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Chronic Sinusitis

Unspecified Sinusitis (chronic)

Chronic sinusitis is defined as a chronic inflammation of the mucosal lining of the paranasal sinuses. It can be classified by the sinus cavity which it affects as maxillary, fontal ethmoid or sphenoid sinusitis.


Presentation

The first thing to note is that there is a poor correlation between symptoms and severity of the disease. Typical symptoms of chronic sinusitis include:

Obtain the following in the history:

  • Duration of symptoms 
  • Environmental living conditions and exposure to pollutants
  • Factors which exacerbate the illness
  • Factors that relive the symptoms
  • Current use of medications, herbs and supplements
  • Other medical problems (eg allergy, asthma, immunosuppression)
  • Prior nasal and sinus surgery
  • Prior treatments for sinusitis
  • Results of previous imaging test
  • Smoking

Physical examination

The physical exam is best performed with the use of a topical nasal decongestant like oxymetazoline as this can help with visualization. The exam must be done in a systemic manner and one needs to assess the turbinates, nasal septum, and middle meatus. Rhinoscopy should be conducted with and without a topical decongestant. During the exam one needs to identify the following?

  • Abnormal features of nasal mucosa, like color or condition
  • Any nasal mass or irregular surface
  • Assess integrity of hard plate
  • Bleeding, ulceration or diffuse areas of hemorrhage
  • Dry crusts or nasal septum perforation should lead one to suspect Wegener granulomatosis
  • Excessive secretion or dryness of nasal mucosa
  • Hypertrophy of turbinates
  • Look at condition of dentition and dental caries
  • Look for evidence of purulent secretions and post nasal drip
  • Palpation of the sinus for tenderness or swelling
  • Presence of any anatomical obstruction, septal deviation
  • Vascular malformations

Other organs systems to examine include the ears for otitis media or middle ear fluid collection and the eyes for cojunctival congestion, lacrimation, proptosis and visual acuity.

