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Infection of the paranasal sinuses may cause localised pain. Localised tenderness and pain may be apparent with frontal or maxillary sinusitis. Sphenoidal or ethmoidal sinusitis causes a constant pain behind the eye or behind the nose, often accompanied by nasal blockage. Chronic infection of the sinuses may be extremely difficult to detect. The commonest organisms are Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis.
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Expanding lesions of the sinuses, such as mucocoeles and tumours, cause local swelling and displace the contents of the orbit—upwards for maxillary, laterally for the ethmoids and downwards for the frontal.
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The maxillary sinus is the one most commonly infected.5 It is important to determine whether the sinusitis is caused by stasis following a URTI or acute rhinitis, or due to dental root infection. Most episodes are of viral origin.
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Clinical features (acute sinusitis)
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Suspect bacterial cause if high fever and purulent nasal discharge.
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Clinical features (chronic sinusitis)
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Vague facial pain
Offensive postnasal drip
Nasal obstruction
Toothache
Malaise
Halitosis
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Some simple office tests
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Diagnosing sinus tenderness6
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To differentiate sinus tenderness from non-sinus bone tenderness palpation is useful. This is best done by palpating a non-sinus area first and last (see FIG. 52.4), systematically exerting pressure over the temporal bones (T), then the frontal (F), ethmoid (E) and maxillary (M) sinuses, and finally zygomas (Z), or vice versa.
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Differential tenderness both identifies and localises the main sites of infection (see FIG. 52.4).
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Diagnosing unilateral sinusitis
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A simple way to assess the presence or absence of fluid in the frontal sinus, and in the maxillary sinus (in particular), is the use of transillumination. It works best when one symptomatic side can be compared with an asymptomatic side.
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It is necessary to have the patient in a darkened room and to use a small, narrow-beam torch. For the maxillary sinuses remove dentures (if any). Shine the light inside the mouth (with lips sealed), on either side of the hard palate, pointed at the base of the orbit. A dull glow seen below the orbit indicates that the antrum is air-filled. Diminished illumination on the symptomatic side indicates sinusitis.
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A CT scan may show mucosal thickening without fluid levels. Plain films are not indicated.
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Management (acute bacterial sinusitis)
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Exclude dental root infection.
Control predisposing factors.
Use appropriate antibiotic therapy.
Establish drainage by stimulation of mucociliary flow and relief of obstruction.
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Guidelines for antibiotic therapy
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Consider therapy for severe cases displaying at least three of the following:
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persistent mucopurulent nasal discharge (>7–10 days)
facial pain
poor response to decongestants
tenderness over the sinuses especially maxillary
tenderness on percussion of maxillary molar and premolar teeth that cannot be attributed to by a single tooth
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Analgesics
Antibiotics:4
amoxycillin 500 mg (o) tds for 7 days
or (if sensitive to penicillin)
doxycycline 100 mg (o) bd for 7 days
or
cefaclor 500 mg (o) tds for 7 days
or
amoxycillin + clavulanate 875/125 mg (o) tds for 7–14 days if poor response to above (indicates resistant H. influenzae)
In complicated or severe disease, use intravenous cephalosporins or flucloxacillin
Nasal decongestants (oxymetazoline-containing nasal drops or sprays)5 for 5 days (only if congestion)
Inhalations (a very important adjunct)
Nasal saline irrigation
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Antihistamines and mucolytics are of no proven value.
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Surgical drainage may be necessary by atrial lavage or frontal sinus trephine.
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Inhalations for sinusitis
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The old method of towel over the head and inhalation bowl can be used, but it is better to direct the vapour at the nose. Equipment needed is a container, which can be an old disposable bowl, a wide-mouthed bottle or tin, or a plastic container.
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For the inhalant, several household over-the-counter preparations are suitable such as Friar’s Balsam (5 mL), Vicks VapoRub (1 teaspoon), or menthol (5 mL).
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The cover can be made from a paper bag (with its base cut out), a cone of paper or a small cardboard carton (with the corner cut away).
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Add 5 mL or 1 teaspoon of the inhalant to 0.5 L (or 1 pint) of boiled water in the container.
Place the paper or carton over the container.
Get the patient to apply nose and mouth to the opening and breathe in the vapour deeply and slowly through the nose, and then out slowly through the mouth.
This should be performed for 5–10 minutes, three times a day, especially before retiring.
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After inhalation, upper airway congestion can be relieved by autoinsufflation.
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Chronic sinusitis or recurrent sinusitis may arise from chronic infection or allergy. It may be associated with nasal polyps and vasomotor rhinitis, but is frequently associated with a structural abnormality of the upper airways. Refer to CHAPTER 59.
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It does not usually cause pain unless an acute infection intervenes. The acute or chronic attack is treated as for the acute attack but with 14 days of antibiotics. Those with an allergic mucous membrane may respond to intranasal corticosteroids. Surgical intervention will benefit chronic recurrence with mechanical blockage.
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This condition is due to abnormal movement of the mandible, especially during chewing. The basic causes are dental malocclusion and masticatory muscle dysfunction. Check for bruxism. The pain is felt over the joint and tends to be localised to the region of the ear and mandibular condyle, but it may radiate forwards to the cheek and even the neck.
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Check for pain and limitation of mandibular movements, especially on opening the mouth.
Palpate about the joint bilaterally for tenderness, which typically lies immediately in front of the external auditory meatus; palpate the temporalis and masseter muscles.
Palpate the TMJ over the lateral aspect of the joint disc.
Ask the patient to open the mouth fully when tenderness is maximal. The TMJ can be palpated posteriorly by inserting the little finger into the external canal.
Check for crepitus in mandibular movement.
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If organic disease such as rheumatoid arthritis and obvious dental malocclusion is excluded, a special set of instructions or exercises can alleviate the annoying problem of TMJ arthralgia in about 3 weeks. Warm packs may help. Provide patient education advice and self-care.
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Method 1: ‘Chewing’ the piece of soft wood
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Obtain a rod of soft wood approximately 15 cm long and 1.5 cm wide. An ideal object is a large carpenter’s pencil.
Instruct the patient to position this at the back of the mouth so that the molars grasp the object with the mandible thrust forward.
The patient then rhythmically bites on the object with a grinding movement for 2–3 minutes at least 3 times a day.
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Method 2: The ‘six by six’ program
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This is a specific program recommended by some dental surgeons. The six exercises should be carried out six times on each occasion, six times a day, taking about 1–2 minutes.
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Instruct the patient as follows:
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Hold the front one-third of your tongue to the roof of your mouth and take six deep breaths.
Hold the tongue to the roof of your mouth and open your mouth six times. Your jaw should not click.
Hold your chin with both hands keeping the chin still. Without letting your chin move, push up, down and to each side. Remember, do not let your chin move.
Hold both hands behind your neck and pull chin in.
Push on upper lip so as to push head straight back.
Pull shoulders back as if to touch shoulder blades together.
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These exercises should be pain-free. If they hurt, do not push them to the limit until pain eases.
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Injection into the TMJ7
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Indications: painful rheumatoid arthritis, osteoarthritis or TMJ dysfunction not responding to conservative measures. Inject a 1 mL solution of local anaesthetic and corticosteroid in equal parts.
Dental management that may be required for malfunction of the bite includes dental occlusal splinting.
NSAIDs: A trial of NSAIDs, e.g. ibuprofen 400 mg (o) tds for 10 days, for TMJ inflammation may need consideration. Cease if no response after 10 days.