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Schematic diagram of motion of a single cilium during the rapid forward beat Schematic diagram of motion of a single cilium during the rapid forward beat and the slower recovery phase.and the slower recovery phase.
Schematic diagram of motion of a single cilium during the rapid forward beat Schematic diagram of motion of a single cilium during the rapid forward beat and the slower recovery phase.and the slower recovery phase.
Change in host milieu Change in host milieu creates culturecreates culture
medium for bacterialmedium for bacterial growth in closed cavitygrowth in closed cavity
Change in host milieu Change in host milieu creates culturecreates culture
medium for bacterialmedium for bacterial growth in closed cavitygrowth in closed cavity
Mucosal congestion or anatomicMucosal congestion or anatomicobstruction blocs airflow and drainageobstruction blocs airflow and drainage
OSTIUM IS CLOSEDOSTIUM IS CLOSED
Mucosal congestion or anatomicMucosal congestion or anatomicobstruction blocs airflow and drainageobstruction blocs airflow and drainage
OSTIUM IS CLOSEDOSTIUM IS CLOSED
Secretions stagnateSecretions stagnateSecretions stagnateSecretions stagnate
Mucosal thickening creates Mucosal thickening creates further blockagefurther blockage
Mucosal thickening creates Mucosal thickening creates further blockagefurther blockage
Cycle of events that leads to chronic rhinosinusitisCycle of events that leads to chronic rhinosinusitis begins with ostial blockagebegins with ostial blockage
Cycle of events that leads to chronic rhinosinusitisCycle of events that leads to chronic rhinosinusitis begins with ostial blockagebegins with ostial blockage
Secretions thicken;Secretions thicken; pH changespH changes
Secretions thicken;Secretions thicken; pH changespH changes
Mucosal gasMucosal gas metabolism changesmetabolism changes
Mucosal gasMucosal gas metabolism changesmetabolism changes
Cilia and epitheliumCilia and epithelium are damagedare damaged
Cilia and epitheliumCilia and epithelium are damagedare damaged
Bacterial infection develops in the Bacterial infection develops in the sinus cavitysinus cavity
Bacterial infection develops in the Bacterial infection develops in the sinus cavitysinus cavity
Retained secretionsRetained secretions
cause tissue inflammationcause tissue inflammation
Retained secretionsRetained secretions
cause tissue inflammationcause tissue inflammation
The expression The expression sinusitis sinusitis describes an inflammatory describes an inflammatory
process present in the paranasal sinuses mucous process present in the paranasal sinuses mucous
membrane, due to disturbances of drainage and membrane, due to disturbances of drainage and
ventilation, as a result of infection, allergy or anatomical ventilation, as a result of infection, allergy or anatomical
variations of the lateral nasal wall. This term refers to variations of the lateral nasal wall. This term refers to
pathological changes present both in one sinus e. g. pathological changes present both in one sinus e. g.
maxillary sinusitismaxillary sinusitis and also in several paranasal and also in several paranasal
sinuses sinuses (hemipansinusitis, pansinusitis)(hemipansinusitis, pansinusitis)..
The expression The expression sinusitis sinusitis describes an inflammatory describes an inflammatory
process present in the paranasal sinuses mucous process present in the paranasal sinuses mucous
membrane, due to disturbances of drainage and membrane, due to disturbances of drainage and
ventilation, as a result of infection, allergy or anatomical ventilation, as a result of infection, allergy or anatomical
variations of the lateral nasal wall. This term refers to variations of the lateral nasal wall. This term refers to
pathological changes present both in one sinus e. g. pathological changes present both in one sinus e. g.
maxillary sinusitismaxillary sinusitis and also in several paranasal and also in several paranasal
sinuses sinuses (hemipansinusitis, pansinusitis)(hemipansinusitis, pansinusitis)..
For practical reasons in the daily clinical work both terms For practical reasons in the daily clinical work both terms
- - sinusitissinusitis and and rhinosinusitisrhinosinusitis are equivalent. are equivalent.