Nasal Congestion
  • A 44-year-old man attended our outpatient clinic with complaints of headache, nasal congestion, and postnasal drainage.[ncbi.nlm.nih.gov]
  • Nasal Obstruction and Congestion Nasal congestion (obstructed nose or diminished airflow through the nose) is certainly uncomfortable but this can also lead to many dental and medical problems.[arizonasinus.com]
  • The most common complaint of patients were nasal congestion and post-nasal drip.[ncbi.nlm.nih.gov]
  • If you have had nasal congestion and drainage for more than 3 months, you may have chronic sinusitis. The primary symptoms are nasal congestion, stuffiness, mouth breathing, and snoring. Nasal blockage often results in loss of taste and smell.[richmondent.com]
  • congestion, secretion and/or post-nasal drip and facial pain/headache.[ncbi.nlm.nih.gov]
Nasal Discharge
  • Chronic rhinosinusitis is diagnosed by the presence of two or more of the following factors facial congestion/fullness, nasal obstruction, nasal discharge or discolored post nasal drainage, hyposmia/anosmia or one major and two of the following minor[ncbi.nlm.nih.gov]
  • After recovery, she developed sinus symptoms of facial pain, green nasal discharge and bilateral hearing loss. ENT review revealed bilateral otitis media with effusion. Flexible naso-endoscopy found a stent fragment lodged in the nasopharynx.[ncbi.nlm.nih.gov]
  • Common Symptoms of Sinusitis Common symptoms of both acute and chronic sinusitis include, but are not limited to: Facial pain, pressure, swelling, or tenderness Nasal obstruction or blockage Nasal discharge that is thick and yellow or greenish in color[virginia-ent.com]
  • Signs and symptoms include headache, nasal discharge, swelling in the face, dizziness, and breathing difficulties. 473 Chronic sinusitis 473.0 Chronic maxillary sinusitis convert 473.0 to ICD-10-CM 473.1 Chronic frontal sinusitis convert 473.1 to ICD-[icd9data.com]
  • discharge or postnasal drip Reduced sense of smell or taste Bad breath Ear, jaw, or teeth pain Cough Nausea Sore throat Fatigue Disturbed sleep Recovery begins with an accurate diagnosis Chronic sinusitis can be somewhat difficult to diagnose because[allergytampa.com]
Snoring
  • Sometimes nasal polyps can make snoring severe enough to tip a patient who snores over to sleep apnea – which has a substantial effect on patients.[uofmhealth.org]
  • Chronic Sinusitis Symptoms Chronic sinusitis can cause considerable discomfort with cold-like symptoms that include: Nasal congestion, facial pain, or pressure and headache Difficulty breathing through the nose; snoring Swelling around the eyes and cheeks[allergytampa.com]
  • Acute and chronic sinusitis may cause or occur simultaneously with other symptoms or conditions including: Facial pain / pressure Headaches Pain in teeth Yellow or green mucus Nasal obstruction Breathing difficulty Snoring Post-nasal drip Reduced sense[entcoe.com]
  • The primary symptoms are nasal congestion, stuffiness, mouth breathing, and snoring. Nasal blockage often results in loss of taste and smell. Pain and fever are less commonly seen in chronic sinusitis than in acute infections.[richmondent.com]
  • Sinusitis can cause a variety of respiratory symptoms, including wheezing, coughing, and snoring, as well as sinus headaches.[houstonsinussurgery.com]
Anosmia
  • BACKGROUND: Chronic sinusitis and nasal polyps with subsequent nasal blocking, anosmia , and relapsing infections are frequent in the rhinological practice.[ncbi.nlm.nih.gov]
  • Chronic rhinosinusitis is diagnosed by the presence of two or more of the following factors facial congestion/fullness, nasal obstruction, nasal discharge or discolored post nasal drainage, hyposmia/anosmia or one major and two of the following minor[ncbi.nlm.nih.gov]
  • Patients may present with symptoms of sinusitis such as nasal obstruction, nasal discharge, facial pain, headache, halitosis, anosmia, etc.[radiopaedia.org]
  • Anorexia Chronic unproductive cough common in children Dental pain often localized to the upper teeth Fatigue Exacerbation of asthma Facial fullness, discomfort, pain, and headache (more with nasal polyposis) Halitosis Fever of unknown origin Hyposmia or anosmia[symptoma.com]
Persistent Cough
  • cough Fatigue To consult a Virginia ENT doctor about sinusitis, schedule an appointment online today.[virginia-ent.com]
Facial Pain
  • After recovery, she developed sinus symptoms of facial pain, green nasal discharge and bilateral hearing loss. ENT review revealed bilateral otitis media with effusion. Flexible naso-endoscopy found a stent fragment lodged in the nasopharynx.[ncbi.nlm.nih.gov]
  • Patients presenting with facial pain as the primary symptom were significantly more likely to have a negative CT (chi squared test, p 0.0001).[ncbi.nlm.nih.gov]
  • Patients will experience mucopurulent drainage, nasal congestion, facial pain-pressure-fullness, or a decreased sense of smell.[mountsinai.org]
  • It is a condition whose exact cause is unknown and it can present with a variety of symptoms that include a runny node, facial pain, fever, blocked nose, polyps, cough, and loss of weight.[symptoma.com]
Sinus Pain
  • However, patients may have exacerbations of acute sinusitis superimposed on the chronic disease, which may cause sinus pain, fever, and malaise.[ncbi.nlm.nih.gov]
  • […] polyps, deviated septum, or other blockages Constant exposure to irritants, such as cigarette smoke or fumes Asthma Acute sinusitis that keeps coming back Common symptoms of chronic sinusitis Symptoms may include: Facial pain and pressure Headache and sinus[saintlukeshealthsystem.org]
  • pain Sinusitis Sinusitis with nasal polyps Sinusitis, chronic Clinical Information Inflammation of the paranasal sinuses that typically lasts beyond eight weeks.[icd10data.com]
  • However, this does not rule out a nasal source of sinus pain. CBC: The amount of eosinophils in Nasal Polyps is related to eosinophilia of the peripheral blood, but not to elevated serum IgE.[cityallergy.com]
Sinus Headache
  • CLINIC FEATURES: A 41-yr-old woman was treated for chronic sinusitis and sinus headaches. She had suffered weight loss and pain over a 2-month period.[ncbi.nlm.nih.gov]
  • The Top 7 Underlying Causes of Sinusitis. by Dan Gay, CMO Sinus Survival You may be surprised to learn what’s causing your sinus headaches, sinus pressure, sinus congestion and post-nasal drip.[sinussurvival.com]
  • headache Sinus pain Sinusitis Sinusitis with nasal polyps Sinusitis, chronic Clinical Information Inflammation of the paranasal sinuses that typically lasts beyond eight weeks.[icd10data.com]
  • Sinus headache. National Headache Foundation website. Available at: . Accessed September 29, 2014. Sinus headaches. American Academy of Otolaryngology website. Available at: . Accessed July 29, 2014. Sinus problems.[cancercarewny.com]
  • Sinusitis can cause a variety of respiratory symptoms, including wheezing, coughing, and snoring, as well as sinus headaches.[houstonsinussurgery.com]
Recurrent Headache
  • headaches Postnasal drip Fatigue Diminished sense of smell Facial pressure Frequent episodes of infections that require antibiotics Can be exacerbated by the following: Nasal polyps, or small growths of tissue that obstruct nasal passages Respiratory[rush.edu]

