AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Chronic sinusitis is one of the more prevalent chronic illnesses in the United States, affecting persons of all age groups. Generally defined as a sinus infection persisting for more than 3 months, this condition usually manifests differently than acute sinusitis. Symptoms of chronic sinusitis include nasal stuffiness, postnasal drip, facial fullness, and malaise. Most cases are continuations of unresolved acute sinusitis. Allergic and nonallergic rhinitis, anatomic obstruction in the ostiomeatal complex, and immunologic disorders are known risk factors.

Pathophysiology

Anatomic considerations

Knowledge of the anatomy of paranasal sinuses is essential to understand the pathophysiology and management of chronic sinusitis.

The 4 pairs of paranasal sinuses are lined with ciliated, pseudostratified columnar epithelium. Goblet cells are interspersed among the columnar cells. The mucosa is attached directly to the bone. Involvement of the surrounding bone and further extension of the infection into the orbital and intracranial compartments occur in inadequately treated patients and in specific types of sinusitis such as fungal sinusitis.

The maxillary, frontal, and anterior ethmoid sinuses drain through their ostia located at the ostiomeatal complex lying lateral to the middle turbinate within the middle meatus. The posterior ethmoid and sphenoid sinuses open into the superior meatus and sphenoethmoid recess, respectively. The maxillary ostium connects to the nasal cavity by a narrow tubular passage called the infundibulum, located at the highest part of the sinus; hence, drainage from the maxillary sinus flows against gravity by mucociliary clearance. Because the floor of the maxillary sinus is the tooth-bearing part of the maxilla, dental infections can easily extend to the maxillary sinus. Even though the nasal cavity is usually colonized with bacteria, sinuses are typically sterile.

Mechanical obstruction at the ostiomeatal complex secondary to anatomic factors or mucosal edema arising from various etiologies (eg, acute viral or allergic rhinitis) triggers the stasis of secretions inside the sinuses. Mucous stagnation in the sinus forms a rich medium for the growth of various pathogens. Initially, resulting acute sinusitis involves only one type of aerobic bacteria. With persistence of the infection, mixed flora, anaerobic organisms, and, occasionally, fungus contribute to the pathogenesis. Most cases of chronic sinusitis develop in patients with acute sinusitis that does not respond to treatment or in those who have not received treatment.

The role of bacteria in the pathogenesis of chronic sinusitis is currently being questioned. Repeated and persistent sinus infections can occur in patients with severe acquired or congenital immunodeficiency states or cystic fibrosis.

Frequency

United States

Chronic sinusitis affects approximately 32 million persons each year and accounts for 11.6 million visits to physicians' offices. Chronic sinusitis ranks fifth compared to all diseases in frequency of antibiotic use associated with treatment. Incidence of chronic sinusitis in patients with AIDS may be as much as 64%.

International

Chronic sinusitis is a common disease worldwide, particularly in places where atmospheric pollution levels are high. Damp, temperate climates along with higher concentrations of pollens are associated with higher prevalence of this disease in the northern hemisphere.

Mortality/Morbidity

Because of its persistent nature, chronic sinusitis can become a significant cause of morbidity. Untreated, it can reduce the quality of life and the productivity of the affected person. Chronic sinusitis is associated with exacerbation of asthma and serious complications such as brain abscess and meningitis, which can produce significant morbidity and mortality.

Race

Chronic sinusitis is observed in all races.

Sex

Both sexes are affected equally.

Age

All age groups are affected.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Chronic sinusitis manifests more subtly than acute sinusitis. Unless an appropriate history is taken, the diagnosis may be missed. The typical symptoms of acute sinusitis, namely fever and facial pain, are usually absent.

• Patients usually present with the following symptoms:
• • Nasal stuffiness
  • Nasal discharge
  • Postnasal drip
  • Facial fullness, discomfort, and headache
  • Chronic unproductive cough
  • Hyposmia
  • Sore throat
  • Fetid breath
  • Malaise
  • Exacerbation of asthma
  • Dental pain
  • Visual disturbances
  • Sneezing
  • Stuffy ears
  • Unpleasant taste
  • Fever of unknown origin

Physical

Physical examination in patients with chronic sinusitis may reveal a variety of findings.

• Pain or tenderness on palpation over frontal or maxillary sinuses: Transillumination of maxillary or frontal sinuses is useful.
• Oropharyngeal erythema, purulent secretions
• Dental caries
• Endoscopic (rhinoscopic) examination findings
• • Nasal mucosal erythema, edema
  • Purulent secretions
  • Nasal obstruction due to deviated nasal septum or hypertrophied turbinates
  • Nasal polyps
• Ophthalmic manifestations
• • Conjunctival congestion
  • Lacrimation
  • Proptosis, extraocular muscle palsies, and visual disturbances (when complicated by orbital extension)

Causes

The bacterial pathogens and their roles are well defined in the etiology of acute sinusitis. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis account for more than 70% of cases of acute sinusitis.