For practical reasons in the daily clinical work both terms For practical reasons in the daily clinical work both terms
- - sinusitissinusitis and and rhinosinusitisrhinosinusitis are equivalent. are equivalent.
Two classifications of chronic rhinosinusitis are currently proposed in Two classifications of chronic rhinosinusitis are currently proposed in
rhinological literature. The classification introduced by Kern in 1984 is rhinological literature. The classification introduced by Kern in 1984 is
based on the duration of the disease process and corresponding based on the duration of the disease process and corresponding
morphological changes in the mucosa of the sinuses:morphological changes in the mucosa of the sinuses:
Acute purulent rhinosinusitisAcute purulent rhinosinusitis - lasting up to 3 weeks, with one or - lasting up to 3 weeks, with one or several several
sinuses involved.sinuses involved.
Subacute purulent rhinosinusitisSubacute purulent rhinosinusitis - lasting up to 3 weeks to 3 - lasting up to 3 weeks to 3 months.months.
Morphological changes in the mucosa which occur withinMorphological changes in the mucosa which occur within that time are that time are
usually reversible.usually reversible.
Chronic purulent rhinosinusitisChronic purulent rhinosinusitis - lasting over 3 months. This form - lasting over 3 months. This form ofof the the
disease process is thought to be a result of untreated ordisease process is thought to be a result of untreated or improperly treated improperly treated
acute inflammation. Surgery to removeacute inflammation. Surgery to remove irreversibly changed mucosa is irreversibly changed mucosa is
recommended.recommended.
Two classifications of chronic rhinosinusitis are currently proposed in Two classifications of chronic rhinosinusitis are currently proposed in
rhinological literature. The classification introduced by Kern in 1984 is rhinological literature. The classification introduced by Kern in 1984 is
based on the duration of the disease process and corresponding based on the duration of the disease process and corresponding
morphological changes in the mucosa of the sinuses:morphological changes in the mucosa of the sinuses:
Acute purulent rhinosinusitisAcute purulent rhinosinusitis - lasting up to 3 weeks, with one or - lasting up to 3 weeks, with one or several several
sinuses involved.sinuses involved.
Subacute purulent rhinosinusitisSubacute purulent rhinosinusitis - lasting up to 3 weeks to 3 - lasting up to 3 weeks to 3 months.months.
Morphological changes in the mucosa which occur withinMorphological changes in the mucosa which occur within that time are that time are
usually reversible.usually reversible.
Chronic purulent rhinosinusitisChronic purulent rhinosinusitis - lasting over 3 months. This form - lasting over 3 months. This form ofof the the
disease process is thought to be a result of untreated ordisease process is thought to be a result of untreated or improperly treated improperly treated
acute inflammation. Surgery to removeacute inflammation. Surgery to remove irreversibly changed mucosa is irreversibly changed mucosa is
recommended.recommended.
The 1995 International Conference on Sinus Disease classification of The 1995 International Conference on Sinus Disease classification of
rhinosinusitis is based on an assessment of the extent of rhinosinusitis is based on an assessment of the extent of
pathophysiological processes involving the mucosa of the sinuses and the pathophysiological processes involving the mucosa of the sinuses and the
nasal cavity:nasal cavity:
Acute rhinosinusitis is defined as an episodic inflammatoryAcute rhinosinusitis is defined as an episodic inflammatory process which process which
does not leave any significant persistent damage ofdoes not leave any significant persistent damage of the mucosa after the mucosa after
conservative treatment.conservative treatment.
Acute recurrent rhinosinusitis refers to repeated episodes of acuteAcute recurrent rhinosinusitis refers to repeated episodes of acute
inflammation with complete recovery after conservativeinflammation with complete recovery after conservative treatment, causing treatment, causing
no persistent damage of the mucosa.no persistent damage of the mucosa.
Chronic rhinosinusitis is defined as persistent inflammation whichChronic rhinosinusitis is defined as persistent inflammation which cannot cannot
be cured with conservative treatment.be cured with conservative treatment.
