Step Perspective, Volume 5, Number 1; A Publication Of The Seattle Treatment Education Project - February 1993
Laury McKean, RN

The most common symptoms of sinusitis include fever, nasal congestion or discharge, and pain. The location of the pain can often indicate which sinuses are infected. Frontal sinusitis often causes pain and tenderness over the cheeks, and can also involve pain in the teeth. Individuals with ethmoidal sinusitis may have pain behind the eyes accompanied by redness and pain on the sides of the nose. The pain associated with sphenoidal sinusitis is more general and may be located in any of the areas mentioned above. Tearing of the eyes, and sensitivity to light has also been associated with sphenoidal sinusitis. Maxillary involvement appears to be the most common site in individuals with HIV, followed by ethmoidal sinusitis. Often both of these sinuses are involved at the same time. Frontal and sphenoidal sinusitis occur less frequently.

In some cases fever and/or headaches are the only symptoms, therefore sinusitis needs to be considered in the differential diagnosis of unexplained fever or headache, especially in individuals with low CD4 counts.

It is not completely understood why people with HIV suffer from sinusitis so frequently. Several factors are probably involved. First, individuals with HIV are at increased risk for any type of bacterial infection due to defects in humoral immunity. Also, defects in humoral immunity have been associated with recurrent sinus infections in other patient groups. Bacterial infections of the oral cavity are common in people with HIV potentially representing a source of contiguous infection. In addition, people with HIV tend to have more problems with allergies and elevated IgE levels, which can cause sinusitis. Other factors that may increase the risk of sinusitis are smoking and internasal cocaine use.

The diagnosis of sinusitis is usually based on the individual's medical history, the presence of sinus tenderness and other symptoms, and sometimes on transillumination and sinus-film findings. It is difficult to pinpoint the type of bacteria that is causing the infection. Nasal cultures are unreliable because they often contain different pathogens than the actual fluid in the sinuses.

The treatment of sinusitis in people with HIV has not been well studied. For acute sinusitis, the first step often includes the use of analgesics (aspirin or Tylenol) and the application of head for comfort. Decongestants such as pseudoephedrine (Sudafed) can be particularly helpful. These can be taken either orally or by nasal spray. The danger of rebound after short-term use of nasal sprays has probably been exaggerated. Spray each nostril once, then wait a minute to allow the anterior nasal mucosa to shrink, then spray again to reach the upper mucosa. This procedure can be repeated every four hours for several days if needed. Antihistamines are not usually helpful because they cause the secretions to thicken and prevent drainage. Antibiotics are commonly used with differing results. One study showed improvements in 79% of the individuals who received antibiotics. However, antibiotics did not appear to affect the clinical outcome in another study although they did appear to hasten radiologic improvements. Although no studies have been done anecdotal reports suggest that individuals taking TMP/SMX (Bactrim or Septra) have a reduced incidence of sinusitis.

One controversial therapy is the use of nasal steroids for chronic sinusitis. Although this is an effective therapy for many individuals, some physicians are concerned about their use because steroids are locally immunosuppressive. This suppression could theoretically allow other organisms to grow, especially funguses. However, one study showed that fungal infections were fairly rare. Researchers were particularly surprised to find a very low incidence of Candida albicans ( the fungus that causes thrush). Because this fungus is so common in the oral cavity with HIV, researchers expected to find it in the sinuses.

Another possible therapy for chronic sinusitis is the administration of intravenous gamma globulin (IgG). The use of this therapy stems from the theory that defective humoral immunity causes sinusitis. The theory is the individual is not able to produce effective antibodies to the bacteria because of damage to the immune system. Intravenous gamma globulin is a concentrated form of antibodies to help the body fight off the bacteria.

If these therapies fail, some individuals resort to surgery. This procedure physically widens the sinus passage to allow for better drainage and is often effective.

Researchers are finally giving greater attention to the high incidence of sinusitis in people with HIV. Hopefully this will lead to a better understanding of the causes and most effective treatments of sinusitis in the near future.

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