Workup

Criteria to make a diagnosis of chronic sinusitis include symptoms present for 12 weeks or longer, 2 or more symptoms and CT scan showing bony changes, diffuse mucosal thickening or air fluid levels. It is important to be aware that using CT scan signs of inflammation can be seen in more than 2/5th of patients with chronic sinusitis in the absence of symptoms. Thus, making a diagnosis of chronic sinusitis on a CT scan alone is not sufficient. The imaging test must be supported with presence of clinical symptoms. CT scan is usually done in patients who fail to respond to therapy to ensure that there is no other pathology. Both plain X-rays and MRI are not recommended in routine cases because they lack specificity. Routine blood work is usually not helpful. Routine culture is not recommended. Culture may be done during endoscopy in individuals with complications like orbital infection or intracranial extension. Biopsy, allergy testing, immunoglobulin levels and sweat test to rule out cystic fibrosis may aid in diagnosis.

Penicillium
  • Penicillium crustosum, Penicillium citrinum, Aspergillus niger, Cladosporium cladosporioides, and Fusarium verticillioides were the most prevalent species.[ncbi.nlm.nih.gov]
Fusarium
  • Penicillium crustosum, Penicillium citrinum, Aspergillus niger, Cladosporium cladosporioides, and Fusarium verticillioides were the most prevalent species.[ncbi.nlm.nih.gov]
Pleural Effusion
  • Yellow nail syndrome is usually described as the combination of yellow nails, lymphoedema and often respiratory manifestations such as chronic sinusitis, bronchiectasis and pleural effusions.[ncbi.nlm.nih.gov]

Treatment

The aim of treatment for chronic sinusitis is to enhance drainage, decrease mucosal edema and eradicate the bacteria that are present. When the diagnosis of chronic sinusitis is made, the first step in the management is to identify the contributing factors. Allergy is frequently associated with chronic sinusitis and it may also need treatment. Experts recommend that testing for allergy may identify a subset of patients whose symptoms may respond to allergy treatment. If the patient has failed successive treatments, check the immune system for defects.

There is no cure for chronic sinusitis and hence the goal is to decrease the symptoms and minimize the complications by controlling the infectious component of the disorder [7] [8] [9] [10]. In general the treatment of chronic sinusitis is use of intranasal corticosteroids. Antibiotics may be required if there are signs of an infection. In most patients with chronic sinusitis without the presence of nasal polyps, there is an underlying infection and hence the treatment is intranasal corticosteroids combined with an antibiotic. The initial therapy is with a broad spectrum antibiotic that will target Staphylococcus aureus, gram negative organisms and anaerobes. Rarely one may need antibiotics to cover for Haemophilus influenzaStreptococcus pneumoniae and Moraxella catarrhalis.

Treatment of chronic sinusitis depends on duration and severity of symptoms plus any objective features of inflamed paranasal sinuses or the nasal mucosa. Presence of nasal polyps leads to slightly different treatment. Chronic rhinosinusitis with nasal polyps is treated with intranasal corticosteroids. Antibiotics are recommended when symptoms indicate infection (pain or purulence).

Control risk & trigger factors

  • Treat upper respiratory tract infections and gastroesophageal reflux disease  
  • Avoid exposure to tobacco smoke and environmental pollutants
  • Allergic patients should be treated with antihistamines, cromolyn or immunotherapy
  • Get control of asthma with prophylactic leukotriene inhibitors
  • Symptoms may be relieved with topical decongestants, topical steroids, antibiotics, nasal saline, topical cromolyn, or mucolytics.
  • Steam inhalation and nasal saline irrigation may help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity. Patients who have facial pain, and documented purulence should be suspected of having a concomitant bacterial infection and antibiotics should be considered.

