Chronic Sinusitis


Article Author:
Edward Kwon


Article Editor:
Maria O'Rourke


Editors In Chief:
Casey Ciresi


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
10/17/2019 11:23:40 AM

Introduction

Sinusitis is inflammation of the sinus or nasal passage. Chronic sinusitis is chronic inflammation of the sinus or nasal passages occurring for more than 12 weeks at a time. Recurrent sinusitis is defined as greater than four episodes of sinusitis within a one-year period. The evaluation and management of acute and chronic sinusitis are similar. Chronic sinusitis may present as (1) chronic sinusitis without nasal polyps, (2) chronic sinusitis with nasal polyps, and (3) allergic fungal rhinosinusitis. [1][2]

Etiology

As stated in the acute sinusitis chapter, viruses and bacteria are the most common etiologies for sinusitis. Streptococcus, pneumococcus, Hemophilus, and Moraxella are the most common bacterial causes. Chronic sinusitis is multifactorial in nature and can include infectious, inflammatory, or structural factors. Thus, other etiologies such as allergic rhinitis (dust mites, molds), exposures (airborne irritants, cigarette smoke or other toxins), structural causes (nasal polyps, deviated nasal septum), ciliary dysfunction, immunodeficiencies, and fungal infections should be considered. Otitis media, asthma, AIDS, and cystic fibrosis, are other medical conditions that can be associated with chronic rhinosinusitis.[3][4]

Epidemiology

When the inflammatory process involves the paranasal sinus, it is sinusitis. It can often involve accompanying nasal airway inflammation, and when it involves both, this is then called rhinosinusitis. Chronic rhinosinusitis is one of the most common chronic conditions. It is prevalent among all age groups and is the fifth most common reason for an antibiotic prescription.[5][6][7]

Pathophysiology

There are four paired sinus cavities: the ethmoid, sphenoid, frontal, and maxillary sinus cavities. These paired cavities allow air to be filtered during inhalation. For the antigens to be filtered and expelled, sinuses need to drain. Chronic inflammation can cause obstruction to the nasal passage, hinder drainage, and lead to lower oxygen tension. This creates foci for bacteria to build up. Ciliary dysfunction or structural abnormalities can further exacerbate this process. [8]

Histopathology

Biopsy samples will usually reveal thickened basement membrane, goblet cell hyperplasia, atypical gland architecture and infiltration with monocytes. Sometimes one may also see neutrophils and eosinophils in chronic cases.

History and Physical

The three cardinal symptoms of sinusitis are:

1) Purulent drainage: green or yellow nasal discharge2) Facial/dental pain: aching, fullness or pressure-like pain 3) Nasal obstruction: this can cause difficulty breathing from one or both nasal passages or cause mouth breathing

Other symptoms of chronic sinusitis include hyposmia (decreased sense of smell), headache, ear pain, halitosis (bad breath), dental pain, cough, or fatigue. Fever only has a 50% sensitivity but is an important factor in determining the severity of sinusitis. The duration of symptoms is the key factor in diagnosing chronic sinusitis. Symptoms should occur for more than 12 weeks. Recurrent sinusitis occurs with four episodes of sinusitis within one year.

Evaluation

Chronic sinusitis is diagnosed when at least two of the following four symptoms are present and occur for more than 12 weeks: (1) purulent drainage, (2) facial and/or dental pain, (3) nasal obstruction, (4) hyposmia. The Infectious Disease Society of America (IDSA) defines sinusitis as two of the following major clinical symptoms: purulent nasal discharge, nasal congestion or obstruction, facial congestion or fullness, facial pain or pressure, hyposmia, anosmia. Alternatively, ISDA defines sinusitis as one of the aforementioned major symptoms plus two or more minor criteria such as a headache, ear pain, pressure, or fullness, halitosis or bad breath, dental pain, cough, or fatigue.

During the history and physical examination evaluation, practitioners should examine the patient for other causes such as nasal polyps. Chronic sinusitis is less common than acute sinusitis. Acute sinusitis can last up to four weeks. However, chronic sinusitis lasts twelve weeks or longer.  Practitioners can seek other non-infectious etiologies such as gastric gastroesophageal reflux, anatomical variations or structural problems of the nasal cavity, history of immunodeficiencies, history of ciliary dysfunction, and history consistent fungal infections.