The role of viruses in the etiology of acute sinusitis has also been documented. In one study, sinus cavity abnormality occurred in 87% of patients with early common viral rhinitis. Bacterial sinusitis complicated up to 2% of viral rhinitis cases.

While the microbiology of acute sinusitis has been well established, various researchers disagree on the microbial etiology of chronic sinusitis. Some studies have documented anaerobes as the prominent pathogens in chronic sinusitis, while others have failed to demonstrate this. The reasons for the variable growth of microbes in the samples obtained from chronic sinusitis may be due to prior exposure of patients with chronic sinusitis to various broad-spectrum antibiotics as well to a difference in sample collection techniques. The exact role of these microbes in the pathogenesis of chronic sinusitis is another unresolved issue.

Increasing attention is currently being focused on ostiomeatal obstruction, allergies, polyps, occult and subtle immunodeficiency states, and dental diseases, while the role of bacteria is being reduced to that of opportunistic colonizer.

• The following bacteria have been reported in samples obtained through endoscopy or sinus puncture in patients with chronic sinusitis:
• • Staphylococcus aureus
  • Coagulase-negative staphylococci
  • H influenzae
  • M catarrhalis
  • S pneumoniae
  • Streptococcus viridans
  • Streptococcus intermedius
  • Pseudomonas aeruginosa
  • Nocardia species
  • Anaerobic bacteria
• The following fungi have been reported in samples obtained through endoscopy or sinus puncture in patients with chronic sinusitis:
• • Aspergillus species
  • Cryptococcus neoformans
  • Candida species
  • Sporothrix schenckii
  • Alternaria species
• The following conditions and risk factors predispose patients to the development of chronic sinusitis:
• • Anatomic abnormalities affecting the ostiomeatal complex (eg, septal deviation, concha bullosa, deviation of uncinate process, Haller cells)
  • Allergic rhinitis
  • Nasal polyps
  • Nonallergic rhinitis (eg, vasomotor rhinitis, rhinitis medicamentosa, cocaine abuse)
  • Nasotracheal intubation
  • Nasogastric intubation
  • Hormonal (eg, puberty, pregnancy, oral contraception)
  • Tumoral obstruction
  • Immunologic disorders (eg, common variable immunodeficiency, immunoglobulin A deficiency, immunoglobulin G subclass deficiency, AIDS)
  • Cystic fibrosis
  • Primary ciliary dyskinesia, Kartagener syndrome
  • Wegener granulomatosis
  • Repeated upper respiratory tract infections
  • Smoking
  • Environmental pollution
  • Gastroesophageal reflux disease (GERD)
  • Periodontitis/significant dental disease

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Temporomandibular Joint Syndrome
Asthma
Other chronic rhinitis
Nasal and sinus cavity tumors
Facial pain attributable to other causes
Nasal polyp

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Studies have demonstrated no correlation between nasal flora and culture from the sinuses.
• Nasal swab cultures have no diagnostic value.
• Occasionally, an abundance of eosinophils in the nasal smear may point to the allergic nature of the nasal problem.
• Specimens obtained from sinus openings through an endoscope correlate well with specimens obtained during endoscopic surgery or sinus puncture.
• Routine blood cell counts and sedimentation rates are generally unhelpful; however, these may be elevated in patients with fever.
• In severe cases, blood cultures, including fungal blood cultures, may be helpful.
• Perform allergy testing if allergy is thought to be the underlying cause.
• Associated immune deficiency is diagnosed by serum immunoglobulin and immunoglobulin G subclass determination, antibody response to specific antigens, and HIV antibody testing (when indicated).

Imaging Studies

• The cornerstone in the diagnostic workup of chronic sinusitis is the radiologic examination.
• Plain radiograph
• • Routine sinus radiographs have limited value in the evaluation of chronic sinusitis.
  • In plain radiographs, mucosal thickenings or sinus opacities may be observed.
  • Air fluid levels are not common in chronic sinusitis.
  • Plain sinus films do not show ethmoid sinuses and the ostiomeatal complex well.
• CT scan
• • Contrast-enhanced CT scan is the current radiologic criterion standard for the evaluation of sinus diseases, although subjecting all patients with chronic sinus disease to scanning may be prohibitively expensive or medically unnecessary.
  • CT scans are usually indicated after failure of maximal medical therapy, before surgical planning for evaluation of suspected complications, and when a concern exists for a possible neoplasm.
  • Coronal CT scan of the sinus correlates best with the surgical approach, permitting visualization of the anatomy of the nasal cavity, ostiomeatal complex, sinus cavities, and surrounding structures such as the orbit, cribriform plate, and optic canal. Anatomic obstructions at the ostiomeatal complex and dental pathologies are visualized well. Specific entities in the sinus cavity, such as aspergilloma, are also visualized well.
  • CT scan combined with endoscopic examination helps the surgeon to make operative decisions.
  • Most centers now offer limited sinus CT scans consisting of 5-12 coronal cuts. These limited or screening CT scans cost about the same as a plain radiograph but provide more information.
• MRI
• • MRI is generally reserved only for complex cases.
  • Soft tissue contrast is better with MRI.
  • Neoplasms, orbital and intracranial complications, and fungal sinusitis can be better evaluated with MRI.

