Introduction
Background
Sinusitis is an inflammation of the mucosal lining of the paranasal sinuses. As the mucosa of the sinuses is continuous with that of the nose, rhinosinusitis is a more suitable term.1
Functional endoscopic sinus surgery (FESS) has revolutionized the treatment of sinusitis in recent years. The therapeutic benefits of FESS have helped a large number of patients with chronic sinus disease.2,3
Obstruction of the draining pathways of the sinuses is now thought to be the main cause of sinusitis. Examples of these pathways include the ostia of the maxillary sinuses and the hiatus semilunaris, where the anterior group of paranasal sinuses drains. Clearance of this obstruction is the aim of endoscopic surgery.
Imaging has also progressed with FESS, and CT scanning can now demonstrate the sinus anatomy and patterns of sinusitis in exquisite detail before surgery.4,5
Images of sinusitis are provided below:
Air-fluid level (arrow) in the maxillary sinus suggests sinusitis.
Deviated nasal septum on a coronal high-resolution CT scan.
Bilateral ethmoid sinusitis on an MRI.
Recent studies
Mcquillan et al asked pediatricians how they diagnose and manage nonsevere acute sinusitis in children. According to the study, pediatricians reported first considering acute sinusitis at the ages of 0-5 (6%), 6-11 (17%), 12-23 (36%), 24-35 (21%), and 36 months or older (20%). Symptoms thought to be very important included prolonged symptom duration (93%), purulent rhinorrhea (55%), and nasal congestion (43%); 60% reported that symptom duration is more important than symptom combination. Symptom duration before considering the diagnosis were 1-6 days (3%), 7-9 days (17%), 10-13 days (37%), 14-16 days (38%), and 17 or more days(6%). CT scanning was reported used by 58% in making the diagnosis of acute sinusitis. Antibiotics were used frequently or always by 96% of the respondents. Adjuvants used frequently or always included saline washes (44%), systemic decongestants (28%), nasal corticosteroids (20%), and systemic antihistamines (13%).6
Catalano et al evaluated balloon dilation for the treatment of chronic frontal sinusitis in 20 patients with advanced sinus disease in whom medical therapy had failed and therefore required operative intervention. Preoperative and postoperative CT scans were compared. There were no significant complications from balloon dilation, and there was significant improvement in patients with certain subsets of chronic rhinosinusitis.7
DelGuadio et al retrospectively reviewed 23 cases (8 epidural, 10 subdural, 2 intracerebral abscess, and 3 meningitis) of intracranial complications of sinusitis (ICS) to identify the role and effectiveness of endoscopic sinus surgery (ESS) in the acute setting of ICS. Of the 23 patients, 22 (96%) had radiologic evidence of frontal sinusitis with prefrontal or frontal lobe ICS at presentation. Medical therapy alone was successful in avoiding craniotomy in only 3 of 8 cases, and endoscopic sinus surgery and intravenous antibiotics was successful in avoiding craniotomy in only 1 of 6 patients. Of 23 patients, 18 required neurosurgical procedures (9 emergent procedures for abscesses more than 1 cm and 9 delayed procedures for persistent disease despite ICS less than 1 cm). The authors concluded that ESS did not alter the need for neurosurgical intervention, which was ultimately necessary in most patients, even those with lesions less than 1 cm.8
Pathophysiology
Sinusitis is an inflammation of the mucosal lining of the paranasal sinuses usually related to viral, bacterial or fungal infections. Allergic sinusitis is also common. Inflammatory response to allergens results in edema and thickening of the mucous membrane. Usually the margins of the edematous mucosa have a scalloped appearance, but in severe cases, mucous may completely fill a sinus, making it difficult to distinguish an allergic process from infectious sinusitis. Characteristically, all of the paranasal sinuses are affected and the adjacent nasal turbinates are swollen. Air-fluid levels and bone erosion are not features of uncomplicated allergic sinusitis; however, swollen mucosa in a poorly draining sinus is more susceptible to secondary bacterial infection.
The sinuses are lined by respiratory epithelium. The mucosal coat lining the sinuses can be subdivided into a superficial viscous layer and a deeper serous layer. Mucous secreted by the sinus mucosa traps bacteria. The mucous is naturally extruded through the normal ostia and expectorated or swallowed. The cilia expel the sinus secretions towards the natural ostia by beating in the serous layer.
