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Zosano Announces Publication of Positive Data on Qtrypta’s™ Potential as an Acute Treatment for Patients with Difficult-to-Treat Migraines

Jocelyn Aspa
Zosano Pharma (NASDAQ:ZSAN) has announced a publication has been released on its Phase 2/3 (ZOTRIP) study in Headache: The Journal of Head and Face Pain, titled “Efficacy of ADAM Zolmitriptan for the Acute Treatment of Difficult to Treat Migraines.” In this post-hoc analysis, researchers examined the efficacy of Qtrypta™ in … Continued
Zosano Pharma (NASDAQ:ZSAN) has announced a publication has been released on its Phase 2/3 (ZOTRIP) study in Headache: The Journal of Head and Face Pain , titled “Efficacy of ADAM Zolmitriptan for the Acute Treatment of Difficult to Treat Migraines.”
In this post-hoc analysis, researchers examined the efficacy of Qtrypta™ in treating subsets of patients whose migraines have traditionally been difficult-to-treat and have been associated with poorer outcomes when treated with oral medications. Migraine characteristics including severe pain, duration of migraine of more than 2 hours, awakening with migraine, and the presence of nausea are established factors that predict a poorer response to traditional migraine treatment.
Results from these post-hoc analyses using the same clinical endpoints of pain freedom and most bothersome symptom (MBS) at 2 hours from the ZOTRIP study demonstrated patients with these difficult-to-treat migraine characteristics had uniformly better headache responses compared to patients who received placebo.
“We are pleased with the results of this retrospective analysis, which demonstrate that Qtrypta may be an effective acute treatment for patients exhibiting migraine characteristics that historically have been difficult to treat,” said Dr. Stewart Tepper, M.D., Professor of Neurology at the Geisel School of Medicine at Dartmouth. “Qtrypta was found to have clinically and statistically significant impact on pain freedom and most bothersome symptom freedom across the entire patient population in the ZOTRIP study, and the results from these subset analyses support the potential for Qtrypta to provide patients with a novel acute treatment that provides rapid relief of pain in patients with these more refractory migraine subtypes.” We found the top performing pharma stocks to watch this year Find out more in our report Get the latest Biotech Investing stock information Get the latest information about companies associated with Biotech Investing Delivered directly to your inbox. Biotech Investing

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Dr. Blake shows changes for neck and also headache alleviation.

Dr. Blake Kalkstein, DC, MS, CCSP Board Certified Sports Chiropractic Physician with Adolph & Kalkstein Chiropractic, Team Chiropractors for Baltimore’s expert baseball team.

Dr. Jeff Kalkstein, DC, ART, Team Chiropractor for Baltimore’s professional baseball group and Chiropractic Physician with Adolph & Kalkstein Chiropractic

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My Top 10 Favorite Things to Battle Symptoms of a Fibromyalgia Flare

January 30, 2019 My Top 10 Favorite Things to Battle Symptoms of a Fibromyalgia Flare
When you live with a chronic illness like Fibromyalgia it doesn’t take much to realize that you need to find ways to deal with your symptoms, and fast! Of course, there are treatments available to help ease the symptoms of a Fibromyalgia flare. Many times though, despite those treatments many of us find ourselves less than comfortable when our chronic illness decides to rear its ugly head.
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Over the years I’ve put together a basket of items I always have on hand to help me when I feel a Fibromyalgia flare coming on. Some are more helpful than others but I like to keep everything readily available so I don’t have to go looking for it when I feel awful. Treating the Symptoms of a Fibromyalgia Flare with Warmth
One thing that makes me absolutely miserable thanks to Fibromyalgia is dealing with cold weather. Whenever the temperature drops my pain levels tend to go through the roof. The small bones in my hands start to ache and the muscles along the outer edge of my neck spike with pain.
When the pain hits I like to have a good supply of items to help keep warm and ease sore muscles as quickly as possible. Soft Plush Weighted Blanket
As many special needs mamas know weighted blankets can be amazing for children with sensory issues. They help to create a comforting feeling with small beads making it fit just a little more snugly than a traditional blanket. I have found that weighted blankets are also great for dealing with the painful symptoms of a Fibromyalgia flare. It makes sense too if you think about it because our sensory input (peripheral nerves) is often working overtime too.
