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 an inflammatory process that involves the paranasal sinuses and persists for 12 weeks or longer. Recently, literature has supported that chronic sinusitis is almost always accompanied by concurrent nasal airway inflammation and is often preceded by rhinitis symptoms; thus, the term chronic rhinosinusitis (CRS) has evolved to more accurately describe this condition. A recent multidisciplinary consensus statement on CRS supported that the definition of CRS requires 2 or more of the following symptoms: anterior or posterior mucopurulent drainage, nasal obstruction, or facial-pain-pressure-fullness. The definition of CRS also requires both endoscopy, to document the presence of inflammation, and evidence of rhinosinusitis on imaging.

Pathophysiology

The pathophysiology of this disorder is poorly defined. Current thinking supports that CRS is predominantly an inflammatory disease. Confounding factors that may contribute to inflammation include the following:

• Persistent infection (including biofilms and osteitis)
• Allergy and other immunologic disorders
• Intrinsic factors of the upper airway
• Superantigens
• Colonizing fungi that induce and sustain eosinophilic inflammation
• Metabolic abnormalities such as aspirin sensitivity

All of these factors can play a role in disruption of the intrinsic mucociliary transport system. This is because an alteration in sinus ostia patency, ciliary function, or the quality of secretions leads to stagnation of secretions, decreased pH levels, and lowered oxygen tension within the sinus. These changes create a favorable environment for bacterial growth that, in turn, further contribute to increased mucosal inflammation.

Frequency

United States

The overall prevalence of CRS in the United States is 146 per 1000 population. This involves nearly 30 million US adults yearly, making CRS more common than any other chronic condition. For unknown reasons, the incidence of this disease appears to be increasing yearly. This results in a conservative estimate of 18-22 million physician visits in the United States each year and a direct treatment cost of $3.4-5 billion annually.

Mortality/Morbidity

Sinusitis is rarely life-threatening, although serious complications can occur because of the proximity to the orbit and cranial cavity.

• Approximately 75% of all orbital infections are directly related to sinusitis.
• Intracranial complications remain comparatively rare, with 3.7-10% of intracranial infections related to sinusitis.

Age

Rhinosinusitis is more common in the pediatric population because this term includes both acute and chronic infection and both viral and bacterial disease. This is likely secondary to an increased frequency of exposure to upper respiratory tract infections in the pediatric population.

CLINICAL

Section 3 of 10  

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

History

Patient history is extremely important in CRS because of the broad overlap between sinus symptoms and other disease processes, as well as poor correlation between symptoms and endoscopic and radiographic findings. Consequently, a number of key factors in the patient's history should be discerned. They are as follows:

• The presence of major symptoms (including purulent anterior nasal drainage, purulent-discolored posterior nasal drainage, nasal obstruction or blockage, facial congestion or fullness, facial pain or pressure, and hyposmia or anosmia)
• The presence of minor symptoms (including headache, ear pain or fullness, halitosis, dental pain, cough, fever, fatigue)
• Duration of symptoms
• Exacerbating and relieving factors
• History of previous nasal or paranasal sinus surgery
• Current medications
• Previous treatments and their duration
• Other confounding health problems (including asthma, allergy, and immunocompromising disorders)

Physical

The physical examination should include a complete head and neck examination to confirm the diagnosis and to rule out more serious disorders.

• Anterior rhinoscopy, with the use of a nasal speculum, to evaluate the condition of the nasal mucosa and to look for purulent drainage or evidence of polyps or other nasal masses (Other contributing factors to CRS that can be evaluated are nasal septal deviation and turbinate hypertrophy. The nasal examination should be carried out both before and after the use of a topical decongestant. If available, this portion of the examination can be supplemented with the use of nasal endoscopy.)
• Ear examination for the presence of middle ear fluid that may be the sign of a mass in the nasopharynx
• Neck examination for lymphadenopathy
• Cranial nerve examination for underlying sinus malignancy or neurological disorder
• Oral cavity and oropharynx examination to evaluate the integrity of the palate, the condition of dentition, and to look for evidence of postnasal drip
• Sinus palpation for evaluation of tenderness or swelling
• Ocular examination for spread of disease to the orbit and function of ocular musculature
• Laryngeal examination to look for other confounding upper airway pathology including laryngeal-pharyngeal reflux (LPR)
• Lung examination to determine if co-existing lower airway disease is present

Causes

A number of factors often contribute to the inflammatory process that causes CRS. Please see Pathophysiology for a discussion on etiology.

