Chronic Rhinosinusitis

Aka: Chronic Rhinosinusitis, Chronic Sinusitis

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II. Epidemiology

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

III. 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

IV. 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

V. 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%)

VI. 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

VII. Precautions: Red Flags suggestive of alternative diagnosis

  1. Nasal mass
  2. Diplopia
  3. Decreased Vision
  4. Periorbital Cellulitis or edema
  5. Ophthalmoplegia
  6. Meningisimus

VIII. 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
  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

IX. 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

X. Management

  1. First-Line
    1. Intranasal Corticosteroids for 8-12 weeks
    2. Low pressure, high volume (240 ml) 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 3 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]

XI. Management: Refractory cases

  1. Leukotriene Antagonists may be considered for refractory Nasal Polyps
  2. Surgery
    1. Septaplasty with or without turbinate reduction
    2. Endoscopic performed outpatient
      1. Removal of anatomic sinus block
      2. Improves symptoms in 85%
  3. Allergy Consultation
  4. Consider Immunologic work-up

XII. 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

XIII. Reference

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

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Related Studies

Ontology: Chronic sinusitis (C0149516)

Definition (NCI) Inflammation of the paranasal sinuses that typically lasts beyond eight weeks. It is caused by infections, allergies, and the presence of sinus polyps or deviated septum. Signs and symptoms include headache, nasal discharge, swelling in the face, dizziness, and breathing difficulties.
Concepts Disease or Syndrome (T047)
ICD9 473.9, 473
ICD10 J32 , J32.9
SnomedCT 155525007, 195792008, 266384001, 155528009, 40055000
English Unspecified sinusitis (chronic), Chronic sinusitis, unspecified, chronic sinusitis, chronic sinusitis (diagnosis), Sinusitis chronic NOS, Sinusitis (chronic) NOS, chronics sinusitis, sinus infection chronic, Sinusitis;chronic, chronic infection sinus, chronic rhinosinusitis, chronic sinus infection, chronic infections sinus, sinusitis chronic, Sinusitis, chronic, Chronic sinusitis NOS (disorder), Chronic sinusitis, Chronic infection of sinus, Chronic rhinosinusitis, Chronic sinusitis (disorder), Chronic infection of sinus, NOS, Chronic sinusitis, NOS, Chronic Sinusitis, Chronic sinusitis NOS, Chronic unspecified sinusitis
Italian Sinusite cronica, Sinusite non specificata (cronica), Sinusite cronica NAS
Dutch chronische sinusitis, niet-gespecificeerd, sinusitis chronisch NAO, niet-gespecificeerde sinusitis (chronisch), Chronische sinusitis, niet gespecificeerd, chronische sinusitis, Chronische sinusitis
French Sinusite non précisée (chronique), Sinusite chronique non précisée, Sinusite chronique SAI, Sinusite chronique
German Sinusitis chronisch NNB, chronische Sinusitis, unspezifisch, unspezifische Sinusitis, chronisch, Chronische Sinusitis, nicht naeher bezeichnet, Chronische Sinusitis, chronische Sinusitis
Portuguese Sinusite crónica NE, Sinusite (crónica) NE, Sinusite crónica
Spanish Sinusitis crónica NEOM, Sinusitis crónica no especificada, Sinusitis no especificada (crónica), sinusitis crónica, SAI, sinusitis crónica, SAI (trastorno), sinusitis crónica (trastorno), sinusitis crónica, Sinusitis crónica
Japanese 慢性副鼻腔炎, 慢性副鼻腔炎ＮＯＳ, 詳細不明の副鼻腔炎（慢性）, 慢性副鼻腔炎、詳細不明, ﾏﾝｾｲﾌｸﾋﾞｸｳｴﾝｼｮｳｻｲﾌﾒｲ, ｼｮｳｻｲﾌﾒｲﾉﾌｸﾋﾞｸｳｴﾝﾏﾝｾｲ, ﾏﾝｾｲﾌｸﾋﾞｸｳｴﾝ, ﾏﾝｾｲﾌｸﾋﾞｸｳｴﾝNOS
Czech Chronická sinusitida, Blíže neurčená sinusitida (chronická), Chronická sinusitida, blíže neurčená, Chronická sinusitida NOS
Korean 만성 굴염, 상세불명의 만성 굴염
Hungarian Nem meghatározott sinusitis (chronicus), chronicus sinusitis, Sinusitis chronica k.m.n., chronicus sinusitis, nem meghatározott
Derived from the NIH UMLS (Unified Medical Language System)

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