Sinusitis Rhinosinusitis Or Nasopharyngitis

The organisms classically associated with acute bacterial respiratory infections—Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis—are not usually considered pathogens of abscess cavities. Rather, they are mucosal pathogens that have proclivities for thriving on damaged respiratory epithelium, whether in the cigarette smoke-damaged lungs of the adult with chronic bronchitis or in the virally damaged airway of the child in daycare. Unfortunately, any attempt to use bacterial samples from the nasal specimens, as opposed to maxillary antral aspirates, would prompt critics to decry the results on the grounds that (1) nasal cultures do not correlate with antral cultures, and (2) the organisms recovered are considered "normal" nasal flora, particularly in children and infants.

To the critics, we might respond by asking, Who cares what is in the maxillary sinus? Our job is to characterize the disease present in the symptomatic patient. Although typical sinusitis pathogens may be present in low to modest numbers in the asymptomatic patient, it appears difficult to classify as "normal" a symptomatic nasal airway with significant damage to the epithelial ultrastructure, a heavy concentration of acute inflammatory cells, and the presence of pathogenic bacteria in high concentrations. This condition may be common, and often self-limiting, but it is certainly not normal. A more accurate differentiation of significant from insignificant bacterial infection should probably be based on quantitative bacteriology combined with an assessment of the inflammatory and immunologic responses, and not by the specific sinus involved. Easier said than done, perhaps, but to assume otherwise leads us clinically astray. The above considerations can be turned into a case for the use of nasal cultures of visible purulence when that purulence is persistent, has failed empirical therapy and is thought to be related to the disease process of interest. Purulent secretions probably have some, but not absolute, predictive value for bacterial infection versus viral processes. Some viral infections can present with thick purulent secretions, especially in the morning, after nocturnal stasis of the nasal secretions.1

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