I have found through trial and error that finding the softest blanket possible is important as well. As mentioned in our article on dealing with itchy winter skin from Fibromyalgia there are some fibers that are best avoided as they can cause skin irritation. It’s also important to get a blanket that will keep you warm, but not too warm since sweating can cause skin irritation as well. Microplush Head and Shoulder Relief Heating Pad If I had to pinpoint one area of my body that is hit hardest by my Fibromyalgia flares it would be my head, neck, and shoulders. Often it starts with a migraine. Then the migraine decides that it wants to turn my headache into a full body affair as it moves down my neck and shoulders. One way that I battle these full upper body migraines is to use a heating pad on my neck and shoulders. This can be a great way to ease sore muscles and sometimes even calm a raging headache if I catch it early enough. Staying Comfortable During a Fibromyalgia Flare Sometimes no matter what you do it’s just impossible to get comfortable when you are dealing with the symptoms of a fibromyalgia flare. The bed is too soft. The couch is too hard. There’s a 20-pound cat on top of you. Oh, that’s just in my house? Anyway, finding a few ways to get a little more comfortable has been a lifesaver during some of my worst Fibromyalgia flares. Comfort U Shaped Total Body Support Pillow A few years ago, when I first started really dealing with awful Fibromyalgia symptoms I would use a pillow under my arm to help relieve back and arm pain. Then I moved up to a body pillow for extra support. The U Shaped body pillow provides support for arm pain, back pain, and neck pain. It truly helps to completely align the body for better comfort. Bohemian Loose Lounge Pants When I started dealing with Fibromyalgia I quickly learned that the clothing I wore made a world of difference. I was working as an EMT and wearing utility pants, military style boots, and tight fitted shirts to work every day. Once I found myself unable to leave the house as much as before I made a quick change of my wardrobe and haven’t looked back since. It is truly amazing the difference that a change in wardrobe can have when it comes to dealing with the symptoms of a Fibromyalgia flare. I almost always go with clothing that has a soft texture and that flows with the body rather than pressing against it as I move throughout the day. Cute Animal Non-Slip Fuzzy Socks
Just about any girl you ask will agree that warm fuzzy socks are pretty awesome. When you have FIbromyalgia they can be a great way of keeping the pain out of all of the little bones, muscles, and tendons in your feet. They can also be a great way to keep the rest of your body warm ( I swear I lose warmth out of my feet constantly)
For those that are a klutz like me, it is a total bonus to have non-slip socks. I mean, I still walk into walls and trip over air but at least with non-slip socks I have a fighting chance to make it through my day with only minimal bruising lol. Tackling Body Aches and Fatigue from a Fibromyalgia Flare
Many times outside factors such as stress can trigger or worsen a Fibromyalgia flare. When we try to push through our illness and find ourselves stressed out or overly tired we end up paying the price. A little self-care can go a long way when it comes to dealing with the symptoms of a flare. Pastel Green Hot/Cold Plush Eye Mask
A good eye mask can go a long way when it comes to dealing with the symptoms of a Fibromyalgia flare. Whether it’s puffiness and inflammation or pain behind the eyes as a migraine takes hold the versatility of a hot/cold mask can be a lifesaver. They are also a great way to block out sensory input when a light-sensitive migraine hits. Aromatherapy Essential Oils Set and Diffuser
Aroma is a hit or miss for me when it comes to living with Fibromyalgia. I am far too sensitive for perfumes or traditional air fresheners. When it comes to essential oils though there are a few that seem to be helpful for me. I find peppermint oil quite helpful for my headaches. I also enjoy lemon oils and find the scent comforting. Organic Hemp Tumeric Pain Cream Some days the whole body hurts. Others are a little easier and you can pinpoint a single area that is feeling pain. On those days I like to use a CBD cream to help ease away sore muscles and joint pain. I have tried a few different brands and found that some are better than others. For the most part, though, any of the organic topical creams have been quite helpful. The addition of Tumeric is great for fighting pain from inflammation. H.P. Lovecraft Tales of Horror
I spend around 3 days a week with a headache. I’ve become quite the reader since the noise of television, radio, and other things can be a bit much more me most days. Although I’ve been reading a lot of ghost stories I’ve always been a fan of horror collections. You can go wrong getting lost in the worlds of classic authors such as Lovecraft or Poe. Nintendo Switch Gaming System
On days that my headache isn’t out of control, I still enjoy quite a bit of gaming. I will always be a fan of the Xbox but lately, I’ve been a huge fan of the Nintendo Switch. There are two reasons for this. For one, the Switch is a handheld device so it is easy to use in any position but the screen is large enough to not bother your eyes. Secondly, with the Nintendo Online service , you get to play tons of games that 80’s kids like me grew up with. You don’t really need to plan or focus as much as you do with survival games and you can just have fun lining up pills in Dr. Mario or smashing pots in Zelda. Do you want to be the first to know when we have a new post on life with a chronic illness? Join our mailing list for all of our latest fun DIYs, tasty recipes, and tips on parenting with a chronic illness. Pin This Article for Later!