• Any disease process or toxin that affects cilia has a negative effect on CRS.
• The bacteria presumed to be involved in CRS differ from those in acute rhinosinusitis. Those most commonly isolated in CRS include Staphylococcus aureus, coagulase-negative Staphylococcus, anaerobic bacteria, and gram-negative bacteria.
• The reflux of gastric contents may play a contributing role in some cases of CRS. This relationship still needs to be better defined.

DIFFERENTIALS

Section 4 of 10  

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

Other Problems to be Considered

Nasal polyposis
Antral-choanal polyp
Inverting papilloma
Dental abscess
Aspirin/nonsteroidal anti-inflammatory drug sensitivity
Chronic headache of other etiology

WORKUP

Section 5 of 10  

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

Lab Studies

• Nasal swab and culture may help in selecting the proper antibiotic.
• Radioallergosorbent assay test (RAST) or skin testing for allergens may play an important role in treating patients with chronic rhinosinusitis (CRS) and confounding allergies.
• A sweat test for cystic fibrosis should be considered in all children with nasal polyposis and CRS.
• Evaluation of cilia function with a brush biopsy or turbinate biopsy can be considered in cases of presumed cilia dysfunction.
• Total immunoglobulin E (IgE) levels can be tested and may be helpful to evaluate for allergic fungal sinusitis.

Imaging Studies

• Plain x-ray films do not have a role in CRS. Today, the clinical role of plain films is limited to documentation of acute maxillary or frontal sinusitis.
• A noncontrast, dedicated sinus CT scan is the current criterion standard to identify and evaluate the details of sinus anatomy and pathology. This modality provides 2.5- to 3-mm cuts through the paranasal sinuses in both the axial and coronal planes.
• Contrast can be added to a sinus CT scan in the case of acute infection with presumed spread beyond the paranasal sinuses (to the orbit or brain).
• For patients with a history of previous sinus surgery, a CT scan with an image-guided protocol may assist the surgeon intraoperatively if the patient requires further surgical intervention.
• An MRI is generally reserved for cases of paranasal sinus tumors or cases with orbital and cranial base involvement.
• Ultrasonography provides variable results and is not recommended.

Other Tests

• Transillumination lacks sensitivity but may have value in experienced hands.
• Nasal endoscopy is recommended in most cases prior to obtaining imaging because it demonstrates the condition of the nasal mucosa and evaluates for purulent drainage.

Procedures

• Traditionally, maxillary sinus tap via inferior meatal puncture was performed for sinus culture.
• Many otolaryngologists have moved away from maxillary sinus tap because of the discomfort of the procedure and the understanding that a culture of an organism from the middle meatus may be more accurate to determine the bacteria involved in the disease process.
• Recent literature has supported the use of endoscopically directed culture of the middle meatus (the primary drainage system of the anterior ethmoid, maxillary, and frontal sinuses) with the use of either a suction trap or a swab.
• Endoscopically directed middle meatal cultures have a sensitivity of 80.9% and specificity of 90.5% in a recent meta-analysis.
• Calcium-alginate tipped applicators are a readily available device that can be used to obtain a culture.

Histologic Findings

Biopsy samples from the maxillary sinus mucosa of patients with chronic sinusitis show basement membrane thickening, atypical gland formation, goblet cell hyperplasia, mononuclear cell infiltration, and subepithelial edema. The mononuclear cell infiltrate often predominantly demonstrates neutrophils in acute disease and eosinophils in chronic disease. Rarely, squamous cell metaplasia may be seen.

Staging

Various staging systems have been proposed; however, no one system is accepted as the standard for use in CRS. Many studies use the Lund-Mackay scale to evaluate radiographic images. This scale grades the right and left sides independently, looking at the maxillary, anterior ethmoids, posterior ethmoids, sphenoid, and frontal sinuses, as well as the ostiomeatal complex. Each sinus is scored a 0 (no abnormality), 1 (partial opacification), or 2 (total opacification), while the ostiomeatal complex is scored either a 0 or 2 (for presence or absence of disease). Scores range between 0 and 24.

