II. Epidemiology
- Prevalence: 1-5% in U.S.
III. 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 Bacterial flora are present
- Staphylococcus aureus
- HaemophilusInfluenzae
- Anaerobes (ID)
- Fungal organisms (Immunocompromised patients)
- Other causes
IV. Risk Factors: Atypical cases
-
Vasculitis (e.g. Granulomatosis with Polyangiitis) or Granulomatis 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
V. 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%)
VI. Signs: Anterior rhinoscopy or Nasolaryngoscopy
- Mucopurulent nasal drainage
- Nasal mucosa edema
- Nasal obstruction
- Septal deviation
- Inferior or middle turbinate enlargement
- Middle meatus polyps
VII. Precautions: Red Flags suggestive of alternative diagnosis
- Nasal mass
- Diplopia
- Decreased Vision
- Periorbital Cellulitis or edema
- Ophthalmoplegia
- Meningisimus
VIII. 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
IX. 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
X. Management
- First-Line
- Intranasal Corticosteroids 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
- Second-line: Systemic Corticosteroids
- Indicated for Nasal Polyps or more severe symptoms
- Limit oral Corticosteroids 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
- References
XI. Management: Refractory cases
- Leukotriene Antagonists may be considered for refractory Nasal Polyps
- 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
XII. 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