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Research shows that wet cupping therapy can improve musculoskeletal pain – NaturalNews.com

Research shows that wet cupping therapy can improve musculoskeletal pain
Wednesday, January 09, 2019 by: Michelle Simmons Tags: alternative medicine , cupping , cupping therapy , healing arts , musculoskeletal pain , natural healing , natural medicine , natural remedies , Natural Treatments , pain , pain relief , systematic review , therapies , traditional medicine , traditional therapy , wet cupping
( Natural News ) Many countries use wet cupping as a traditional therapy for relieving musculoskeletal pain, so researchers in Saudi Arabia and Singapore aimed to evaluate the safety and efficacy of this traditional therapy through a systematic review. In their review, which was published in The Journal of Alternative and Complementary Medicine , they found that there is promising evidence in favor of the use of wet cupping for musculoskeletal pain , particularly nonspecific back pain, neck pain, carpal tunnel syndrome, and brachialgia.
In many countries, wet cupping is a widely used traditional therapy for many conditions, including low back pain, neck pain, carpal tunnel syndrome, and brachialgia. Researchers in Saudi Arabia and Singapore found promising evidence on the safety and efficacy of this traditional therapy through a systematic review.
For the review, the researchers gathered and analyzed the available evidence of wet cupping in traditional and complementary medicine. A total of 14 studies were included in the review. These studies were randomized clinical trials that evaluated wet cupping against any type of control interventions in patients with any clinical condition and healthy individuals.
Out of the 14 studies, nine favored wet cupping over various control interventions in nonspecific low back pain, hypertension, brachialgia, chronic neck pain, oxygen saturation in smokers with chronic obstructive pulmonary disease (COPD), and oral and genital ulcers due to Behçet disease. On the other hand, five trials revealed that wet cupping did not cause any effect on nonspecific low back pain, hypertension, brachialgia, migraine headaches, and physiologic and biochemical parameters of healthy individuals. Mother Nature’s micronutrient secret : Organic Broccoli Sprout Capsules now available, delivering 280mg of high-density nutrition, including the extraordinary “sulforaphane” and “glucosinolate” nutrients found only in cruciferous healing foods. Every lot laboratory tested. See availability here.
Based on these findings, the researchers concluded that wet cupping is a promising treatment for musculoskeletal pain, especially nonspecific back pain, neck pain, carpal tunnel syndrome, and brachialgia. (Related: Pilot study concludes pain-relieving effects of wet cupping therapy .) More on cupping therapy
Cupping therapy, in general, is a type of alternative therapy originating in China that involves placing cups on the skin to create suction . The suction enhances blood flow to the area where the cups are placed, relieving muscle tension, improving overall blood flow and promoting cell repair. Cupping therapy can also help in the formation of new connective tissues and the creation of new blood vessels in the tissue.
Wet cupping is one of the two main categories of cupping done today; the other one is dry cupping. Dry cupping is a suction-only method; on the other hand, wet cupping involved both suction and controlled medicinal bleeding.
People use cupping to treat a wide variety of conditions. It is said to be particularly effective at relieving conditions that cause muscle aches and pain. This practice may also be potentially effective at treating digestive problems, skin problems, and other conditions commonly treated with acupressure because the cups can also be applied to major acupressure points. Some people use cupping therapy as a complementary treatment.
A review published in the journal PLOS ONE suggested that cupping therapy’s therapeutic effect may be more than just a placebo effect as the researchers found that it may help with many conditions, such as acne, cervical spondylosis, cough and dyspnea, facial paralysis, herpes zoster, and lumbar disc herniation.
Read more news stories and studies on other alternative treatments like wet cupping by going to AlternativeMedicine.news .
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Enjoy this super soft ASMR massage with some real skin and hair sounds. It is designed especially for headache relief even though I am massaging also the neck, the shoulders and the scalp. This massage is very different from a usual deep tissue massage as it relaxes the muscles with a very gentle contact; the muscles release automatically when you feel touched and safe.