Either CT or nasal endoscopy, confirming the presence of inflammation must be documented to confirm the diagnosis of chronic sinusitis. CT is more sensitive but also more expensive than nasal endoscopy. Anterior rhinoscopy has limited visualization and has lower sensitivity and should not be used to confirm chronic sinusitis. There is a large role for shared decision-making when discussing which option to choose. Cone-beam CT scanning has become a point-of-care alternative imaging study.

Routine lab work is not necessary to diagnose chronic rhinosinusitis. Cultures are not necessary but can be helpful in treatment. If a practitioner does a nasal endoscopy, the sinus cultures should be done and are much more accurate than nasopharyngeal swabs. This can assist in providing targeted antibiotic therapy.

Allergy testing, in general, is helpful and should be considered as an option.[9][10][11]

Treatment / Management

There is no consensus on an approach to the management of chronic sinusitis. The treatment should focus on modulating triggers, reducing inflammation, and eradicating the infection.[12][5]

Trigger Reduction

  • Allergy testing can help identify environmental triggers that patients should avoid.

Medical Management

  • Nasal steroids should be used with or without nasal saline irrigation. The treatment should last at least eight to 12 weeks with proper usage.
  • Nasal saline irrigation is inferior to nasal steroids. However,  nasal saline irrigation can serve as a useful adjunct. High volume nasal saline irrigation was found to be more effective than low-volume nasal spray techniques.
  • Antihistamines should only be used if an allergic component is suspected.
  • Decongestants can be used for symptomatic relief, but evidence for supporting their use in chronic sinusitis is lacking.
  • Antibiotics can be given for an extended period of three weeks. However, there is no consensus on their routine use in chronic sinusitis, nor is their consensus on antibiotic selection.
  • Anti-fungal empiric therapy should not be given.
  • Oral steroids can be used. However, their use is not routinely indicated. Comments regarding their use are given below.  Should oral steroids be used, physicians should engage in shared decision-making with patients.

Nasal Polyps

  • Chronic sinusitis with polyps should be treated with topical nasal steroids. If severe or unresponsive to therapy after 12 weeks, a short course of oral steroids can be considered.
  • Leukotriene antagonists can be considered.

Surgical Management

  • Functional endoscopic sinus surgery can be considered for patients who fail medical management. In more complicated cases, it can serve as an adjunct to medical management. The goal of this surgery is to relieve obstructions, restore drainage and mucociliary clearance, and to ventilate the sinuses.

If an underlying medical condition is found, then therapy should target the underlying condition. This could include surgical and medical approaches to fungal sinusitis or Intravenous immunoglobulin for immunodeficiencies. Management for both of these conditions is beyond the scope of this chapter.

Other associated and predisposing medical conditions should also be treated. These include asthma, otitis media, and cystic fibrosis.

Differential Diagnosis

  • Asthma
  • Sinus tumors
  • Oral cavity infections
  • Nasal and sinus papillomas

Complications

  • Laryngitis
  • Dacryocystitis 
  • Orbital cellulitis/abscess
  • Cavernous sinus thrombosis
  • Meningitis, subdural abscess, brain abscess
  • Frontal bone osteomyelitis

Enhancing Healthcare Team Outcomes

The management of chronic sinusitis is best done with an interprofessional team of healthcare workers that includes primary care, infectious disease experts, otolaryngologists, and radiologists, and specialty trained nurses. Otolaryngology nurses should educate the patient on controlling the trigger factors like avoiding tobacco, which can exacerbate the symptoms of chronic sinusitis. The pharmacist should educate the patient on antiallergy therapies that can help control the symptoms. The patients should also be told to manage gastroesophageal reflux disease because it is a known trigger for chronic sinusitis. Finally, the patients should be educated on the possible complications of chronic sinusitis and when to seek medical assistance.[13][14][15] [Level V]