The 1995 International Conference on Sinus Disease classification of The 1995 International Conference on Sinus Disease classification of
rhinosinusitis is based on an assessment of the extent of rhinosinusitis is based on an assessment of the extent of
pathophysiological processes involving the mucosa of the sinuses and the pathophysiological processes involving the mucosa of the sinuses and the
nasal cavity:nasal cavity:
Acute rhinosinusitis is defined as an episodic inflammatoryAcute rhinosinusitis is defined as an episodic inflammatory process which process which
does not leave any significant persistent damage ofdoes not leave any significant persistent damage of the mucosa after the mucosa after
conservative treatment.conservative treatment.
Acute recurrent rhinosinusitis refers to repeated episodes of acuteAcute recurrent rhinosinusitis refers to repeated episodes of acute
inflammation with complete recovery after conservativeinflammation with complete recovery after conservative treatment, causing treatment, causing
no persistent damage of the mucosa.no persistent damage of the mucosa.
Chronic rhinosinusitis is defined as persistent inflammation whichChronic rhinosinusitis is defined as persistent inflammation which cannot cannot
be cured with conservative treatment.be cured with conservative treatment.
The patient may complain of:The patient may complain of:The patient may complain of:The patient may complain of:
nasal blockage or congestion;nasal blockage or congestion;
nasal discharge - serous, seropurulent,nasal discharge - serous, seropurulent, purulent;purulent;
postnasal discharge;postnasal discharge;
pain or pressure in the orbital region, pain orpain or pressure in the orbital region, pain or pressure in the region of the sinus affected bypressure in the region of the sinus affected by inflammation;inflammation;
headache;headache;
toothache.toothache.
nasal blockage or congestion;nasal blockage or congestion;
nasal discharge - serous, seropurulent,nasal discharge - serous, seropurulent, purulent;purulent;
postnasal discharge;postnasal discharge;
pain or pressure in the orbital region, pain orpain or pressure in the orbital region, pain or pressure in the region of the sinus affected bypressure in the region of the sinus affected by inflammation;inflammation;
headache;headache;
toothache.toothache.
Physical examination reveals:Physical examination reveals:Physical examination reveals:Physical examination reveals:
oedema and reddening of the nasal cavities mucosa;oedema and reddening of the nasal cavities mucosa;
oedema of the skin in the region of the root of the nose and inoedema of the skin in the region of the root of the nose and in the the
region of the palpebras;region of the palpebras;
mucous, mucopurulent or purulent secretion in the nasal cavities;mucous, mucopurulent or purulent secretion in the nasal cavities;
mucous or purulent secretion in the nasopharynx;mucous or purulent secretion in the nasopharynx;
purulent secretion on the lateral wall of the nasal cavity;purulent secretion on the lateral wall of the nasal cavity;
painfulness of the cheek when exerting pressure on the caninepainfulness of the cheek when exerting pressure on the canine
fossa (in the maxillary sinusitis) and when exerting pressure onfossa (in the maxillary sinusitis) and when exerting pressure on the the
upper wall of the orbit (in the frontal sinusitis).upper wall of the orbit (in the frontal sinusitis).
oedema and reddening of the nasal cavities mucosa;oedema and reddening of the nasal cavities mucosa;
oedema of the skin in the region of the root of the nose and inoedema of the skin in the region of the root of the nose and in the the
region of the palpebras;region of the palpebras;
mucous, mucopurulent or purulent secretion in the nasal cavities;mucous, mucopurulent or purulent secretion in the nasal cavities;
mucous or purulent secretion in the nasopharynx;mucous or purulent secretion in the nasopharynx;
purulent secretion on the lateral wall of the nasal cavity;purulent secretion on the lateral wall of the nasal cavity;
painfulness of the cheek when exerting pressure on the caninepainfulness of the cheek when exerting pressure on the canine
fossa (in the maxillary sinusitis) and when exerting pressure onfossa (in the maxillary sinusitis) and when exerting pressure on the the
upper wall of the orbit (in the frontal sinusitis).upper wall of the orbit (in the frontal sinusitis).
Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis
Anatomic:Anatomic:deviation of the nasal septum;deviation of the nasal septum;anatomical variations of the nasal lateral wall:anatomical variations of the nasal lateral wall:
of the middle nasal concha,of the middle nasal concha,
of the uncinate process,of the uncinate process,
of the ridge of the nose,of the ridge of the nose,
of the ethmoidal bulla,of the ethmoidal bulla,
of the Haller’s cels;of the Haller’s cels;
Morphological:Morphological: nasal polyps;nasal polyps; nasal tumours;nasal tumours; adenoids.adenoids.
Anatomic:Anatomic:deviation of the nasal septum;deviation of the nasal septum;anatomical variations of the nasal lateral wall:anatomical variations of the nasal lateral wall:
of the middle nasal concha,of the middle nasal concha,
of the uncinate process,of the uncinate process,
of the ridge of the nose,of the ridge of the nose,
of the ethmoidal bulla,of the ethmoidal bulla,
of the Haller’s cels;of the Haller’s cels;
Morphological:Morphological: nasal polyps;nasal polyps; nasal tumours;nasal tumours; adenoids.adenoids.
Oedemas of the mucosa:infection;
allergy;
rhinitis vasomotorica;
rhinitis medicamentosa;
hormonal disturbances.
Traumas:
local traumas;
barotrauma;
foreign bodies;
iatrogenic.
Constitutional:syndromes of ciliary disturbances;
cystic fibrosis;
immunological deficiencies.
Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis
The most often used antibiotics in the therapy of rhinosiusitisThe most often used antibiotics in the therapy of rhinosiusitis The most often used antibiotics in the therapy of rhinosiusitisThe most often used antibiotics in the therapy of rhinosiusitis
Supplementary treatmentSupplementary treatmentSupplementary treatmentSupplementary treatment
1.1. DecongestantsDecongestants should ensure restoration of the patency of the should ensure restoration of the patency of the
ostio-meatal complex and thereby the sinuses ostia.ostio-meatal complex and thereby the sinuses ostia.
2.2. Mucolytic drugsMucolytic drugs act on the retained in the sinuses secretion in such act on the retained in the sinuses secretion in such
a way that it becomes more liquid thus easier to move.a way that it becomes more liquid thus easier to move.
3.3. Corticosteroids are recommended Corticosteroids are recommended first of all in the therapy offirst of all in the therapy of
chronic inflammation.chronic inflammation.
4.4. Recommendation for the administration of Recommendation for the administration of antihistaminesantihistamines requires requires
comprehensive reasoning, because allergy plays a far smaller rolecomprehensive reasoning, because allergy plays a far smaller role
in the pathogenesis of rhinosinusitis than it is assumed.in the pathogenesis of rhinosinusitis than it is assumed.
1.1. DecongestantsDecongestants should ensure restoration of the patency of the should ensure restoration of the patency of the
ostio-meatal complex and thereby the sinuses ostia.ostio-meatal complex and thereby the sinuses ostia.
2.2. Mucolytic drugsMucolytic drugs act on the retained in the sinuses secretion in such act on the retained in the sinuses secretion in such
a way that it becomes more liquid thus easier to move.a way that it becomes more liquid thus easier to move.
3.3. Corticosteroids are recommended Corticosteroids are recommended first of all in the therapy offirst of all in the therapy of
chronic inflammation.chronic inflammation.
4.4. Recommendation for the administration of Recommendation for the administration of antihistaminesantihistamines requires requires
comprehensive reasoning, because allergy plays a far smaller rolecomprehensive reasoning, because allergy plays a far smaller role
in the pathogenesis of rhinosinusitis than it is assumed.in the pathogenesis of rhinosinusitis than it is assumed.
Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis
In adultsIn adults
8 weeks of persistent symptoms and sings8 weeks of persistent symptoms and sings
oror
Four episodes per year of recurrent acute sinusitis, each Four episodes per year of recurrent acute sinusitis, each
lasting at least 10 dayslasting at least 10 days
in association within association with
Persistent changes on computer tomography 4 weeksPersistent changes on computer tomography 4 weeks
after medical therapy without intervening acute infectionafter medical therapy without intervening acute infection
In adultsIn adults
8 weeks of persistent symptoms and sings8 weeks of persistent symptoms and sings
oror
Four episodes per year of recurrent acute sinusitis, each Four episodes per year of recurrent acute sinusitis, each
lasting at least 10 dayslasting at least 10 days
in association within association with
Persistent changes on computer tomography 4 weeksPersistent changes on computer tomography 4 weeks
after medical therapy without intervening acute infectionafter medical therapy without intervening acute infection
Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis
In childrenIn children
12 weeks of persistent symptoms and sings12 weeks of persistent symptoms and sings
or:or:
Six episodes per year of recurrent acute sinusitis, eachSix episodes per year of recurrent acute sinusitis, each
lasting at least 10 dayslasting at least 10 days
in association within association with
Persistent changes on computer tomography 4 weeksPersistent changes on computer tomography 4 weeks
after medical therapy without intervening acute infectionafter medical therapy without intervening acute infection
In childrenIn children
12 weeks of persistent symptoms and sings12 weeks of persistent symptoms and sings
or:or:
Six episodes per year of recurrent acute sinusitis, eachSix episodes per year of recurrent acute sinusitis, each
lasting at least 10 dayslasting at least 10 days
in association within association with
Persistent changes on computer tomography 4 weeksPersistent changes on computer tomography 4 weeks
after medical therapy without intervening acute infectionafter medical therapy without intervening acute infection
Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis
Symptoms and singsSymptoms and sings
Adults and childrenAdults and childrenMajorMajor
Nasal congestionNasal congestionNasal dischargeNasal dischargeHeadacheHeadacheFacial pain or pressureFacial pain or pressureOlfactory disturbanceOlfactory disturbance
MinorMinorFeverFeverHalitiosisHalitiosis
Children onlyChildren onlyCoughCoughIrritabilityIrritability
Symptoms and singsSymptoms and sings
Adults and childrenAdults and childrenMajorMajor
Nasal congestionNasal congestionNasal dischargeNasal dischargeHeadacheHeadacheFacial pain or pressureFacial pain or pressureOlfactory disturbanceOlfactory disturbance
MinorMinorFeverFeverHalitiosisHalitiosis
Children onlyChildren onlyCoughCoughIrritabilityIrritability
The most often isolated microorganisms in rhinosiusitisThe most often isolated microorganisms in rhinosiusitis
Streptococcus pneumoniaeStreptococcus pneumoniae
Haemophilus influenzaeHaemophilus influenzae
Streptococcus pyogenesStreptococcus pyogenes
Staphylococcus aureusStaphylococcus aureus
Anaerobes:Anaerobes:
BacteroidesBacteroides
FusobacteriumFusobacterium
PeptostreptococcusPeptostreptococcus
Alpha- and beta-haemolytic streptococciAlpha- and beta-haemolytic streptococci
Other Gram-negative bacteriasOther Gram-negative bacterias
Streptococcus pneumoniaeStreptococcus pneumoniae
Haemophilus influenzaeHaemophilus influenzae
Streptococcus pyogenesStreptococcus pyogenes
Staphylococcus aureusStaphylococcus aureus
Anaerobes:Anaerobes:
BacteroidesBacteroides
FusobacteriumFusobacterium
PeptostreptococcusPeptostreptococcus
Alpha- and beta-haemolytic streptococciAlpha- and beta-haemolytic streptococci
Other Gram-negative bacteriasOther Gram-negative bacterias
Surgical indicationsSurgical indicationsSurgical indicationsSurgical indications