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Enjoy the Health Benefits From These “Indulgences”

You are here: Home / Sexual Health, Weight Loss / Enjoy the Health Benefits From These “Indulgences” Enjoy the Health Benefits From These “Indulgences” January 27, 2019 By admin Leave a Comment
At this time of year, stuck between snow storms, freezing temperatures and pelting ice, it’s easy to cramp your shoulders in a permanent painful hunch, never get truly warm and feel tight, anxious and tensed.
Fortunately, it’s also easy to combat physical and emotional stressors, right here in your neighborhood – even in your own home – with spa treatments such as massage and hydrotherapy. These are not just sybaritic indulgences as many of these treatments have real health benefits. They can relieve pain, reduce stress and anxiety and give you a better quality of life – and they don’t have to break the bank.
Humans instinctively understand massage helps; when we bump a calf or elbow, the first thing we do is rub the spot. Just a 10-minute massage can reduce soreness by 30%. Massage pain relief includes back and neck pain, osteoarthritis and fibromyalgia. Massage reduces swelling and helps heal overworked, stressed or strained muscles. Massage also helps relieve migraines and other headaches. Massage can help stimulate your immune system, and has been shown to improve – with your physician’s approval – cancer pain and symptoms.
Studies show sleep improves after a massage, and so can depression. After a massage, the stress hormone cortisol can drop by 31%, while your levels of the feel-good hormones dopamine and serotonin can increase by 30%. Research proves massage causes increased blood flow to the areas of your brain that control mood and stress balance.
Hydrotherapy, whether floating in a warm pool of water or being pelted with splashes of cold water, has also been scientifically proven to generate health benefits. Water therapy will lower your heart rate and blood pressure and improve vascular and cardiovascular functioning. Water therapy can reduce colds and other infections and reduce pain from rheumatism, fibromyalgia, muscle damage and musculoskeletal challenges such as arthritis and general stiffness. It also helps chronic fatigue, chronic obstructive pulmonary disease (COPD) and asthma symptoms.
Swimming and water therapies have been shown to significantly decrease fatigue, anxiety and tension while increasing memory, positive moods and improved general well-being. As a result of water therapies, studies show that participants become more active overall.
Thinking that this all sounds expensive? It doesn’t have to be. Purchase a high density foam roller, kind of like a grown-up pool noodle on steroids, available online for as low as $20 and dive into online videos that will help you with massage placement and method. Even if you use a foam roller for just 5-10 minutes a day, you will reap significant health benefits. As for water therapy, fill your bathtub with warm water and plain old epsom salts! Soak for as long as you’d like, and finish with a cool, nearly cold splash.
Enjoy a moment of healthy indulgence in your home or from a professional. Getting a massage or enjoying hydrotherapy is scientifically good for you!

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sinusitis

siinusitis
https://en.wikipedia.org/wiki/Sinusitis
Sinusitis , also known as a sinus infection or rhinosinusitis , is inflammation of the mucous membrane that lines the sinuses resulting in symptoms. [1] [7] Common symptoms include thick nasal mucus , a plugged nose , and facial pain . [1] [7] Other signs and symptoms may include fever , headaches, poor sense of smell, sore throat, and cough. [2] [3] The cough is often worse at night. [3] Serious complications are rare. [3] It is defined as acute sinusitis if it lasts less than 4 weeks, and as chronic sinusitis if it lasts for more than 12 weeks. [1]
Sinusitis can be caused by infection , allergies , air pollution , or structural problems in the nose. [2] Most cases are caused by a viral infection . [2] A bacterial infection may be present if symptoms last more than ten days or if a person worsens after starting to improve. [1] Recurrent episodes are more likely in people with asthma , cystic fibrosis , and poor immune function . [1] X-rays are not typically needed unless complications are suspected. [1] In chronic cases confirmatory testing is recommended by either direct visualization or computed tomography . [1]
Some cases may be prevented by hand washing, avoiding smoking, and immunization . [2] Pain killers such as naproxen , nasal steroids , and nasal irrigation may be used to help with symptoms. [1] [5] Recommended initial treatment for acute sinusitis is watchful waiting . [1] If symptoms do not improve in 7–10 days or get worse, then an antibiotic may be used or changed. [1] In those in whom antibiotics are used, either amoxicillin or amoxicillin/clavulanate is recommended first line. [1] Surgery may occasionally be used in people with chronic disease. [8]
Sinusitis is a common condition. [1] It affects between about 10% and 30% of people each year in the United States and Europe. [1] [6] Women are more often affected than men. [9] Chronic sinusitis affects approximately 12.5% of people. [10] Treatment of sinusitis in the United States results in more than US$ 11 billion in costs. [1] The unnecessary and ineffective treatment of viral sinusitis with antibiotics is common.
