Sinus
Chronic Rhinosinusitis
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Chronic Rhinosinusitis
, Chronic Sinusitis
See Also
Allergic Fungal Sinusitis
Epidemiology
Prevalence
: 1-5% in U.S.
Pathophysiology
Chronic Sinusitis is an inflammatory condition (along the lines of
Asthma
,
Allergic Rhinitis
)
Mucous membrane loses normal function
Contributing factors
Inadequately treated
Allergic Rhinitis
Repeated cases of
Acute Sinusitis
(due to predisposing conditions such as
Cystic Fibrosis
)
Inflammatory more than infectious, but typically mixed
Bacteria
l flora are present
Staphylococcus aureus
Haemophilus
Influenza
e
Anaerobe
s (ID)
Fungal organisms (
Immunocompromised
patients)
Other causes
Allergic Fungal Sinusitis
Risk Factors
Atypical cases
Vasculitis
(e.g.
Granulomatosis with Polyangiitis
) or
Granuloma
tis disease (e.g.
Sarcoidosis
)
May results in increased nasal inflammation and obstruction
Cystic Fibrosis
Poor mucociliary clearance
Chronic Rhinosinusitis is very common in CF, and may predispose to pumonary infection
Immunodeficiency
Increased risk of fungal organisms
Symptoms
Facial pain or pressure (70-85%)
Hyposmia
or
Anosmia
or decreased or absent
Sense of Smell
(61 to 69%)
Discolored nasal drainage (51-83%)
Nasal obstruction (81-95%)
Signs
Anterior rhinoscopy or
Nasolaryngoscopy
Mucopurulent nasal drainage
Nasal mucosa edema
Nasal obstruction
Septal deviation
Inferior or middle turbinate enlargement
Middle meatus polyps
Precautions
Red Flags suggestive of alternative diagnosis
Nasal mass
Diplopia
Decreased
Vision
Periorbital Cellulitis
or edema
Ophthalmoplegia
Meningisimus
Diagnosis
At least 12 consecutive weeks of findings AND
Objective evidence of
Rhinosinusitis
AND
Exam with mucopurulent drainage, edema, middle meatus polyps (on anterior rhinoscopy or
Nasolaryngoscopy
) or
Imaging (preferably
Sinus CT
) consistent with
Sinusitis
related inflammation
At least 2 of the following 4 cardinal symptoms
Facial pain or pressure
Hyposmia
or
Anosmia
(decreased or absent
Sense of Smell
)
Nasal drainage
Nasal obstruction
Imaging
Sinus CT
(non-contrast)
Preferred imaging modality
Radiation exposure <1 mSv
False Positive
(e.g. after
Upper Respiratory Infection
)
Sinus XRay
Not recommended due to poor accuracy
Management
First-Line
Intranasal Corticosteroid
s for 8-12 weeks
Low pressure, high volume (240 ml)
Nasal Saline
irrigation (e.g.
Neti Pot
) three times daily
Precede each dose of
Intranasal Corticosteroid
with saline irrigation
Neti Pot
type irrigation is significantly better than nasal spray
Chong (2016) Cochrane Database Syst Rev (4):CD011995 [PubMed]
Second-line:
Systemic Corticosteroid
s
Indicated for
Nasal Polyp
s or more severe symptoms
Limit oral
Corticosteroid
s to short course (one week to no longer than 3 weeks)
Third-line: Antibiotics
Indicated for signs of acute on Chronic Sinusitis (e.g. fever) or if not improved in 8-12 weeks
Consider antibiotics guided by endoscopic sinus culture
Amoxicillin
-Clavulanate (
Augmentin
) for 2 weeks
Doxycycline
for 3 weeks (for antiinflammatory effects)
Avoid longterm use (>3 weeks) due to poor benefit and associated risk
Head (2016) Cochrane Database Syst Rev (4):CD011994 [PubMed]
References
Rudmick (2015) JAMA 314(9):926-39 +PMID:26325561 [PubMed]
Management
Refractory cases
Leukotriene Antagonist
s may be considered for refractory
Nasal Polyp
s
Surgery
Septaplasty with or without turbinate reduction
Endoscopic performed outpatient
Removal of anatomic sinus block
Improves symptoms in 85%
Allergy
Consultation
Consider Immunologic work-up
Complications
Acute Sinusitis
exacerbations
Treat as
Acute Rhinosinusitis
with antibiotics
Serious complications from Chronic Rhinosinusitis are rare
Most of the following complications occur more commonly with
Acute Bacterial Rhinosinusitis
Periorbital Cellulitis
or
Orbital Cellulitis
Orbital abscess
Cavernous Sinus Thrombosis
Meningitis
Epidural Abscess
Comorbities exacerbated by Chronic Rhinosinusitis
Cystic Fibrosis
Asthma
Reference
Chester (1996) Am Fam Physician 53(3): 877-887 [PubMed]
Rosenfeld (2015) Otolaryngol Head Neck Surg 152(2 Suppl):S1-39 [PubMed]
Rudmik (2015) JAMA 314(9): 926-39 [PubMed]
Sedaghat (2017) Am Fam Physician 96(8): 500-6 [PubMed]
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