu can bring on secondary bacterial and viral infections like pneumonia, bronchitis, acute sinusitis and middle-ear infections.
Allergic rhinitis is the most common allergic disorder all over the world. Patients with allergic rhinitis are hypersensitive to pollens, dust mites, animal dander, or moulds.
|•||Bilateral nasal obstruction and nasal pruritis.|
|•||Frequent eye symptoms that include irritation, lacrimation, and pruritis.|
|•||Associated symptom complexes can include asthma, and atopic dermatitis.|
|•||Pale, boggy, bluish nasal mucosa and clear to slightly discoloured nasal secretions.|
About 10 to 20% of patients may have symptoms suggestive of allergic rhinitis, although they have no history of atopy and have negative results on allergy skin testing. In some of these patients, eosinophilia (a subtype of white blood cells increases in cases of allergy) is clearly demonstrated on nasal cytological analysis.
Vasomotor rhinitis is a vaguely defined syndrome of upper respiratory disorder.
Trigger factors seem to be non-specific, including irritants (strong odours and fumes), temperature changes, humidity, and air conditioning. Psycologic factors may have a major role. Allergy skin test results are negative, and other diagnoses must be excluded.
Atrophic rhinitis is characterized by atrophy of the nasal mucosa and nasal or sinus bony structures.
|•||Crusting and foul odour that is detectable by others.|
|•||Frequently, such patients experience loss of the senses of smell and taste.|
Reported abnormalities include infection with Klebsiella ozaenae, atoxic Corynebacterium diphtheria, and deficiencies of vitamin A and iron. Secondary atrophic rhinitis can occur after a nasal or sinus operation involving extensive nasal mucosal resection.
Nasal polyps, most likely, develop because of chronic sinus obstruction and mucosal inflammation. The polyps are smooth grapelike benign masses that usually arise from the paranasal sinuses. The major complications are nasal and sinus obstruction, development of chronic and recurrent sinusitis, and loss of the sense of smell. Nasal polyposis can be associated with intrinsic asthma, aspirin-sensitivity asthma, and cystic fibrosis in children, and is sometimes complicated by fungal sinus infection.
Gustatory rhinitis is a common condition, especially in elderly persons, in which Rhinorrhea occurs with eating, particularly spicy and hot foods. The mechanism seems to be an exaggerated parasympathetic response, with transudation of serum to nasal secretions.
Trauma during delivery or later during life frequently causes septal deformities that can be responsible for nasal obstruction and sinus disease. The mechanism of sinus disease as a result of septal deformity is due to direct interference of drainage from the sinuses or to turbulence in the nasal flow; normal laminar flow is needed for normal drainage of the paranasal sinuses.
Other anatomic abnormalities include nasal valvular collapse, which is frequently noted in elderly patients and in those with prior rhinoplasties, septal hematomas, abscess, neoplasm, foreign bodies, and choanal atresia (children).
Sinusitis is one of the most common health problems all over the world. Sinusitis affects people of all ages, males and females.
It is an inflammation of any one of the eight sinuses adjacent to the nose. These sinuses are categorized in four groups.
|•||Frontal sinuses, just above the eyes|
|•||Ethmoid sinuses, between the eyes just over the nose|
|•||Maxillary sinuses, on either side of the nose below the eyes|
|•||Sphenoid sinuses, at the base of the skull behind all of the other sinus cavities|
Sinusitis causes the linings of the sinuses (mucus membranes) to become swollen through contact with an allergen, virus, bacteria, or fungus. This swelling obstructs drainage and leads to a blockage that feeds bacteria, which then leads to an infection. Sinusitis may be short-lived and acute, or a long-standing, chronic condition. The duration and severity of sinusitis depends on the cause, or causes, and the predisposition of the individual.
|Computed tomographic scan of sinuses, showing importance of anatomy of ostium of maxillary sinus. Right maxillary sinus opens to nose through narrow infundibulum, mucosa is normal, and opening is not occluded (arrow). Opening of left maxillary sinus is distorted (arrowhead), mucosa is congested, and normal drainage is obstructed.|
X-rays are a form of electromagnetic radiation (like light); they are of higher energy, however, and can penetrate the body to form an image on film and are commonly used for the diagnosis of sinusitis. Structures that are dense (such as bone) will appear white, air will be black, and other structures will be shades of grey. CT scan or even MRI may be required for proper diagnosis.
Other laboratory tests include full blood picture as increased total white cell count indicate bacterial infection. Postnasal swab for bacterial culture and antibiotic sensitivity is often essential before starting antibiotic therapy.
The main features of sinusitis are:
|•||Nasal congestion and swelling around the affected sinus area.|
|•||Tenderness, pain, and redness may also occur around the inflamed sinuses.|
|•||Discharge of a green-yellow colour (possibly blood-tinged) may accompany the early stages of sinusitis, while in later stages discharge is usually blocked, leading to an increase of pain.|
|•||Headaches that worsen in the morning or when bending forward, cheek pain that may resemble a toothache, and non-productive coughs can all indicate sinusitis.|
A general feeling of weakness and fever or chills suggests that the infection has spread beyond the sinuses. On rare occasions, acute sinusitis can result in brain infection and serious complications.
By becoming aware of the precise symptoms, it is possible to determine which sinus area is affected. If the pain is centered over the cheeks just below the eyes, or is connected to a toothache or headache, it is most likely maxillary sinusitis. Headaches over the forehead are usually connected to frontal sinusitis. Splitting headache pain, generated from behind and between the eyes, could be produced from ethmoid sinusitis. If the pain is undefined by specific areas and is felt in the front or back of the head, it is likely to be connected to sphenoid sinusitis.
Acute bacterial sinusitis is an infection of the sinus cavities caused by bacteria. It is usually preceded by a cold, allergy attack, or irritation by environmental pollutants. Unlike a cold, or allergy, bacterial sinusitis requires a physician's diagnosis and treatment to cure the infection and prevent future complications.
When patients have frequent sinusitis, or the infection lasts three months or more, it could be chronic sinusitis. Symptoms of chronic sinusitis may be less severe than those of acute; however, untreated chronic sinusitis can cause damage to the sinuses and cheekbones that sometimes requires surgery to repair.
Normally, mucus collecting in the sinuses drains into the nasal passages. After having cold or allergy attack, the sinuses become inflamed and are unable to drain. This can lead to congestion and infection. Diagnosis of sinusitis usually is based on a physical examination and a discussion of the symptoms. Doctor also may use x-rays of the sinuses or obtain a sample of the nasal discharge to test for bacteria.