Steroids

Most trials have shown a benefit from use of steroids in chronic sinusitis. In patients with severe sinusitis with polyps which has failed to respond to intranasal steroid, a 2 week course of oral prednisone may help improve symptoms. Steroids have also been used before and after endoscopic sinus surgery with effectiveness. When starting steroids, the minimal dose of the drug must be started and the patient must be told of all the potential adverse effects.

Adjunct therapies

  • Saline irrigation
  • Mucolytics
  • Antihistamines
  • Nasal decongestant

No solid evidence that any of the above therapies work. In addition, prolonged use of nasal decongestants can lead to development of rhinitis medicmentosa.

Antimicrobial therapy

  • At least 4-6 weeks of antibiotic treatment is required. Antibiotics selected should have broad spectrum coverage until culture results are available. Antibiotic therapy is continued until patient is asymptomatic, otherwise a relapse can occur. In refractory cases or in people with poor IV access, nebulized antibiotics can be administered.
  • Typical antibiotics used include amoxicillin plus clavulanate, macrolide plus metronidazole, 3rd generation cephalosporin or a quinolone. MRSA coverage is essential.
  • Experts recommend tailoring therapy to the clinical presentation. Patients with chronic sinusitis without nasal polyps are usually treated with a short course of prednisone and intranasal steroid.
  • Patients with chronic sinusitis and nasal polyps need relief from the obstruction and improved sinus drainage. This is achieved with use of systemic steroids and sometimes surgery.

If patient fails to respond, consider other disorders like:

Surgical care

  • Surgery is never the first choice treatment for chronic sinusitis. It is reserved for cases that have failed to respond to medical therapy and in patients with obstruction. The aim of surgery is allow for ventilation of the sinuses and correct mucosal opposition so that mucociliary clearance can be reestablished. Surgery can help remove thick and viscid secretions, and polys.
  • Fungal sinusitis (with fungal balls) is resistant to medical care and usually requires surgical debridement. Role of antifungal agents in chronic sinusitis is not clear. Allergic fungal sinusitis that presents with nasal polys is treated with systemic steroids followed by surgical removal of the polyps.

Consultations

All recurrent cases of chronic sinusitis should be referred to an otolaryngologist. In addition, any ocular involvement requires consultation with an ophthalmologist. If there is poor dental hygiene or dental caries, a consultation with a dentist is recommended.

Prognosis

Chronic sinusitis is associated with high morbidity because of its chronicity. Despite treatment, relapses are common. The patients usually have a poor quality of life. The disorder can exacerbate asthma and if left untreated can lead to osteomyelitis, meningitis, brain abscess and ocular complications. Even though medical and surgical treatment is available, the outcomes are not always predictable or consistent. Some patients do obtain relief from symptoms, but the treatment if often for prolonged time periods.

Complications

Finally the cost of medical care for chronic sinusitis is prohibitively expensive. Absenteeism from work is frequent leading to low productivity.

Etiology

The causes of chronic sinusitis include the following:

Common types of bacteria involved include:

The exact role of these bacteria in chronic sinusitis is not known. Even with proper techniques of isolation, bacteria are isolated in only about 50% of patients with chronic sinusitis. The only thing certain is that bacteria can exacerbate the symptoms. Fungal agents involved include Aspergillus, Cryptococcus and Candida.

Risk factors

Epidemiology

Chronic sinusitis is a common global medical disorder. In the US alone it is estimated that nearly one out of every seven individuals are affected. The disorder occurs in both genders and requires multiple visits to the emergency room and outpatient clinics. The chronicity of symptoms adds to a significant financial burden to the individual and the healthcare system.

In most cases, chronic sinusitis is seen in late adulthood and is now being reported in countries with high pollution like China. Damp and wet climates and places associated with higher pollen concentration also have a high prevalence. In children chronic sinusitis is more common and most likely related to prior upper respiratory tract infections [5] [6].

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of chronic sinusitis is not well understood. It is widely believed that presence of a bacterial infection or bacterial biofilms contribute to chronic or persistent sinus disease. The problem is exacerbated in the presence of antibiotic resistant strains of bacteria. However, the contribution of bacteria, fungi, other immunological deficits, susceptibility factors and role of environment remains unknown. It is now accepted that there is a spectrum of chronic sinusitis with various subtypes which present different pathological mechanism.

