Introduction:
Sinusitis is a common problem worldwide; by definition, acute maxillary sinusitis is when the patient has inflammation and associated symptoms of the maxillary (upper jaw) sinuses for more than four weeks. Our face has four pairs of nasal sinuses- a) maxillary sinuses, b) ethmoid sinuses, c) frontal sinuses, and d) sphenoid sinuses; they are interconnected air-filled cavities lined by mucus present inside the bones of the nasal cavity. They drain mucus through openings called ostia into the nose. The primary function of these sinuses is to humidify the air and prevent the body from infections.
What Is Acute Maxillary Sinusitis?
When a virus or bacteria enters the body, it triggers an immune reaction causing inflammation and swelling of the mucus lining in the sinus. This swelling blocks the ostia from draining the mucus into the nose leading to nasal congestion (stuffy nose), facial pain, fullness, and other symptoms. For many patients, the symptoms relieve themselves after a week or two once the body gets rid of the infection. However, in a few, the symptoms persist and get worse, often needing medical intervention, this stage of the infection is termed acute, and if it happens in the maxillary sinus, it is known as acute maxillary sinusitis.
How Does The Maxillary Sinus Get Infection?
The maxillary sinus is a triangle-shaped cavity in the upper jaw, just below the eyes. It opens into the nose through an opening called maxillary ostia. An infection (a virus or bacteria) can enter the sinus cavity through the nose or an infected tooth; it can even be passed down to the maxillary sinus from a different sinus. In acute maxillary sinusitis, the severity of the infection also depends on the associated risk factors, some of which are:
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Allergies - People are allergic to different things; an allergen can be any foreign body that can trigger an immune reaction; it does not have to be a virus or a bacteria; for example, pollen from flowers can be an allergen. These allergies make the individual more susceptible to sinusitis.
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Anatomical Variation - Nasal polyps (soft tissue growths), septal deviation, etc., are a few variations that make it difficult for the sinuses to drain the mucus.
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Comorbid conditions - Diabetes mellitus, HIV, smoking, etc., also predispose the individual to infections.
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Immune Deficiency - It is often seen in children whose immune system has not fully developed yet and in older people whose immunity has been compromised due to debilitating conditions. Also seen in malnourished adults, immune deficiency makes the individuals more susceptible to infections.
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Asthma - It is a condition that inflames and constricts the lungs resulting in difficulty in breathing. Individuals with asthma are at an increased risk of developing sinusitis.
Along with the risks mentioned above, conditions like cystic fibrosis, sarcoidosis, Wegener's granulomatosis, Samter's triad, etc., also increase the chances of acute maxillary sinusitis.
What Are The Symptoms Of Acute Maxillary Sinusitis?
Symptoms of acute maxillary sinusitis are non-specific and similar to regular sinusitis or the common cold. However, a few are mentioned below:
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Fever and headache
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Cough and fatigue.
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A blocked nose or a runny nose.
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Pain and tenderness over the infected sinus intensify when the patient bends over.
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If the infection is due to an infected tooth, then dental pain radiation to the ear can be seen along with halitosis (bad breath).
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Purulent (yellow or green colored pus) discharge can be seen through the nose or spit.
Along with these symptoms, if there is facial swelling, abnormal eye movement, and neck stiffness, then it is indicative of extra-sinus involvement (the infection has spread to other parts of the face).
How Is Acute Maxillary Sinusitis Diagnosed?
The symptoms help in the initial diagnosis, based on which the clinician will start the patient on maximum medical therapy (MMT) with antibiotics, nonsteroidal anti-inflammatory drugs, antihistamines, and corticosteroids. Ancillary therapy includes nasal decongestants, nasal irrigation, and steam inhalation.
If the symptoms are not relieved after MMT, further investigations are needed, like a blood test (to check erythrocyte sedimentation rate), an ultrasound, and a computed tomographic (CT) scan; in a few cases, sinus puncture and culture of aspirate have also been requested.
How Is Acute Maxillary Sinusitis Treated?
As mentioned above, the first line of treatment is always medication for acute maxillary sinusitis; if that fails to relieve the symptoms, the clinician will perform a surgery called antral lavage (also known as an antral washout or maxillary sinus puncture) which will flush out the thick, purulent sinus secretions from the maxillary sinus. The following are different techniques through which the maxillary sinus can be drained:
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Canine Fossa Puncture - This is done intra-orally (through the mouth). Once the area is anesthetized, a trocar (a sharp-pointed surgical instrument fitted with a cannula) is used to puncture; the maxillary sinus just above the maxillary canine (third tooth from the center). The sinus is then irrigated with 100 ml saline solution through the puncture, the saline, along with the purulent discharge, will flow through the natural ostium in the nose. The procedure is complete once the irrigating fluid comes out clear through the nose.
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Inferior Meatal Puncture - This procedure is done through the nose; theinferior meatus is one of the passages in the nasal cavity. Lateral to this passage is a bone called the inferior turbinate which separates the maxillary sinus from the inferior meatus. A puncture is done through the inferior turbinate into the maxillary sinus using a curved trocar. This is followed by saline irrigation and drainage through the maxillary ostium.
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Endoscopic Puncture - With the advent of technology, an endoscope (an illuminated tube) is used to locate the maxillary ostium; the opening is then enlarged with special surgical instruments to allow for optimal drainage of the pus-filled mucus.
All the techniques can be performed in adults with local anesthesia; however, general anesthesia is necessary for children.
What Are The Complications Of Antral Lavage?
It is a well-tolerated procedure; a few rare complications are:
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Epistaxis (bleeding of the nose).
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Orbital injury, given the closeness of the sinus to the eye.
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Air embolism might happen when air is injected into the sinus during the aspiration of fluid from the sinus.
Are There Any Contraindications For the Surgery?
Patients under the age of three years are not advised to have an antral wash, given the proximity of the orbit to their small under-developed maxillary sinus. It is also contraindicated in patients with bleeding disorders, midfacial trauma, and untreated febrile acute maxillary sinusitis (puncture in patients without prior antibiotics will cause maxillary osteomyelitis and septicemia).
Conclusion
Post-surgery, the patient will be instructed to continue the medication along with intranasal irrigation with a neti-pot and steam inhalation. Chronic sinusitis can develop from acute sinusitis, the most common compilation and often seen in many patients. Once the underlying cause is addressed, there is less chance of recurrence, and the patient will fully recover.