Classification
Sinusitis (or rhinosinusitis) is defined as an inflammation of the mucous membrane that lines the paranasal sinuses and is classified chronologically into several categories: [11]
Acute sinusitis – A new infection that may last up to four weeks and can be subdivided symptomatically into severe and non-severe. Some use definitions up to 12 weeks. [1] Recurrent acute sinusitis – Four or more full episodes of acute sinusitis that occur within one year Subacute sinusitis – An infection that lasts between four and 12 weeks, and represents a transition between acute and chronic infection Chronic sinusitis – When the signs and symptoms last for more than 12 weeks. [1] Acute exacerbation of chronic sinusitis – When the signs and symptoms of chronic sinusitis exacerbate, but return to baseline after treatment Roughly ninety percent of adults have had sinusitis at some point in their life.
Signs & symptoms
Headache/facial pain or pressure of a dull, constant, or aching sort over the affected sinuses is common with both acute and chronic stages of sinusitis. This pain is typically localized to the involved sinus and may worsen when the affected person bends over or when lying down . Pain often starts on one side of the head and progresses to both sides. [13] Acute sinusitis may be accompanied by thick nasal discharge that is usually green in color and may contain pus (purulent) and/or blood. [14] Often a localized headache or toothache is present, and it is these symptoms that distinguish a sinus-related headache from other types of headaches, such as tension and migraine headaches. Another way to distinguish between toothache and sinusitis is that the pain in sinusitis is usually worsened by tilting the head forwards and with valsalva maneuvers . [15]
Infection of the eye socket is possible, which may result in the loss of sight and is accompanied by fever and severe illness. Another possible complication is the infection of the bones ( osteomyelitis ) of the forehead and other facial bones – Pott’s puffy tumor . [13]
Sinus infections can also cause middle ear problems due to the congestion of the nasal passages. This can be demonstrated by dizziness, “a pressurized or heavy head”, or vibrating sensations in the head. Post-nasal drip is also a symptom of chronic rhinosinusitis.
Halitosis (bad breath) is often stated to be a symptom of chronic rhinosinusitis; however, gold standard breath analysis techniques have not been applied. Theoretically, there are several possible mechanisms of both objective and subjective halitosis that may be involved. [15]
A 2004 study suggested that up to 90% of “sinus headaches” are actually migraines . [16] [17] [ verification needed ] The confusion occurs in part because migraine involves activation of the trigeminal nerves , which innervate both the sinus region and the meninges surrounding the brain. As a result, it is difficult to accurately determine the site from which the pain originates. People with migraines do not typically have the thick nasal discharge that is a common symptom of a sinus infection
by Location
There are four paired paranasal sinuses , the frontal, ethmoidal, maxillary and sphenoidal sinuses. The ethmoidal sinuses are further subdivided into anterior and posterior ethmoid sinuses, the division of which is defined as the basal lamella of the middle nasal concha . In addition to the severity of disease , discussed below, sinusitis can be classified by the sinus cavity which it affects:
Maxillary – can cause pain or pressure in the maxillary ( cheek ) area ( e.g., toothache , [15] or headache ) (J01.0/J32.0) Frontal – can cause pain or pressure in the frontal sinus cavity (located above the eyes), headache, particularly in the forehead (J01.1/J32.1) Ethmoidal – can cause pain or pressure pain between/behind the eyes, the sides of the upper part of the nose (the medial canthi ), and headaches (J01.2/J32.2) [19] Sphenoidal – can cause pain or pressure behind the eyes, but is often felt in the top of the head , over the mastoid processes , or the back of the head
complications
The proximity of the brain to the sinuses makes the most dangerous complication of sinusitis, particularly involving the frontal and sphenoid sinuses, infection of the brain by the invasion of anaerobic bacteria through the bones or blood vessels. Abscesses , meningitis and other life-threatening conditions may result. In extreme cases, the patient may experience mild personality changes, headache, altered consciousness, visual problems, seizures, coma, and possibly death.