Prevention

Chronic sinusitis is difficult to prevent because the actual cause is not known. However, once diagnosed patients should avoid triggers like allergens, environmental pollutants, discontinue smoking and stress. The individual should follow up with a healthcare provide to ensure that the asthma is well controlled. The earlier the symptoms are controlled, the better is the quality of life.

Summary

Chronic sinusitis is a very common medical disorder not only in the US, but globally. This inflammatory disorder affects the paranasal sinuses and is usually accompanied by varying degrees of nasal inflammation. When the condition lasts more than 12 weeks, it is considered chronic. Chronic sinusitis is classified as:

  • Chronic sinusitis without presence of nasal polyps 
  • Chronic sinusitis with nasal polyps 
  • Allergic fungal rhinosinusitis

In the majority of cases, chronic sinusitis evolves from an acute sinusitis, but the symptoms are much intense in chronic sinusitis. Even though bacterial involvement can occur in chronic sinusitis, there are medical disorders which can present with chronic sinusitis in the absence of bacteria. These include cystic fibrosis, allergies, gastroesophageal reflux disease (GERD) or exposure to environmental agents. Fungal sinusitis can present in the same way as bacterial sinusitis but most patients tend to be diabetic, immunosuppressed or are on a prolonged course of corticosteroids. Allergic fungal sinusitis may present with nasal polyps. Chronic sinusitis is a disorder difficult to treat. Even with current day treatment, relapses are common the quality of life is poor [1] [2] [3].

Patient Information

Chronic sinusitis is a disorder of the nasal passages and the sinuses. It is a condition whose exact cause is unknown and it can present with a variety of symptoms that include a runny node, facial pain, fever, blocked nose, polyps, cough, and loss of weight. The diagnosis is made from a physical exam and use of a CT scan. Some people may need a endoscopy for biopsy. The treatment involves use of intranasal steroids and antibiotics. People who fail to respond need endoscopic surgery. The results of treatment are not always consistent and not everyone benefits. If left untreated, chronic sinusitis can extend to the eyes, brain and other facial areas.

References

Article

  1. Benninger MS, Hopkins C, Tantilipikorn P. Measuring outcomes in rhinosinusitis. Am J Rhinol Allergy. 2014 May-Jun;28(3):249-54
  2. Orlandi RR, Smith TL, Marple BF, Harvey RJ, Hwang PH, Kern RC, Kingdom TT, Luong A, Rudmik L, Senior BA, Toskala E, Kennedy DW. Update on evidence-based reviews with recommendations in adult chronic rhinosinusitis. Int Forum Allergy Rhinol. 2014 Jul;4 Suppl 1:S1-S15
  3. Georgalas C, Vlastos I, Picavet V, van Drunen C, Garas G, Prokopakis E. Is chronic rhinosinusitis related to allergic rhinitis in adults and children? Applying epidemiological guidelines for causation. Allergy. 2014 Jul;69(7):828-33
  4. Stevens WW, Peters AT. Immunodeficiency in chronic sinusitis: recognition and treatment. Am J Rhinol Allergy. 2015 Mar-Apr;29(2):115-8
  5. Brietzke SE, Shin JJ, Choi S, Lee JT, Parikh SR, Pena M, Prager JD, Ramadan H, Veling M, Corrigan M, Rosenfeld RM. Clinical consensus statement: pediatric chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2014 Oct;151(4):542-53
  6. Silviu-Dan F. Pediatric chronic rhinosinusitis. Pediatr Ann. 2014 Aug;43(8):e201-9.
  7. Kang SH, Dalcin Pde T, Piltcher OB, Migliavacca Rde O. Chronic rhinosinusitis and nasal polyposis in cystic fibrosis: update on diagnosis and treatment. J Bras Pneumol. 2015 Jan-Feb;41(1):65-76
  8. Sharma R, Lakhani R, Rimmer J, Hopkins C. Surgical interventions for chronic rhinosinusitis with nasal polyps. Cochrane Database Syst Rev. 2014 Nov 20;11:CD006990
  9. Marglani O. Update in the management of allergic fungal sinusitis. Saudi Med J. 2014 Aug;35(8):791-5.
  10. DeYoung K, Wentzel JL, Schlosser RJ, Nguyen SA, Soler ZM. Systematic review of immunotherapy for chronic rhinosinusitis. Am J Rhinol Allergy. 2014 Mar-Apr;28(2):145-50.

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Last updated: 2018-06-22 06:58