Procedures

• Cultures are most accurate if obtained by endoscopy.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

Medical therapy is often considered an adjunct to surgical treatment and is directed toward controlling predisposing factors, treating concomitant infections, reducing edema of sinus tissues, and facilitating the drainage of sinus secretions. The role of bacteria in the pathogenesis of chronic sinusitis remains debatable; however, when diagnosed early and intensively treated with oral antibiotics, topical nasal steroids, decongestants, and saline nasal sprays, significant numbers of patients have relief from symptoms, and many can be cured. When medical therapy is unsuccessful, refer patients for surgical evaluation.

• Control of predisposing factors: As the risk factors and etiologies for the development of chronic sinusitis are numerous, apply a combined approach to control or modify these factors in the management of chronic sinusitis.
• • Viral upper respiratory tract infections: Reduce viral exposures by improved personal hygiene. The roles of zinc and vitamin C in prevention of viral upper respiratory tract infection are controversial.
  • Environmental factors: Reduce exposure to dust, molds, cigarette smoke, and other environmental chemical irritants.
  • Allergic rhinitis: Environmental control, antihistamines, cromolyn, topical steroids, or immunotherapy may be necessary.
  • Patients with adult chronic sinusitis may benefit from control of GERD. GERD has increasingly been implicated in causing or exacerbating respiratory ailments such as asthma and chronic sinusitis. The exact relationships and mechanisms are presently a matter of speculation.
  • Immunodeficiency states: Appropriate control of various congenital and acquired immunodeficiency states is necessary to cure chronic sinusitis.
• Symptomatic measures
• • Symptoms may be relieved with topical decongestants, topical steroids, antibiotics, nasal saline, topical cromolyn, or mucolytics. See the Medication section for further discussion.
  • Steam inhalation and nasal saline irrigation may help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity.

Surgical Care

Recent advances in endoscopic technology and better understanding of the importance of the ostiomeatal complex in the pathophysiology of sinusitis have led to the establishment of functional endoscopic sinus surgery (FESS) as the surgical procedure of choice for the treatment of chronic sinusitis. FESS facilitates the removal of disease in key areas, restores adequate aeration and drainage of the sinuses by establishing patency of the ostiomeatal complex, and causes less damage to normal nasal functioning. FESS is successful in restoring sinus health, with complete or at least moderate relief of symptoms in 80-90% of patients. Continue supportive medical treatment preoperatively and postoperatively. In children, surgical management is not as well established and should be reserved for complicated cases.

• Fungal sinusitis: Fungal sinusitis can manifest in different ways.
• • Acute invasive fungal sinusitis is observed in patients who are immunosuppressed or diabetic and is usually caused by members of the genera Aspergillus, Mucor, and Rhizopus. This condition requires urgent workup and aggressive medical and surgical therapy. Mortality rates are very high.
  • Chronic fungal sinusitis is usually observed in patients who are immunocompetent. Surgical debridement is the preferred treatment.
  • Mycetomas or fungus balls may be asymptomatic or may manifest as chronic sinusitis. Surgical removal is the preferred treatment.
  • Allergic fungal sinusitis usually manifests as nasal polyps and allergic sinusitis. Fungal elements in the sinuses are the inciting allergens. Treatment consists of systemic steroids and surgical removal of polyps and mucinous secretions.

Consultations

• Persistent or recurrent episodes of sinusitis despite appropriate medical therapy necessitate referral to an otolaryngologist. Examination, including nasal endoscopy and CT scanning, is mandatory to exclude surgically amenable conditions.
• Seek an ophthalmology consult at the earliest suggestion of orbital involvement.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

The goals of pharmacotherapy are to eradicate the infection, reduce morbidity, and prevent complications.

