Chronic Rhinosinusitis

Aka: Chronic Rhinosinusitis, Chronic Sinusitis

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II. Definitions

  1. Chronic Rhinosinusitis
    1. Three or more months of continuous symptomatic inflammation of the nose and Paranasal Sinuses

III. Epidemiology

  1. Prevalence: 1-5% in U.S.

IV. Pathophysiology

  1. Chronic Sinusitis is an inflammatory condition (along the lines of Asthma, Allergic Rhinitis)
  2. Mucous membrane loses normal function
  3. Contributing factors
    1. Inadequately treated Allergic Rhinitis
    2. Repeated cases of Acute Sinusitis (due to predisposing conditions such as Cystic Fibrosis)
  4. Inflammatory more than infectious, but typically mixed Bacterial flora are present
    1. Staphylococcus aureus
    2. HaemophilusInfluenzae
    3. Anaerobes (ID)
    4. Fungal organisms (Immunocompromised patients)
  5. Other causes
    1. Allergic Fungal Sinusitis

V. Types

  1. Primary Chronic Rhinosinusitis
    1. Non-Type 2 Inflammation
      1. Non-Eosinophilic Chronic Rhinosinusitis
    2. Type 2 Inflammation
      1. Associated with Asthma and allergic disease
      2. Eosinophils and Immunoglobulin E levels are often elevated
      3. Includes Allergic Triad of Aspirin sensitivity, Nasal Polyps and Eosinophilic Asthma
  2. Secondary Chronic Rhinosinusitis
    1. Dental Infection
    2. Sinus fungal ball
    3. Immunodeficiency
    4. Impaired mucociliary clearance (e.g. Cystic Fibrosis)
    5. Autoimmune disorders (e.g. Granulomatosis with Polyangiitis)

VI. Risk Factors: Atypical cases

  1. Vasculitis (e.g. Granulomatosis with Polyangiitis) or Granulomatis disease (e.g. Sarcoidosis)
    1. May results in increased nasal inflammation and obstruction
  2. Cystic Fibrosis
    1. Poor mucociliary clearance
    2. Chronic Rhinosinusitis is very common in CF, and may predispose to pumonary infection
  3. Immunodeficiency
    1. Increased risk of fungal organisms

VII. Symptoms

  1. Facial pain or pressure (70-85%)
  2. Hyposmia or Anosmia or decreased or absent Sense of Smell (61 to 69%)
  3. Discolored nasal drainage (51-83%)
  4. Nasal obstruction (81-95%)

VIII. Signs: Anterior rhinoscopy or Nasolaryngoscopy

  1. Mucopurulent nasal drainage
  2. Nasal mucosa edema
  3. Nasal obstruction
    1. Septal deviation
    2. Inferior or middle turbinate enlargement
    3. Middle meatus polyps

IX. Precautions: Red Flags suggestive of alternative diagnosis

  1. Nasal mass
  2. Diplopia
  3. Decreased Vision
  4. Periorbital Cellulitis or edema
  5. Ophthalmoplegia
  6. Meningisimus
  7. Severe Headache
  8. Neurologic findings
  9. Uncontrolled Epistaxis

X. Differential Diagnosis

  1. Acute Bacterial Sinusitis
  2. Sinonasal mass
  3. Sinus abscess
  4. Orbital Cellulitis
  5. Cerebrospinal Fluid Leak
  6. Nasal Foreign Body
  7. Obstructive Sleep Apnea
  8. Primary Headache (e.g. Tension Headache, Migraine Headache)
  9. Rhinitis
    1. See Rhinitis
    2. Vasomotor Rhinitis
    3. Allergic Rhinitis
    4. Hormonal Rhinitis (e.g. pregnancy, Menses, OCP use)
    5. Irritant Rhinitis
    6. Rhinitis Medicamentosa