TREATMENT

Section 6 of 10  

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

Medical Care

No one treatment regimen exists in CRS. However, the principles involved in the treatment of CRS consist of identifying and treating the underlying causes and confounding variables.

• An adequate antibiotic trial in CRS usually consists of a minimum of 3-4 weeks of treatment, preferably culture directed.
• Other therapeutic entities used include intranasal corticosteroids, saline irrigations, short courses of oral steroids, decongestants, topical vasoconstrictors, and mucolytics.
• For patients with confounding nasal allergy, other antiallergy therapies, including antihistamines and immunotherapy, may play an important role.
• For patients with co-existing asthma, leukotriene inhibitors may play a role.
• Recent literature has suggested that topical antifungals may have a role in the treatment of CRS; however, this treatment remains controversial.
• Smoking cessation likely plays a large role in the success of both medical and surgical treatments because tobacco products act as an irritant to normal nasal mucosa and cilia function.

Surgical Care

Should be used as an adjunct to medical treatment in most cases.

• Surgical care is usually reserved for cases that are refractory to medical treatment and for patients with anatomic obstruction.
• Recent studies suggest that preoperative CT findings prior to sinus surgery may be poor predictors of surgical outcomes.
• The goal in surgical treatment is to reestablish sinus ventilation and to correct mucosal opposition in order to restore the mucociliary clearance system. Surgery strives to restore the functional integrity of the inflamed mucosal lining.

Diet

• Garlic has an active ingredient (allyl thiosulfinate) that provides a short-term decongestant effect. Eating foods highly seasoned with garlic has been considered therapeutic.
• Chewing horseradish root is another home remedy reported by some patients as effective for clearing the sinuses, but no scientific data support this belief.

MEDICATION

Section 7 of 10  

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

The goals of pharmacotherapy are to reduce morbidity, improve symptoms, and to prevent complications.

Drug Category: Antibiotics

Management of sinusitis usually includes an oral antibiotic. Criteria of antibiotic selection include (1) culture-directed when possible; (2) knowledge of changing antimicrobial resistance in a community; (3) history of medication allergy, especially the sulfa drugs and penicillins; (4) adverse effect profile of the medication; (5) cost of the medication and the economic status of the patient; and (6) other factors that affect compliance, such as dosing and formulation.

Currently, first-line antibiotics for patients with chronic sinusitis include amoxicillin-clavulanate, second-generation cephalosporins, and erythromycin-sulfasoxazole. Beta-lactamase–mediated resistance to the early second-generation cephalosporins is high among strains of Haemophilus influenzae and Moraxella catarrhalis. Cefixime, a third-generation cephalosporin, may be selected for infections caused by H influenzae or M catarrhalis, but it has a poor spectrum of activity against Streptococcus pneumoniae. The newer-generation macrolides, clarithromycin and azithromycin, achieve excellent mucosal levels and should be considered in patients with penicillin allergies. Some recent studies suggest that macrolides may also have some anti-inflammatory effects. Clindamycin should be reserved for resistant S pneumoniae.

Drug Category: Decongestants

Goals include reduction of tissue edema, facilitation of drainage, and maintenance of patency of sinus ostia. In short, decongestants are necessary to meet the management goals for sinusitis. Decongestants are available in 2 forms, topical and oral. Each agent differs slightly in its method of action.

Topical agents are locally active vasoconstrictor agents such as phenylephrine HCl 0.5% and oxymetazoline HCl 0.5% that provide almost immediate symptomatic relief by shrinking the inflamed and swollen nasal mucosa. Topical nasal formulations should not be used for longer than 3-5 consecutive days because of the risk of development of tolerance, rhinitis medicamentosa, and rebound after drug withdrawal.

Oral systemic agents are used when decongestion is necessary for longer than 3 days. An oral systemic agent, such as phenylpropanolamine (recalled from US market) or pseudoephedrine, is preferred. Oral decongestants are alpha-adrenergic agonists that reduce nasal blood flow. Theoretically, these oral systemic agents have the potential to act on tissues deep in the ostiomeatal complex, where topical agents may not penetrate effectively.

