eMedicine Specialties > Infectious Diseases > HEENT Infections

Sinusitis, Chronic

Author: Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Coauthor(s): Himal Bajracharya, MBBS, Assistant Professor, Department of Internal Medicine, Division of Infectious Diseases, Kansas University Medical Center; Daniel Hinthorn, MD, Director, Division of Infectious Diseases, Professor, Departments of Internal Medicine, Pediatrics and Family Medicine, University of Kansas
Contributor Information and Disclosures

Updated: Jun 17, 2009

Introduction

Background

Chronic sinusitis is one of the more prevalent chronic illnesses in the United States, affecting persons of all age groups. Generally defined as a sinus infection that persists for more than 3 months, chronic sinusitis usually manifests differently than acute sinusitis. Symptoms of chronic sinusitis include nasal stuffiness, postnasal drip, facial fullness, and malaise. Most cases of chronic sinusitis are continuations of unresolved acute sinusitis.

Allergic rhinitis, nonallergic rhinitis, anatomic obstruction in the ostiomeatal complex, and immunologic disorders are known risk factors for chronic sinusitis.

Pathophysiology

Anatomic considerations

Knowledge of the anatomy of paranasal sinuses is essential for understanding the pathophysiology and management of chronic sinusitis.

The 4 pairs of paranasal sinuses are lined with ciliated, pseudostratified columnar epithelium. Goblet cells are interspersed among the columnar cells. The mucosa is attached directly to the bone. Involvement of the surrounding bone and further extension of the infection into the orbital and intracranial compartments can result from inadequate treatment of sinusitis and specific types of sinusitis (eg, fungal sinusitis).

The maxillary, frontal, and anterior ethmoid sinuses drain through their ostia located at the ostiomeatal complex lying lateral to the middle turbinate within the middle meatus. The posterior ethmoid and sphenoid sinuses open into the superior meatus and sphenoethmoid recess, respectively. The maxillary ostium is connected to the nasal cavity by a narrow tubular passage called the infundibulum, located at the highest part of the sinus; hence, drainage from the maxillary sinus flows against gravity via mucociliary clearance. Because the floor of the maxillary sinus is the tooth-bearing part of the maxilla, dental infections can easily extend to the maxillary sinus. Although the nasal cavity is usually colonized with bacteria, the sinuses are typically sterile.

Stasis of secretions inside the sinuses can be triggered by (1) mechanical obstruction at the ostiomeatal complex due to anatomic factors or (2) mucosal edema caused by various etiologies (eg, acute viral or allergic rhinitis). Mucous stagnation in the sinus forms a rich medium for the growth of various pathogens. Initially, resulting acute sinusitis involves only one type of aerobic bacteria. With persistence of the infection, mixed flora, anaerobic organisms, and, occasionally, fungus¹ contribute to the pathogenesis. Most cases of chronic sinusitis are due to acute sinusitis that either is untreated or does not respond to treatment.

The role of bacteria in the pathogenesis of chronic sinusitis is currently being questioned. Repeated and persistent sinus infections can develop in persons with severe acquired or congenital immunodeficiency states or cystic fibrosis.

Frequency

United States

• Chronic sinusitis affects approximately 32 million persons each year and accounts for 11.6 million visits to physicians' offices.
• Chronic sinusitis is the fifth most common disease treated with antibiotics.
• Up to 64% of patients with AIDS develop chronic sinusitis.

International

• Chronic sinusitis is a common disease worldwide, particularly in places with high levels of atmospheric pollution.
• In the northern hemisphere, damp temperate climates along with higher concentrations of pollens are associated with a higher prevalence of chronic sinusitis.

Mortality/Morbidity

• Because of its persistent nature, chronic sinusitis can become a significant cause of morbidity. Untreated, it can reduce the quality of life and the productivity of the affected person.
• Chronic sinusitis is associated with exacerbation of asthma and serious complications such as brain abscess and meningitis, which can produce significant morbidity and mortality.

Race

Chronic sinusitis is observed in all races.

Sex

Chronic sinusitis has no sexual predilection.

Age

Chronic sinusitis has no age predilection.

Clinical

History

Chronic sinusitis manifests more subtly than acute sinusitis. Unless an appropriate history is taken, the diagnosis may be missed. The typical symptoms of acute sinusitis—fever and facial pain—are usually absent in chronic sinusitis.

• Patients with chronic sinusitis usually present with the following symptoms:
  • Nasal stuffiness
  • Nasal discharge
  • Postnasal drip
  • Facial fullness, discomfort, and headache
  • Chronic unproductive cough
  • Hyposmia
  • Sore throat
  • Fetid breath
  • Malaise
  • Exacerbation of asthma
  • Dental pain
  • Visual disturbances
  • Sneezing
  • Stuffy ears
  • Unpleasant taste
  • Fever of unknown origin

Physical

Physical examination in patients with chronic sinusitis may reveal various findings.