XI. Diagnosis

  1. At least 12 consecutive weeks of findings AND
  2. Objective evidence of Rhinosinusitis AND
    1. Exam with mucopurulent drainage, edema, middle meatus polyps (on anterior rhinoscopy or Nasolaryngoscopy) or
    2. Imaging (preferably Sinus CT) consistent with Sinusitis related inflammation (mucosal thickening, ostiomeatal complex changes)
  3. At least 2 of the following 4 cardinal symptoms
    1. Facial pain or pressure
    2. Hyposmia or Anosmia (decreased or absent Sense of Smell)
    3. Nasal drainage
    4. Nasal obstruction

XII. Imaging

  1. Sinus CT (non-contrast)
    1. Preferred imaging modality
    2. Radiation exposure <1 mSv
    3. False Positive (e.g. after Upper Respiratory Infection)
  2. Sinus XRay
    1. Not recommended due to poor accuracy

XIII. Management

  1. First-Line
    1. Intranasal Corticosteroids
      1. Continue for at least 12 to 20 weeks
    2. Low pressure, high volume (240 ml) hypertonic Nasal Saline irrigation (e.g. Neti Pot) three times daily
      1. Precede each dose of Intranasal Corticosteroid with saline irrigation
      2. Neti Pot type irrigation is significantly better than nasal spray
        1. Chong (2016) Cochrane Database Syst Rev (4):CD011995 [PubMed]
  2. Second-line: Systemic Corticosteroids
    1. Indicated for Nasal Polyps or more severe symptoms
    2. Limit oral Corticosteroids to short course (one week to no longer than 2 weeks)
  3. Third-line: Antibiotics
    1. Indicated for signs of acute on Chronic Sinusitis (e.g. fever) or if not improved in 8-12 weeks
    2. Consider Antibiotics guided by endoscopic sinus culture
    3. Amoxicillin-Clavulanate (Augmentin) for 2 weeks
    4. Doxycycline for 3 weeks (for antiinflammatory effects)
    5. Avoid longterm use (>3 weeks) due to poor benefit and associated risk
      1. Head (2016) Cochrane Database Syst Rev (4):CD011994 [PubMed]
  4. References
    1. Rudmick (2015) JAMA 314(9):926-39 +PMID:26325561 [PubMed]

XIV. Management: Refractory cases

  1. Leukotriene Antagonists (Montelukast)
    1. Consider for refractory Nasal Polyps, or comorbid Allergic Rhinitis, Asthma
  2. Surgery (otolaryngology)
    1. Septaplasty with or without turbinate reduction
    2. Endoscopic performed outpatient
      1. Removal of anatomic sinus block
      2. Improves symptoms in 85%
  3. Refractory Nasal Polyps
    1. Dupilumab (Dupixent)
    2. Omalizumab (Xolair)
    3. Mepolizumab (Nucala)
  4. Allergy Consultation
  5. Consider Immunologic work-up

XV. Complications

  1. Acute Sinusitis exacerbations
    1. Treat as Acute Rhinosinusitis with Antibiotics
  2. Serious complications from Chronic Rhinosinusitis are rare
    1. Most of the following complications occur more commonly with Acute Bacterial Rhinosinusitis
    2. Periorbital Cellulitis or Orbital Cellulitis
    3. Orbital abscess
    4. Cavernous Sinus Thrombosis
    5. Meningitis
    6. Epidural Abscess
  3. Comorbities exacerbated by Chronic Rhinosinusitis
    1. Cystic Fibrosis
    2. Asthma
  4. Overall reduced quality of life
    1. Fatigue
    2. Sleep Disorders
    3. Depressed mood
    4. Cognitive impacts

XVI. Reference

  1. Chester (1996) Am Fam Physician 53(3): 877-887 [PubMed]
  2. Keating (2023) Am Fam Physician 108(4): 370-7 [PubMed]
  3. Rosenfeld (2015) Otolaryngol Head Neck Surg 152(2 Suppl):S1-39 [PubMed]
  4. Rudmik (2015) JAMA 314(9): 926-39 [PubMed]
  5. Sedaghat (2017) Am Fam Physician 96(8): 500-6 [PubMed]

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