Sinus infection can spread through anastomosing veins or by direct extension to close structures. Orbital complications were categorized by Chandler et al. [20] into five stages according to their severity (see table). Contiguous spread to the orbit may result in periorbital cellulitis, subperiosteal abscess, orbital cellulitis, and abscess. Orbital cellulitis can complicate acute ethmoiditis if anterior and posterior ethmoidal veins thrombophlebitis enables the spread of the infection to the lateral or orbital side of the ethmoid labyrinth. Sinusitis may extend to the central nervous system, where it may cause cavernous sinus thrombosis, retrograde meningitis, and epidural, subdural, and brain abscesses. [21] Orbital symptoms frequently precede intracranial spread of the infection . Other complications include sinobronchitis, maxillary osteomyelitis, and frontal bone osteomyelitis. [22] [23] [24] [25] Osteomyelitis of the frontal bone often originates from a spreading thrombophlebitis. A periostitis of the frontal sinus causes an osteitis and a periostitis of the outer membrane, which produces a tender, puffy swelling of the forehead.
The diagnosis of these complications can be assisted by noting local tenderness and dull pain, and can be confirmed by CT and nuclear isotope scanning. The most common microbial causes are anaerobic bacteria and S. aureus . Treatment includes performing surgical drainage and administration of antimicrobial therapy. Surgical debridement is rarely required after an extended course of parenteral antimicrobial therapy. [26] Antibiotics should be administered for at least 6 weeks. Continuous monitoring of patients for possible intracranial complication is advised.
Causes
Maxillary sinusitis may also be of dental origin (“odontogenic sinusitis”), [27] and constitutes a significant percentage (about 20% of all cases of maxillary sinusitis), [28] given the close proximity of the teeth and the sinus floor. The cause of this situation is usually a periapical or periodontal infection of a maxillary posterior tooth, where the inflammatory exudate has eroded through the bone superiorly to drain into the maxillary sinus. Once an odontogenic infection involves the maxillary sinus, it is possible that it may then spread to the orbit or to the ethmoid sinus . [28] Complementary tests based on conventional radiology techniques and modern technology may be indicated, based on the clinical context.
Chronic sinusitis can also be caused indirectly through a common but slight abnormality in the auditory or eustachian tube , which is connected to the sinus cavities and the throat. Other diseases such as cystic fibrosis and granulomatosis with polyangiitis can also cause chronic sinusitis. This tube is usually almost level with the eye sockets but when this sometimes hereditary abnormality is present, it is below this level and sometimes level with the vestibule or nasal entrance.
acute
Acute sinusitis is usually precipitated by an earlier upper respiratory tract infection , generally of viral origin, mostly caused by rhinoviruses , coronaviruses , and influenza viruses , others caused by adenoviruses , human parainfluenza viruses , human respiratory syncytial virus , enteroviruses other than rhinoviruses, and metapneumovirus . If the infection is of bacterial origin, the most common three causative agents are Streptococcus pneumoniae , Haemophilus influenzae , and Moraxella catarrhalis . [29] Until recently, Haemophilus influenzae was the most common bacterial agent to cause sinus infections. However, introduction of the H. influenza type B (Hib) vaccine has dramatically decreased H. influenza type B infections and now non-typable H. influenza (NTHI) are predominantly seen in clinics. Other sinusitis-causing bacterial pathogens include Staphylococcus aureus and other streptococci species , anaerobic bacteria and, less commonly, gram negative bacteria. Viral sinusitis typically lasts for 7 to 10 days, [29] whereas bacterial sinusitis is more persistent. Approximately 0.5% to 2% of viral sinusitis results in subsequent bacterial sinusitis. It is thought that nasal irritation from nose blowing leads to the secondary bacterial infection. [30]
Acute episodes of sinusitis can also result from fungal invasion. These infections are typically seen in patients with diabetes or other immune deficiencies (such as AIDS or transplant patients on immunosuppressive anti-rejection medications) and can be life-threatening. In type I diabetics, ketoacidosis can be associated with sinusitis due to mucormycosis . [31]
Chemical irritation can also trigger sinusitis, commonly from cigarette smoke and chlorine fumes. [32] Rarely, it may be caused by a tooth infection.
chronic
By definition chronic sinusitis lasts longer than 12 weeks and can be caused by many different diseases that share chronic inflammation of the sinuses as a common symptom. Symptoms of chronic sinusitis may include any combination of the following: nasal congestion , facial pain, headache , night-time coughing, an increase in previously minor or controlled asthma symptoms, general malaise , thick green or yellow discharge , feeling of facial ‘fullness’ or ‘tightness’ that may worsen when bending over, dizziness, aching teeth, and/or bad breath . [11] Each of these symptoms has multiple other possible causes, which should be considered and investigated as well. Often chronic sinusitis can lead to anosmia , the inability to smell objects. [11] In a small number of cases, acute or chronic maxillary sinusitis is associated with a dental infection. Vertigo , lightheadedness , and blurred vision are not typical in chronic sinusitis and other causes should be investigated. [ citation needed ]
Chronic sinusitis cases are subdivided into cases with polyps and cases without polyps. When polyps are present, the condition is called chronic hyperplastic sinusitis; however, the causes are poorly understood [29] and may include allergy, environmental factors such as dust or pollution, bacterial infection, or fungus (either allergic, infective, or reactive).