Normal sinus function is maintained as long as the ostia remain patent and the cilia function normal. Another ingredient of normal function is the quality of the mucous secreted.
The most important factor in the pathogenesis of sinus disease is ostial obstruction, which leads to hypo-oxygenation, which in turn results in poor ciliary function and secretion of suboptimal quality of the mucous. Ciliary dysfunction leads to retention of the mucous within the sinuses.
Several other factors that can lead to impaired ciliary function. Cold air is said to stun the ciliary epithelium, leading to impaired ciliary movement and retention of secretions in the sinus cavities. On the contrary, inhaling dry air desiccates the sinus mucous coat, leading to reduced secretions. Any mass lesion with the nasal air passages and sinuses, such as polyps, foreign bodies, tumors, and mucosal swelling from rhinitis, may block the ostia and predispose to retained secretions and subsequent infection. Drinking alcohol can also cause nasal and sinus mucosa to swell and cause impairment of mucous drainage. Kartagener syndrome is associated with immobile cilia and hence the retention of secretions and predisposition to sinus infection.
Sinusitis can be subdivided into acute, subacute, and chronic disease. Acute sinusitis is defined as disease lasting less than 1 month, subacute disease lasts 1-3 months, and chronic sinusitis lasts longer than 3 months and generally related to suboptimally treated acute or subacute disease. Acute and subacute sinusitis is treated medically, whereas chronic sinusitis may require surgical intervention.
Frequency
United States
Sinusitis is one of the most common diseases in the United States, affecting an estimated 15% of the population. The incidence of sinusitis has increased dramatically with the increasing incidence of asthma, allergies, and other upper respiratory tract infections. Each year, an estimated 50 million people in the United States have sinusitis, but the incidence of clinical frontal sinusitis specifically is lower.
CT scans depict sinus abnormalities in 31-45% of the asymptomatic pediatric population.
International
Acute sinusitis affects 3 in 1000 people in the United Kingdom. Chronic sinusitis affects 1 in 1000 people. Sinusitis is more common in winter than in summer. Rhinoviral infections are prevalent in autumn and spring. Coronaviral infection occurs mostly from December to March.
Mortality/Morbidity
Sinusitis does not cause any significant mortality by itself. However, complicated sinusitis may lead to morbidity and, in rare cases, mortality.
Complications of sinusitis include acute and chronic sequelae. The incidence of intracranial complications in all patients hospitalized with sinusitis has been reported as 3.7%. Sinusitis is implicated as a source of subdural abscess in 35-65% of cases.
- Acute distant effects include toxic shock syndrome. Acute local effects can also occur. Acute orbital complications include the following: cellulitis, proptosis, chemosis, ophthalmoplegia, orbital cellulitis, subperiosteal abscess, and orbital abscess.
- Other acute complications include intracranial sequelae such as meningitis; encephalitis; cavernous or sagittal sinus thrombosis; and extradural, subdural, or intracerebral abscesses. Bony complications include dental involvement and osteitis or osteomyelitis. Potts puffy tumor refers to swelling of the scalp, caused by an underlying osteitis of the skull or extradural abscess. A classical cause of such a swelling is complicated frontal sinusitis.
- Chronic complications of sinusitis include mucocele and pyocele.
Race
No significant race preponderance exists.
Sex
Women have more episodes of infective sinusitis than men because they tend to have more close contact with young children. The rate in women is 20.3%, compared with 11.5% in men.
Age
Sinusitis is more common in children and young adults, who are particularly susceptible to rhinovirus infections, than in others.
Anatomy
The paranasal sinuses are hollow cavities within the bones of the face and base of skull. The sinuses are lined by mucous membrane that is continuous with that of the nasal cavity. In addition, the sinuses are all paired.
The frontal sinuses are posterior to the superciliary arch between the outer and inner tables of the frontal bone. The ethmoidal sinuses consist of thin-walled cavities in the ethmoid labyrinth. They vary in number and size from 3 large to 18 small sinuses. Their openings into the nasal cavity are highly variable.
The 2 sphenoid sinuses are sited posterior to the upper part of the nasal cavity contained within the body of the sphenoid bone. The posterior ethmoid and sphenoid sinuses are in close relation to the optic nerve and the nerve may even be enclosed within the sphenoid sinus at times. The 2 maxillary sinuses are pyramidal cavities in the bodies of the maxillae. Their ostia are positioned nearer the roof than the floor.
The anatomy of the sinuses on CT scans is described under CT Scan.