Outcomes

Chronic sinusitis may be a benign disorder, but it has significant morbidity. If not treated, the quality of life is poor. The condition is known to exacerbate asthma and can even lead to meningitis and brain abscess formation- which increases morbidity and mortality. Patients with chronic sinusitis who are treated usually have satisfactory outcomes. Symptom relief can be obtained after functional endoscopic sinus surgery in about 75% of patients who fail to respond to medical management. In rare cases, chronic sinusitis can result in orbital and intracranial infections, leading to visual and neurological deficits. [16][17][Level V]


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Chronic Sinusitis - Questions

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A 33-year-old male presents with persisting bilateral maxillary sinus pressure and congestion for the past four months. He has no chronic health conditions. He initially presented to an urgent care clinic two months ago and was prescribed Azithromycin for a five-day course and nasal fluticasone, which he has used daily since then. He added on a nasal saline rinse last month but has not yet improved. Vital signs reveal blood pressure of 130/85mmHg, heart rate 96bpm, respiratory rate 16 breaths per minute, oxygen saturation 95%, temperature 98.5 degrees Fahrenheit. His maxillary sinuses are non-tender. His tympanic membranes reveal no erythema or bulging. Nasal passages show a small amount of erythema. Neck exam reveals mild bilateral cervical lymphadenopathy. Heart exam reveals no murmurs. Lungs reveal clear breath sounds bilateral. A sinus CT scan reveals inflammation consistent with sinusitis. What is the best next step in the management of this patient?



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A 56-year-old male with a history of allergic rhinitis and hypertension presents with a 4-month history of chronic nasal congestion, obstruction, and discharge. He has had no fevers or chills. He has been treated with fluticasone nasal spray once daily, cetirizine 10mg once daily, and was recently started on montelukast 10mg once daily. He also has been using a nasal saline rinse up to three times daily with no relief. He presented to urgent care 4 weeks ago, where he was prescribed a 21-day course of amoxicillin/clavulanate, which he has since completed. His symptoms have persisted. His vitals signs reveal a blood pressure of 140/90mmHg, heart rate of 90, respiratory rate of 16, oxygen saturation of 95%, and a temperature of 97.8 degrees Fahrenheit. Physical examination reveals tender maxillary sinuses bilaterally, no lymphadenopathy, normal tympanic membranes, normal heart sounds, and clear breath sounds bilaterally. A sinus CT scan from last month reveals evidence of chronic inflammation without nasal polyps. Allergy testing was also completed and returned negative. His symptoms have continued to worsen and are beginning to affect his work life and sleep quality. What is the next best step in management?



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A 33-year-old male presents with a 14-week history of persisting runny-nose and sinus pain. He often complains that it is difficult to breathe through his nose. He was been treated with a 10-day course of Azithromycin. After this did not work, he saw an allergist. Allergy testing was negative. He was prescribed nasal mometasone once daily and fexofenadine 180mg once daily. He returns to his primary care physician with persisting symptoms 2 weeks later. Vital signs reveal a blood pressure of 130/80, a heart rate of 90, a respiratory rate of 16, oxygen saturation of 100%, and a temperature of 99.0 degrees Fahrenheit. Physical examination reveals bilateral maxillary sinus tenderness, no lymphadenopathy, clear tympanic membranes, normal heart sounds, and bilateral non-vesicular breathing. A sinus CT is completed showing evidence of maxillary sinus inflammation. What would be a reasonable next step in management?



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A 44-year-old female presents with a 4-month history of nasal obstruction, discharge, and congestion. She has a history of osteoporosis and migraine headaches. She is on a fluticasone nasal steroid spray once daily, which has provided minimal relief. Her vital signs reveal a blood pressure of 120/82 mmHg, a heart rate of 92bpm, respiratory rate of 16breats per minute, oxygen saturation of 97%, and a temperature of 98.5 degrees Fahrenheit. Her physical exam reveals a normal tympanic membrane, bilateral maxillary sinus tenderness, normal oropharynx, and bilateral cervical lymphadenopathy. Her lung sounds are clear, and her heart sounds reveal no murmurs. She saw an allergist and otolaryngologist for allergy testing and nasal endoscopy done, which revealed inflammation in the maxillary sinuses. What is the most common expected complication of this condition?