• Pain or tenderness on palpation over frontal or maxillary sinuses: Transillumination of maxillary or frontal sinuses is useful.
• Oropharyngeal erythema, purulent secretions
• Dental caries
• Endoscopic (rhinoscopic) examination findings
  • Nasal mucosal erythema, edema
  • Purulent secretions
  • Nasal obstruction due to deviated nasal septum or hypertrophied turbinates
  • Nasal polyps
• Ophthalmic manifestations
  • Conjunctival congestion
  • Lacrimation
  • Proptosis, extraocular muscle palsies, and visual disturbances (when complicated by orbital extension)

Causes

Sinusitis has a pattern of several phases. The early stage of sinusitis is often a viral infection that generally lasts up to 10 days and that completely resolves in 99% of cases. However, a small number of patients may develop a secondary acute bacterial infection that is generally caused by aerobic bacteria (ie, Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis). If the infection does not resolve, anaerobic bacteria of oral flora origin eventually predominate. In a 1996 study, these bacterial changes were demonstrated with repeated endoscopic aspiration in patients with maxillary sinusitis.²

Currently, etiologic studies of sinusitis are increasingly focussing on ostiomeatal obstruction, allergies, polyps, occult and subtle immunodeficiency states, and dental diseases, while the role of bacteria in the etiology of sinusitis has been reduced to that of an opportunistic colonizer.

While the microbiology of acute sinusitis has been well established, various researchers disagree on the microbial etiology of chronic sinusitis. Much of the disagreement may be explained by methodology. Studies that have used adequate methods for recovery of anaerobes have demonstrated their prominence in chronic sinusitis, while those that did not use such methods have failed to recover them. When proper techniques are used, anaerobic bacteria can be recovered in 50-70% of specimens. The variable growth of microbes in samples may also be due to prior exposure of various broad-spectrum antibiotics in patients involved in the studies.

Jyonouchi et al (1999) successfully induced chronic sinusitis in rabbits via intrasinus inoculation of Bacteroides fragilis. The authors subsequently identified immunoglobulin G (IgG) antibodies against this organism in the infected animals. In addition, IgG antibodies to anaerobic organisms have been observed in patients with chronic sinusitis. These findings further support a role for anaerobes in chronic sinusitis.

Microbiologic studies of chronic sinusitis often show that the infection is polymicrobial, with isolation of 1-6 isolates per specimen.

In some cases, the baseline chronic sinusitis worsens suddenly or causes new symptoms. This acute exacerbation of chronic sinusitis is often polymicrobial, with anaerobic bacteria predominating. However, aerobic bacteria that are usually associated with acute sinusitis (eg, S pneumoniae, H influenzae, M catarrhalis) may emerge.

Gram-negative facultative and aerobic bacteria, including Pseudomonas aeruginosa, are more often isolated in patients with chronic sinusitis who have undergone endoscopic sinus surgery.

• The following bacteria have been reported in samples obtained through endoscopy or sinus puncture in patients with chronic sinusitis. The exact role of all of these microbes in the pathogenesis of chronic sinusitis is uncertain.
  • Staphylococcus aureus (both methicillin-susceptible S aureus [MSSA] and methicillin-resistant S aureus [MRSA] strains)
  • Coagulase-negative staphylococci
  • H influenzae
  • M catarrhalis
  • S pneumoniae
  • Streptococcus intermedius
  • P aeruginosa
  • Nocardia species
  • Anaerobic bacteria (Peptostreptococcus, Prevotella, Porphyromonas, Bacteroides, Fusobacterium species³ )
• The following fungi have been reported in samples obtained with endoscopy or sinus puncture in patients with chronic sinusitis:
  • Aspergillus species
  • Cryptococcus neoformans
  • Candida species
  • Sporothrix schenckii
  • Alternaria species
• The following conditions and risk factors predispose patients to the development of chronic sinusitis:
  • Anatomic abnormalities of the ostiomeatal complex (eg, septal deviation, concha bullosa, deviation of uncinate process, Haller cells)
  • Allergic rhinitis
  • Nasal polyps
  • Nonallergic rhinitis (eg, vasomotor rhinitis, rhinitis medicamentosa, cocaine abuse)
  • Nasotracheal intubation
  • Nasogastric intubation
  • Hormonal (eg, puberty, pregnancy, oral contraception)
  • Tumoral obstruction
  • Immunologic disorders (eg, common variable immunodeficiency, immunoglobulin A [IgA] deficiency, IgG subclass deficiency, AIDS)
  • Cystic fibrosis
  • Primary ciliary dyskinesia, Kartagener syndrome
  • Wegener granulomatosis
  • Repeated upper respiratory tract infections
  • Smoking
  • Environmental pollution
  • Gastroesophageal reflux disease (GERD)
  • Periodontitis/significant dental disease

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