Presentation
Clinical findings may include the following: (1) pain over cheek and radiating to frontal region or teeth, increasing with straining or bending down; (2) redness of nose, cheeks, or eyelids; (3) tenderness to pressure over the floor of the frontal sinus immediately above the inner canthus; (4) referred pain to the vertex, temple, or occiput; (5) postnasal discharge; (6) a blocked nose; (7) persistent coughing or pharyngeal irritation; (8) facial pain; and (9) hyposmia.
Preferred Examination
Radiography
Plain radiography is generally obsolete, but exceptions include its use in confirming air-fluid levels in acute sinusitis and evaluating size and integrity of the paranasal sinuses. Radiographs may still provide a useful adjunct to diagnosis in parts of the world, where sophisticated imaging is not yet available.
Whether the Waters view is sufficient for evaluating suspected acute bacterial sinusitis is debated. In general, Waters, Caldwell, and lateral views are obtained.
Magnetic resonance imaging
MRI is generally reserved for the evaluation of any complications of local sinus infections, particularly suspected intracranial extension.
T1-weighted images and fat-suppressed T2-weighted images effectively depict the paranasal sinuses and adjacent facial compartments. Fat-suppressed gadolinium-enhanced T1-weighted images are helpful for assessing extension to the skull base and intracranial cavity. MRI is useful in differentiating sinusitis from neoplasia and in imaging patients with dental fillings that cause artifacts on CT scans and patients who cannot lie prone because of kyphoscoliosis.
MRI clearly depicts tumor from surrounding inflammatory tissue and secretions within the sinuses. Typically, edema of inflamed tissue and retained secretions have low intensity on T1-weighted images and high intensity on T2-weighted images because of their increased water content. However, because of the often chronic nature of these secretions at diagnosis, a certain amount of free water will have been absorbed, and a variable pattern of intensity may be seen. On the contrary, 95% of sinus tumors are highly cellular with decreased water content, resulting in low-to-intermediate signal intensity on both T1- and T2-weighted imaging.
Gadolinium enhancement provides additional information. Most sinus tumors show diffuse enhancement, whereas inflamed mucosa enhances more intensely and peripherally. Perineural spread to tumor can also be shown on MRI; this is most important in the context of adenoid cystic carcinoma. The correlation of MRI and histologic findings at surgery is as high as 94% with improvement to 98% with gadolinium enhancement.
Some of the advantages of MRI are now being eroded by modern multisection CT with its capability for instant axial and coronal reformatting, which avoids dental artifact. In fact, MRI may now be limited by dental amalgams.
Gadolinium-based contrast agents (gadopentetate dimeglumine [Magnevist], gadobenate dimeglumine [MultiHance], gadodiamide [Omniscan], gadoversetamide [OptiMARK], gadoteridol [ProHance]) have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). For more information, see the eMedicine topic Nephrogenic Fibrosing Dermopathy. The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans.
NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness. For more information, see the FDA Public Health Advisory.
CT scanning
CT is the examination of choice in the evaluation of sinusitis, particularly chronic sinus disease providing excellent detail of sinus anatomy. However, CT is usually not useful in acute sinusitis, as diagnosis is primarily based on clinical findings. Good anatomic definition is desirable before surgical intervention.
CT scans are more sensitive than plain radiography for depicting sinus pathology, especially in the sphenoid and ethmoid sinuses. However, CT findings can also be nonspecific and many centers do not use it routinely in the diagnosis of acute sinusitis.
Coronal CT imaging is the preferred initial procedure. Bone-window views provide excellent resolution and a good definition of the complete osteomeatal complex and other anatomic details that play a role in sinusitis. In addition, the coronal view is best correlated with findings from sinus surgery.
In general, nonenhanced CT scans suffice in cases of uncomplicated sinusitis. Multisection CT seems to have the potential to replace primary coronal CT of the paranasal sinuses without any loss of image quality, and it may even improve the overall diagnostic value. However, the doses of radiation may still have to be reduced.
Limitations of Techniques
On plain radiographs, other bony structures overlap the sinuses, and the rate of false-negative results is high. The posterior ethmoids are poorly visualized. The osteomeatal complex cannot be adequately assessed.