Chronic rhinosinusitis represents a multifactorial inflammatory disorder, rather than simply a persistent bacterial infection. [29] The medical management of chronic rhinosinusitis is now focused upon controlling the inflammation that predisposes patients to obstruction, reducing the incidence of infections. However, all forms of chronic rhinosinusitis are associated with impaired sinus drainage and secondary bacterial infections. Most individuals require initial antibiotics to clear any infection and intermittently afterwards to treat acute exacerbations of chronic rhinosinusitis.
A combination of anaerobic and aerobic bacteria are detected in conjunction with chronic sinusitis. Also isolated are Staphylococcus aureus (including methicilin resistant S.aureus ) and coagulase-negative Staphylococci and Gram negative enteric organisms can be isolated.
Attempts have been made to provide a more consistent nomenclature for subtypes of chronic sinusitis. The presence of eosinophils in the mucous lining of the nose and paranasal sinuses has been demonstrated for many patients, and this has been termed eosinophilic mucin rhinosinusitis (EMRS). Cases of EMRS may be related to an allergic response, but allergy is not often documented, resulting in further subcategorization into allergic and non-allergic EMRS. [33]
A more recent, and still debated, development in chronic sinusitis is the role that fungi play in this disease. [34] It remains unclear if fungi are a definite factor in the development of chronic sinusitis and if they are, what the difference may be between those who develop the disease and those who remain free of symptoms. Trials of antifungal treatments have had mixed results.
Recent theories of sinusitis indicate that it often occurs as part of a spectrum of diseases that affect the respiratory tract ( i.e. , the “one airway” theory) and is often linked to asthma . [35] [36] All forms of sinusitis may either result in, or be a part of, a generalized inflammation of the airway , so other airway symptoms , such as cough , may be associated with it.
Both smoking and secondhand smoke are associated with chronic rhinosinusitis
Pathophysiology
It has been hypothesized that biofilm bacterial infections may account for many cases of antibiotic -refractory chronic sinusitis. [37] [38] [39] Biofilms are complex aggregates of extracellular matrix and inter-dependent microorganisms from multiple species, many of which may be difficult or impossible to isolate using standard clinical laboratory techniques. [40] Bacteria found in biofilms have their antibiotic resistance increased up to 1000 times when compared to free-living bacteria of the same species. A recent study found that biofilms were present on the mucosa of 75% of people undergoing surgery for chronic sinusitis
Diagnosis
acute
Health care providers distinguish bacterial and viral sinusitis by watchful waiting . [1] If a person has had sinusitis for fewer than 10 days without the symptoms becoming worse, then the infection is presumed to be viral. [1] When symptoms last more than 10 days or get worse in that time, then the infection is considered bacterial sinusitis. [42] Imaging by either X-ray, CT or MRI is generally not recommended unless complications develop. [42] Pain caused by sinusitis is sometimes confused for pain caused by pulpitis (toothache) of the maxillary teeth, and vice versa. Classically, the increased pain when tilting the head forwards separates sinusitis from pulpitis.
chronic
For sinusitis lasting more than 12 weeks a CT scan is recommended. [42] On a CT scan, acute sinus secretions have a radiodensity of 10 to 25 Hounsfield units (HU), but in a more chronic state they become thickened, with a radiodensity of 30 to 60 HU. [43]
Nasal endoscopy and clinical symptoms are also used to make a positive diagnosis. [29] A tissue sample for histology and cultures can also be collected and tested. [44] Allergic fungal sinusitis (AFS) is often seen in people with asthma and nasal polyps . In rare cases, sinusoscopy may be made.
Nasal endoscopy involves inserting a flexible fiber-optic tube with a light and camera at its tip into the nose to examine the nasal passages and sinuses. This is generally a completely painless (although uncomfortable) procedure which takes between five and ten minutes to complete.
CT of chronic sinusitis
CT scan of chronic sinusitis, showing a filled right maxillary sinus with sclerotic thickened bone.
MRI image showing sinusitis. Edema and mucosal thickening appears in both maxillary sinuses.
Maxillary sinusitis caused by a dental infection associated with periorbital Cellulitis
Frontal sinusitis
X-ray of left-sided maxillary sinusitis marked by an arrow. There is lack of the air transparency indicating fluid in contrast to the other side.