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A 43-year-old male with a 3-month history of chronic nasal congestion and nasal discharge presents to the clinician. He was treated previously with Augmentin (amoxicillin and clavulanate) and has been on a 3-month course of Flonase (fluticasone) with no relief. He has a history of seasonal allergies, which he uses Cetirizine as needed. His physical examination reveals a blood pressure of 120/80 mmHg, a heart rate of 90 beats per minute, a respiratory rate of 16 breaths per minute, a temperature of 98.6 degrees Fahrenheit, and 96% oxygen saturation. He has minimal bilateral sinus tenderness, no lymphadenopathy, and a small amount of fluid behind the tympanic membranes. His lung sounds are clear bilaterally, and his heart exam reveals a regular rate and rhythm without murmurs. A sinus CT scan is performed, which reveals nasal polyps and evidence of sinus inflammation. No further laboratory work is sent. Which of the following is the next best step in management?



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A 53-year-old male with a history of hypertension, hyperlipidemia, and coronary artery disease presents for three months of nasal congestion, discharge, and obstruction. He was previously treated with Amoxicillin/Clavulanate, Azithromycin, Fluticasone nasal spray, and a nasal saline rinse. Physical examination reveals a blood pressure of 130/84mmHg, a heart rate of 96bpm, a respiratory rate of 16 breaths per minute, oxygen saturation of 96%, and a temperature of 98.9 degrees Fahrenheit. His physical examination reveals a well-appearing male, tympanic membranes with a small effusion bilaterally, bilateral tender maxillary sinuses, no lymphadenopathy, clear lung sounds, and normal heart sounds. His sinus CT reveals inflammation of the maxillary sinuses. Which part of the clinical evaluation is most revealing of the patient's diagnosis?



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A 16-year-old male presents to your office with persisting sinus pain and nasal discharge. This started with a sinus infection three months ago that has never fully recovered. He attends college and has no other chronic health conditions. His prior treatments include pseudoephedrine, cetirizine, oxymetazoline nasal spray, each of which provided no relief. He is currently on Fluticasone nasal spray and nasal saline irrigations daily, both of which have moderately helped. His vital signs reveal a blood pressure of 118/70 mmHg, heart rate of 90bpm, respiratory rate of 20 breaths per minute, oxygen saturation of 95%, and a temperature of 98.9 degrees Fahrenheit. Physical examination reveals healthy tympanic membranes, normal oropharynx, no neck lymphadenopathy, no sinus tenderness, clear breath sounds bilateral, and no murmurs on cardiac examination. Which of the following is most accurate regarding this patient's management plan?



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A 26-year-old male presents with a 4-month history of recurrent nasal obstruction and nasal discharge. He is otherwise healthy. He has been using nasal saline irrigation on and off without significant relief. Vital signs reveal a blood pressure of 138/80 mmHg, a heart rate of 80/minute, respiratory rate of 20/minute, oxygen saturation of 97%, and temperature of 98.9 degrees Fahrenheit. Physical exam reveals no sinus tenderness, a tympanic membrane with mild effusions, bilateral cervical adenopathy, normal oropharynx, clear breath, and normal heart sounds bilaterally. Sinus CT shows inflammation of the sinuses bilaterally. Which of the following symptoms can occur with this diagnosis?



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Chronic Sinusitis - References

References

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Stryjewska-Makuch G,Janik MA,Lisowska G,Kolebacz B, Bacteriological analysis of isolated chronic sinusitis without polyps. Postepy dermatologii i alergologii. 2018 Aug     [PubMed]
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Levy JM,Rudmik L,Peters AT,Wise SK,Rotenberg BW,Smith TL, Contemporary management of chronic rhinosinusitis with nasal polyposis in aspirin-exacerbated respiratory disease: an evidence-based review with recommendations. International forum of allergy     [PubMed]
Sedaghat AR, Chronic Rhinosinusitis. American family physician. 2017 Oct 15     [PubMed]
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