The superiority of CT over other methods of imaging the sinuses can be summarized as follows: First, coronal CT is ideal for evaluating sinusitis because the anatomy and pathology visualized in a plane almost identical to that seen by the endoscopist, and this imaging plane displays the osteomeatal unit. Second, the bony walls of the sinuses are better demonstrated with CT in the high-resolution mode than with other modalities. Third, CT provides an excellent anatomic display of soft tissue attenuation. This depiction includes fluid levels and polypoid masses within the normally air-filled cavities of the sinuses, nasal cavity, and postnasal space. Most important, disease extending beyond the bony perimeters of the sinuses into the adjacent soft tissue of the orbit,9 brain, and infratemporal fossa can be imaged.
These applications of CT have disappointed in only one way. Although it provides an excellent anatomic display, CT generally does not help in predicting the histologic nature of the pathologic process.
A major milestone in radiology occurred with the introduction of MRI. This modality provides greater soft-tissue contrast, tissue differentiation, and marginal lesion definition than those achieved with other studies. However, the bony margins of the sinuses are imaged as a plane of absent signal intensity on MRIs. Moreover, the signal intensity from the high fat content of bone narrow, as in the basisphenoid and petrous apices and around the frontal sinuses, can be confusing, particularly because fluid retained in the sinuses has signal intensity similar to that of the high water content.
On CT scans, it is difficult or impossible to differentiate tumor tissue from retained fluid in sinuses, where the drainage of a sinus is blocked by obstruction from the tumor. Extension of disease into the cranial cavity is shown well on MRIs, and the ability to image in any plane is a considerable advantage.
Differential Diagnoses
Other Problems to Be Considered
Wegener granulomatosis: This involves angiitis associated with focal necrosis and granulomatous reaction, which initially affects the respiratory tract but which may progress to involve other organs.
Ataxia-telangiectasia: This autosomal recessive disorder is associated with recurrent sinusitis, pulmonary infections, bronchiectasis, pulmonary fibrosis, tracheomegaly, diminished lymphoid tissue, and cerebral and cerebellar atrophy.
Cystic fibrosis: This autosomal recessive disorder associated with respiratory, GI, cardiovascular and sinus abnormalities, among others.
Immotile cilia syndrome: This autosomal recessive disorder is associated with recurrent chest infections and/or pulmonary consolidation, sinusitis, bronchiectasis, and Kartagener syndrome.
Kartagener syndrome: This autosomal recessive disease is associated with sinusitis, situs inversus, recurrent respiratory infections, and bronchiectasis, among other abnormalities.
Nasal polyposis: Hyperallergic patients may have innumerable polyps filling the nasal cavity and obstructing the paranasal sinuses, giving a characteristic imaging appearance. This disease is closely associated with asthma.
Wiskott-Aldrich syndrome: This X-linked, recessive, immune deficiency disease is associated with recurrent respiratory tract infections and/or pneumonia, sinusitis, and mastoiditis.
Yellow-nail syndrome: The mode of inheritance is not known. This syndrome is associated with recurrent pleural effusions, pericardial effusions, chylothorax, bronchiectasis, and sinusitis.
Young syndrome: The mode of inheritance is unknown. The syndrome is associated with azoospermia secondary to epididymal obstruction and recurrent respiratory infections and sinusitis.
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Further Reading
Related eMedicine topics
Sinusitis, Chronic
Sinusitis, Frontal, Acute, Surgical Treatment
Pediatric Sinusitis, Medical Treatment
Sinusitis, Acute, Medical Treatment
Sinusitis (Pediatrics: surgery)
Clinical guidelines
Clinical practice guideline: adult sinusitis.
American Academy of Otolaryngology - Head and Neck Surgery Foundation - Medical Specialty Society. 2007 Sep. 31 pages. NGC:006414
Diagnosis and treatment of respiratory illness in children and adults.
Institute for Clinical Systems Improvement - Private Nonprofit Organization. 1994 Jun (revised 2008 Jan). 71 pages. NGC:006369
Acute rhinosinusitis in adults.
University of Michigan Health System - Academic Institution. 1996 May (revised 2007 Mar). 8 pages. NGC:006570
Clinical trials
Sinuclean's Treatment Of Sinusitis' Symptoms
Comparing the Use of Saline or Saline Plus Gentamycin in Nasal Irrigation to Treat Chronic Sinusitis in Children
Pilot Study To Evaluate A Pharmacologically Active Nasal Sponge Following Endoscopic Sinus Surgery
Keywords
sinusitis, rhinosinusitis, functional endoscopic sinus surgery, FESS