Drug Category: Antibiotics

Many antibiotics have been used in the treatment of chronic sinusitis; the most common ones are presented. Ideally, direct antibiotics against the organism obtained from endoscopic sampling and based on microbial sensitivity testing. If the patient is ill, then empiric antimicrobial therapy may be indicated, which should be comprehensive and cover all likely pathogens in the context of the clinical setting. Duration of antibiotics is not well established. An initial 2- to 4-week trial of antibiotics may be reasonable. After surgical management for uncomplicated chronic sinusitis is completed, antibiotics are of unclear benefit. Invasion of bone or deep structures may require a prolonged antibiotic course.

Drug Category: Decongestants, topical

Alpha-adrenergic agonists that act by constricting dilated mucosal vessels. Topical preparations of oxymetazoline, naphazoline, tetrahydrozoline, and xylometazoline are available. Use all adrenergic topical preparations with caution in young patients and the elderly population. Topical agents can produce rebound vasodilation on discontinuation and rhinitis medicamentosa on prolonged use. Both of these adverse effects respond well to topical steroids.

Drug Category: Corticosteroids, topical

Particularly effective for chronic sinusitis associated with allergic rhinitis, nasal polyps, and rhinitis medicamentosa. Topical steroids along with systemic antibiotics are now the key components of the medical armamentarium in the management of chronic sinusitis.

Drug Category: Nasal sprays

Nasal saline spray and steam inhalation help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity. Symptomatic relief gained in some patients can be substantial; moreover, these are benign modalities of therapy.

Drug Category: Mast cell stabilizers

May be helpful in chronic sinusitis associated with allergic rhinitis.

Drug Category: Expectorants

Although no controlled studies on the efficacy of mucolytics in chronic sinusitis are available, guaifenesin (mucolytic agent) may be helpful in ameliorating some symptoms.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Inpatient treatment is indicated for patients with orbital and intracranial complications.
• Patients who are immunosuppressed and pediatric patients may need inpatient care, depending upon the severity of the disease.

Further Outpatient Care

• Continued outpatient medical treatment with nasal decongestants and topical steroids is important even after surgical treatment.

Deterrence/Prevention

• Certain conditions cause a predisposition to chronic sinusitis. Environmental factors or allergic factors may predispose some individuals to the condition. In these patients, the following preventive measures may be helpful:
• • Reduce exposure to dust, molds, cigarette smoke, and other environmental chemical irritants.
  • Environmental control, antihistamines, cromolyn, topical steroids, or immunotherapy may reduce recurrences and symptoms of allergic rhinitis.

Complications

• Orbital cellulitis
• Cavernous sinus thrombosis
• Intracranial extension (eg, brain abscess, meningitis)
• Mucocele formation

Prognosis

• Satisfactory outcomes result when a patient with chronic sinusitis is treated early with aggressive medical management.
• FESS restores sinus health with complete or moderate relief of symptoms in 80-90% of patients with recurrent or medically unresponsive chronic sinusitis.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Nasal swab culture does not correlate with sinus culture results. The role and type of microbes in pathogenesis are controversial.
• Always consider serious underlying conditions, such as tumors and immunodeficiency states, in the workup.
• Fungal sinusitis can be devastating in patients who are immunosuppressed and, rarely, in patients who are immunocompetent.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• Biel MA, Brown CA, Levinson RM. Evaluation of the microbiology of chronic maxillary sinusitis. Ann Otol Rhinol Laryngol. Nov 1998;107(11 Pt 1):942-5. [Medline].
• Brook I. Microbiology and management of sinusitis. J Otolaryngol. Aug 1996;25(4):249-56. [Medline].
• Evans KL. Recognition and management of sinusitis. Drugs. Jul 1998;56(1):59-71. [Medline].
• Gwaltney JM Jr, Phillips CD, Miller RD. Computed tomographic study of the common cold. N Engl J Med. Jan 6 1994;330(1):25-30. [Medline].
• Hafidh M, Harney M, Kane R. The role of fungi in the etiology of chronic rhinosinusitis: A prospective study. Auris Nasus Larynx. Oct 26 2006.
• Hinthorn D, Schwartz J. Efficacy and safety of cefixime and cefaclor in adults with purulent maxillary sinusitis. Postgrad Med. May 1998;58-62.
• Johnson JT, Ferguson BJ. Infection/paranasal sinus. Otolaryngol Head Neck Surg. 1998;2:1107-1134.
• Lockey RF. Management of chronic sinusitis. Hosp Pract (Off Ed). Mar 15 1996;31(3):141-6,149-5. [Medline].
• Lund VJ. Surgical outcomes in chronic rhinosinusitis and nasal polyposis. Rhinology. Jun 2006;44(2):97.
• Lusk R. Pediatric chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg. Dec 2006;14(6):393-6.
• Slavin RG. Nasal polyps and sinusitis. JAMA. Dec 10 1997;278(22):1849-54. [Medline].

Article Last Updated: Feb 20, 2007