FOLLOW-UP

Section 8 of 10  

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

Further Inpatient Care

• Generally, CRS can be treated on an outpatient basis. If intracranial or orbital complications are suggested, the patient should be admitted and properly investigated.

Further Outpatient Care

• Nasal douching may improve symptoms, particularly following surgical treatment.
• Steam inhalation may have a role to liquefy and soften crusts while moisturizing dry inflamed mucosa.
• Nasal cavity irrigation using buffered normal saline may have a role in decreasing mucosal edema. Irrigation should be performed at least twice daily.
• Patients with presumed allergic rhinitis in conjunction with sinusitis may benefit from an evaluation by an otolaryngologist trained in otolaryngic allergy or an allergist/immunologist. In most instances, prick/puncture tests are performed to clarify the role of allergies.

Transfer

• Ophthalmology or neurosurgery consultation should be sought in those cases in which sinusitis has spread beyond the paranasal sinuses.
• Neurology consultation should be considered in cases of sinus symptoms without positive findings on CT to evaluate for migraine or other neurological causes for the patient's symptom.

Complications

• The most common complication of chronic sinusitis is superimposed acute sinusitis.
• In children, the presence of pus in the nasopharynx may cause adenoiditis, and a high percentage of such patients develop secondary serous or purulent otitis media.
• Dacryocystitis and laryngitis may also occur as complications of chronic sinusitis in children.
• Orbital complications include preseptal cellulitis, subperiosteal abscess, orbital cellulitis, orbital abscess, and cavernous sinus thrombosis.
• Intracranial complications include meningitis, epidural abscess, subdural abscess, and brain abscess.
• Other complications include osteomyelitis or mucocele formation.

Patient Education

• Patients should be educated on the importance of smoking cessation because tobacco use has negative effects on sinus function as well as other negative health effects.
• For excellent patient education resources, see eMedicine's patient section: http://www.emedicinehealth.com/sinus_infection/article_em.htm

MISCELLANEOUS

Section 9 of 10  

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

Medical/Legal Pitfalls

• Failure to identify and treat sinusitis in cases that progress to more serious infections beyond the paranasal sinuses
• Failure to consider malignancy, particularly in cases that are unilateral in nature or that demonstrate a nasal mass on examination or imaging

Special Concerns

• Rhinitis of pregnancy is an entity that should be entertained in women who present with sinus symptoms for the first time during pregnancy.
• Pediatric patients with CRS and particularly with nasal polyps should be assessed for immunodeficiency, especially cystic fibrosis.

REFERENCES

Section 10 of 10

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

• Arjmand EM, Lusk RP. Management of recurrent and chronic sinusitis in children. Am J Otolaryngol. Nov-Dec 1995;16(6):367-82. [Medline].
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• Parsons DS. Chronic sinusitis: a medical or surgical disease?. Otolaryngol Clin North Am. Feb 1996;29(1):1-9. [Medline].
• Ponikau JU, Sherris DA, Weaver A. Treatment of chronic rhinosinusitis with intranasal amphotericin B: a randomized, placebo-controlled, double-blind pilot trial. J Allergy Clin Immunol. Jan 2005;115(1):125-31. [Medline].
• Stafford CT. The clinician''s view of sinusitis. Otolaryngol Head Neck Surg. Nov 1990;103(5 (Pt 2)):870-4; discussion 874-5. [Medline].
• Weir NA. Infective rhinitis and sinusitis. In: Scott-Brown WG, Kerr AG, eds. Scott-Brown's Otolaryngology. Vol 3. 6th ed. Boston, Mass: Butterworth-Heinemann Medical; 1997:. 8, 23-5.
• Witsell DL, Stewart MG, Monsell EM. The Cooperative Outcomes Group for ENT: a multicenter prospective cohort study on the effectiveness of medical and surgical treatment for patients with chronic rhinosinusitis. Otolaryngol Head Neck Surg. Feb 2005;132(2):171-9. [Medline].

Article Last Updated: Aug 4, 2006