Another important subject among respiratory
tract infections is that of sinusitis.
And we can define acute sinusitis
as an inflammation of the mucosa
of the paranasal sinuses of
less than four weeks' duration.
The main problem in
sinusitis is obstruction
of the ostia of the
And of course that can be caused by
malfunction of the ciliary apparatus
that lines all the
sinuses in the mucosa
The other thing in evaluating a person with
sinusitis or possible bacterial sinusitis
is the character of
the sinus secretions.
If they are too thick, normally
they can block the ostia.
So we need to discuss the systemic
factors that cause blockage
of the ostia of the sinuses.
And these include most commonly viral
upper respiratory tract infection,
a common cold for instance,
These are the two
most common reasons.
Then patients can be born with a problem,
very mucoid secretions,
like cystic fibrosis,
and the mucus of the sinuses and
the entire respiratory tract
is supposed to be of a certain viscosity
so that the cilia within it can beat.
The cilia beat within this mucous lining,
and if it’s too viscid they
will not beat normally,
or if people for example are smoking
they will not beat normally.
There are a variety of immune disorders
which affect ciliary action,
and then there’s this rather curious
entity called ciliary dyskinesia,
the most important manifestation
of which is Kartagener syndrome.
Kartagener syndrome is the
constellation of sinusitis,
situs inversus, and
These patients have all
three of those findings.
And if particularly in somebody
with Kartagener syndrome,
the heart is on the right side
of the chest, not the left.
Wouldn’t it be embarrassing
to not recognize that?
So if somebody has ciliary dyskinesia,
make sure you would pick out the
right side for the heart exam.
And then as I mentioned tobacco smoke,
it’s interesting, you may
know several people who smoke
and who are always complaining
of having sinus problems.
Then of course there can
be some local insults
to the face that cause obstruction
of the ostia of the sinuses
and they can result in bacterial
sinusitis, like facial trauma for example,
People who do a lot of swimming and diving
either for recreation or professionally
can have sinus problems.
All of you who have done any swimming
recognize the changes in
pressure when you go underwater.
Sinusitis can be a very severe
and career-ending problem
For example, if a pilot develops
some problem with the sinuses,
that pilot probably shouldn’t fly if
he’s flying one of these fighter jets
because particularly on descent,
the sinus pressures can
change so dramatically
they can have that sudden onset
of very severe facial pain
which could result in
So high-altitude aviation maneuvers
are very important in the military.
Then there are people who chronically
take decongestants or antihistamines
and actually they can become
rather dependent on those
such that their ostia seem
to be always blocked.
And then if a patient has to
come in the hospital for surgery
or for admission to the ICU, they may have
to be intubated and put on a ventilator.
That can certainly block the ostia of the
sinuses if they are nasally intubated.
There can be mechanical obstruction
of the ostia of the sinuses
as some people are born
with choanal atresia.
One of the important exams of
a newborn is to make sure the
external nares are
Some people have
deviated nasal septum.
This is a pretty common problem.
Most people don’t have enough
deviation of their nasal septum
to obstruct the sinus ostia, but this is
something that has to be examined for.
Nasal polyps occur.
Little kids can get foreign
bodies like little plastic
automobiles and things
like that in their nose.
And then some large bullae may
form in the ethmoid sinuses
that can block the ostia there.
So we’ve been talking about
blockage of the sinus ostia.
Well, what are the consequences
of that happening?
Well, if the sinus gets blocked,
then you get initially an
increase in sinus pressure,
and of course fluid is going to
build up behind the blockage.
Now eventually, the oxygen is going to
be absorbed out of the blocked sinus
and eventually there’ll be
negative pressure in the sinus.
Now, the other thing is that bacteria,
nasal and nasopharyngeal bacteria,
can enter the sinus during sniffing.
Some people have a chronic habit
of sniffing, kind of a tic.
And then a lot of people when they
have for example a common cold
will blow their nose very hard.
Some of them sound like a foghorn
when they blow their nose.
Well, they may actually get
sinusitis from doing that.
So if you have a common cold and
if you’re advising your patients,
you should tell them to blow their nose
gently, never blow their nose very hard.
So the bottom line is that fluid becomes
static inside of a blocked sinus,
and if there are bugs there,
then the bugs can, as we say, set
up light housekeeping in the sinus.
And if the ciliary apparatus
doesn’t work properly,
that can also complicate problems.
A typical viral infection can
actually eliminate some of the cilia.
They’ll come back,
but during a viral infection
sometimes the cilia are destroyed.
And as I mentioned, if the
mucous layer is abnormal,
the ciliary action is abnormal.
You don’t think of this often, but your
sinuses are not supposed to be dry.
There’s supposed to be mucus every
day, all day, in your sinuses
and that keeps the cilia moving
as they are supposed to move
and they normally beat toward
the posterior pharynx.
And the secretions are
Patients who smoke cigarettes have a
change in the viscosity of that mucus.
And I think you can imagine how that
may mess up the motility of the cilia.
So no wonder they have sinus congestion
and no wonder they have
frequent episodes of sinusitis.