Treatment
Recommended treatments for most cases of sinusitis include rest and drinking enough water to thin the mucus. [47] Antibiotics are not recommended for most cases. [47] [48]
Breathing low-temperature steam such as from a hot shower or gargling can relieve symptoms. [47] [49] There is tentative evidence for nasal irrigation in acute sinusitis, for example during upper respiratory infections. [5] Decongestant nasal sprays containing oxymetazoline may provide relief, but these medications should not be used for more than the recommended period. Longer use may cause rebound sinusitis . [50] It is unclear if nasal irrigation, antihistamines , or decongestants work in children with acute sinusitis
antibiotics
Most sinusitis cases are caused by viruses and resolve without antibiotics. [29] However, if symptoms do not resolve within 10 days, amoxicillin is a reasonable antibiotic to use first for treatment [29] with amoxicillin/clavulanate being indicated when the person’s symptoms do not improve after 7 days on amoxicillin alone. [42] A 2012 Cochrane review, however, found only a small benefit between 7 and 14 days, and could not recommend the practice when compared to potential complications and risk of developing resistance. [52] [ needs update ] Antibiotics are specifically not recommended in those with mild / moderate disease during the first week of infection due to risk of adverse effects, antibiotic resistance , and cost. [53]
Fluoroquinolones , and a newer macrolide antibiotic such as clarithromycin or a tetracycline like doxycycline , are used in those who have severe allergies to penicillins. [54] Because of increasing resistance to amoxicillin the 2012 guideline of the Infectious Diseases Society of America recommends amoxicillin-clavulanate as the initial treatment of choice for bacterial sinusitis. [55] The guidelines also recommend against other commonly used antibiotics, including azithromycin , clarithromycin, and trimethoprim/sulfamethoxazole , because of growing antibiotic resistance. The FDA recommends against the use of fluoroquinolones when other options are available due to higher risks of serious side effects. [56]
A short-course (3–7 days) of antibiotics seems to be just as effective as the typical longer-course (10–14 days) of antibiotics for those with clinically diagnosed acute bacterial sinusitis without any other severe disease or complicating factors. [57] The IDSA guideline suggest five to seven days of antibiotics is long enough to treat a bacterial infection without encouraging resistance. The guidelines still recommend children receive antibiotic treatment for ten days to two weeks
corticosteroid
For unconfirmed acute sinusitis, intranasal corticosteroids have not been found to be better than a placebo either alone or in combination with antibiotics. [58] For cases confirmed by radiology or nasal endoscopy, treatment with corticosteroids alone or in combination with antibiotics is supported. [59] The benefit, however, is small. [60]
There is only limited evidence to support short treatment with oral corticosteroids for chronic rhinosinusitis with nasal polyps.
surgery
For chronic or recurring sinusitis, referral to an otolaryngologist may be indicated, and treatment options may include nasal surgery. Surgery should only be considered for those people who do not benefit with medication. [61] [63] It is unclear how benefits of surgery compare to medical treatments in those with nasal polyps as this has been poorly studied. [64]
Maxillary antral washout involves puncturing the sinus and flushing with saline to clear the mucus. A 1996 study of patients with chronic sinusitis found that washout confers no additional benefits over antibiotics alone. [65]
A number of surgical approaches can be used to access the sinuses and these have generally shifted from external/extranasal approaches to intranasal endoscopic ones. The benefit of functional endoscopic sinus surgery (FESS) is its ability to allow for a more targeted approach to the affected sinuses, reducing tissue disruption, and minimizing post-operative complications. [66] The use of drug eluting stents such as propel mometasone furoate implant may help in recovery after surgery. [67]
Another recently developed treatment is balloon sinuplasty . This method, similar to balloon angioplasty used to “unclog” arteries of the heart, utilizes balloons in an attempt to expand the openings of the sinuses in a less invasive manner.
For persistent symptoms and disease in patients who have failed medical and the functional endoscopic approaches, older techniques can be used to address the inflammation of the maxillary sinus, such as the Caldwell-luc antrostomy . This surgery involves an incision in the upper gum, opening in the anterior wall of the antrum, removal of the entire diseased maxillary sinus mucosa and drainage is allowed into inferior or middle meatus by creating a large window in the lateral nasal wall
Epidemiology
Sinusitis is a common condition, with between 24 and 31 million cases occurring in the United States annually. [69] [70] Chronic sinusitis affects approximately 12.5% of People

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