Otorrinolaringologia

Primary Care; Clinics in Office Practice
Volume 25 • Number 3 • September 1998
Copyright © 1998 W. B. Saunders Company
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EAR, NOSE AND THROAT DISORDERS

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NASAL DISORDERS AND SINUSITIS

Genadi Maltinski MD

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Department of Family Medicine, Community Memorial Hospital, Oconto Falls, Wisconsin; the Department of Otorhinolaryngology, Siena University, Siena,Italy; and the Department of Voice Instruction and Language Phonology, Florence University, Florence, Italy
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Address reprint requests to
Genadi Maltinski, MD
Community Memorial Hospital
Primary Care Clinic
340 North Green Bay Avenue
Gillett, WI 54124

Nose- and sinus-related medical complaints are most common in a primary care setting. The vast majority of office ear, nose, andthroat (ENT) problems are benign in nature and have a self-limiting course. However, an obstructed nose, with or without rhinorrhea, may significantly affect lifestyle by compromising comfortable breathing, disrupting normal sleep patterns, interfering with daily activities, and persuading the patient to consult his or her physician for relief. In addition, some patients are prone to frequent,prolonged, and complicated upper respiratory episodes or suffer the symptoms year round. Management of even these difficult patients can be very rewarding for both patient and caregiver because in most cases adequate treatment leads to complete resolution of symptoms, as opposed to other chronic debilitating conditions that compromise a patient's lifestyle in spite of the physician's best efforts.According to the Health Interview Survey, more than 122 million respiratory infections that restrict activity to some degree occur yearly in the United States. [33] The actual number of respiratory episodes per person per year varies by age and population studied. Adults average three episodes per year. Young children average six per year. Most sources report that only up to 0.5% of upper respiratorytract infections (URTIs) are complicated by a sinus disease. [11] [17] Nevertheless, it translates to as many as 30 million people per year treated for sinus infection in the United States. These data make sinusitis the leading and probably the most over-diagnosed condition for a number of reasons.
The diagnosis of sinusitis in most cases is based on a clinical impression
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only.The lack of a simple diagnostic test similar to a throat culture creates the tendency to label many common colds as sinusitis. [19] [30] [31] We assume that a patient who felt sick enough to be evaluated by a physician for URTI deserves a somewhat less common diagnosis than the common cold, for example, sinusitis. Television commercials also promote a sinus brainwash campaign with the frighteningpictures of sinus headaches and postnasal drip.
Once the diagnosis of sinusitis has been entertained, the gold standard of care, a full course of antimicrobial agents, is safely offered. Although today it is safer to over-diagnose and over-treat than to be on the opposite side, without a profound understanding of the modern pathophysiology of sinus disease, a stereotyped, purely antimicrobialapproach often will fail or achieve a temporary sterilization of the sinuses at best. [4] [5] [20] [51]
The purpose of this article is to identify the pathophysiologic basis of rhinosinus disease; to introduce the concept that a turbulent course of infections often is caused by a variable degree of mechanical obstruction of the nasal passages and ostia; to identify which pertinent historical datashould be obtained; and to emphasize the importance of an adequate focused physical exam, the ancillary tests, and treatment strategies.
The ultimate goal of this article is to enhance the autonomy and diagnostic accuracy of primary care physicians in managing nose and sinus related problems. The author reviews additional therapeutic options and discusses nasal hygiene and the prevention of sinus...