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Sinusitis, Chronic, Medical Treatment: Differential Diagnoses & Workup

Author: Seth M Brown, MD, MBA, Assistant Clinical Professor, Department of Surgery, Division of Otolaryngology, University of Connecticut School of Medicine; Director, The Connecticut Sinus Institute
Coauthor(s): Marvin P Fried, MD, FACS, Professor and University Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine; Babak Sadoughi, MD, Resident Physician, Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine; Osama A Abdel Razek, MB, BCh, MSc, Research Fellow, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard University Medical School; Dennis Poe, MD, Clinical Assistant Professor, Departments of Otology and Laryngology, Harvard University Medical Center, Boston University School of Medicine
Contributor Information and Disclosures

Updated: Nov 17, 2009

Overview
Differential Diagnoses & Workup
Treatment & Medication
Follow-up
Multimedia

Differential Diagnoses

Allergic Fungal Sinusitis	Malignant Tumors of the Nasal Cavity
Allergic Rhinitis	Malignant Tumors of the Sinuses
Cystic Fibrosis	Nonallergic Rhinitis
Foreign Bodies of the Airway	Sinusitis, Fungal
Juvenile Nasopharyngeal Angiofibroma	Skull Base, Benign Tumors
Malignant Nasopharyngeal Tumors	Turbinate Dysfunction

Workup

Laboratory Studies

Nasal swab and culture may help in selecting the proper antibiotic.
Radioallergosorbent assay test (RAST) or skin testing for allergens may play an important role in treating patients with chronic rhinosinusitis (CRS) and confounding allergies.
A sweat test for cystic fibrosis should be considered in all children with nasal polyposis and chronic rhinosinusitis (CRS).
Evaluation of cilia function with a brush biopsy or turbinate biopsy can be considered in cases of presumed cilia dysfunction.
Total immunoglobulin E (IgE) levels as well as the degree of staining of IgE in sinus epithelium and subepithelium can be tested and may be helpful to evaluate for allergic fungal sinusitis.²

Imaging Studies

Plain radiographs do not have a role in chronic rhinosinusitis (CRS). Today, the clinical role of plain films is limited to documentation of acute maxillary or frontal sinusitis.
A noncontrast, dedicated sinus CT scan is the current criterion standard to identify and evaluate the details of sinus anatomy and pathology. This modality provides 2.5- to 3-mm cuts or smaller through the paranasal sinuses in both the axial and coronal planes.
Contrast can be added to a sinus CT scan in the case of acute infection with presumed spread beyond the paranasal sinuses (to the orbit or brain).
For patients with a history of previous sinus surgery, a CT scan with an image-guided protocol may assist the surgeon intraoperatively if the patient requires further surgical intervention.
An MRI is generally reserved for cases of paranasal sinus tumors or cases with orbital and cranial base involvement.
Ultrasonography provides variable results and is not recommended.

Other Tests

Transillumination lacks sensitivity but may have value in experienced hands.
Nasal endoscopy is recommended in most cases prior to obtaining imaging because it demonstrates the condition of the nasal mucosa and evaluates for purulent drainage.

Procedures

Traditionally, maxillary sinus tap via inferior meatal puncture was performed for sinus culture.
Many otolaryngologists have moved away from maxillary sinus tap because of the discomfort of the procedure and the understanding that a culture of an organism from the middle meatus may be more accurate to determine the bacteria involved in the disease process.
Recent literature has supported the use of endoscopically directed culture of the middle meatus (the primary drainage system of the anterior ethmoid, maxillary, and frontal sinuses) with the use of either a suction trap or a swab.
Endoscopically directed middle meatal cultures have a sensitivity of 80.9% and specificity of 90.5% in a recent meta-analysis.³
Calcium-alginate tipped applicators are a readily available device that can be used to obtain a culture.

Histologic Findings

Biopsy samples from the maxillary sinus mucosa of patients with chronic sinusitis show basement membrane thickening, atypical gland formation, goblet cell hyperplasia, mononuclear cell infiltration, and subepithelial edema. The mononuclear cell infiltrate often predominantly demonstrates neutrophils in acute disease and eosinophils in chronic disease. Rarely, squamous cell metaplasia may be seen.

Staging

Various staging systems have been proposed; however, no one system is accepted as the standard for use in chronic rhinosinusitis (CRS). Many studies use the Lund-Mackay scale to evaluate radiographic images. This scale grades the right and left sides independently, looking at the maxillary, anterior ethmoids, posterior ethmoids, sphenoid, and frontal sinuses, as well as the ostiomeatal complex. Each sinus is scored a 0 (no abnormality), 1 (partial opacification), or 2 (total opacification), while the ostiomeatal complex is scored either a 0 or 2 (for presence or absence of disease). Scores range from 0-24.

More on Sinusitis, Chronic, Medical Treatment

Overview: Sinusitis, Chronic, Medical Treatment

Differential Diagnoses & Workup: Sinusitis, Chronic, Medical Treatment

Treatment & Medication: Sinusitis, Chronic, Medical Treatment

Follow-up: Sinusitis, Chronic, Medical Treatment

Multimedia: Sinusitis, Chronic, Medical Treatment

References

Rosenfeld RM. Clinical practice guideline on adult sinusitis. Otolaryngol Head Neck Surg. Sep 2007;137(3):365-77. [Medline].
Wise SK, Ahn CN, Lathers DM, Mulligan RM, Schlosser RJ. Antigen-specific IgE in sinus mucosa of allergic fungal rhinosinusitis patients. Am J Rhinol. Sep-Oct 2008;22(5):451-6. [Medline].
Benninger MS, Payne SC, Ferguson BJ, et al. Endoscopically directed middle meatal cultures versus maxillary sinus taps in acute bacterial maxillary rhinosinusitis: a meta-analysis. Otolaryngol Head Neck Surg. Jan 2006;134(1):3-9. [Medline].
Ponikau JU, Sherris DA, Weaver A, et al. Treatment of chronic rhinosinusitis with intranasal amphotericin B: a randomized, placebo-controlled, double-blind pilot trial. J Allergy Clin Immunol. Jan 2005;115(1):125-31. [Medline].
Bhattacharyya N. Radiographic stage fails to predict symptom outcomes after endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope. Jan 2006;116(1):18-22. [Medline].
Arjmand EM, Lusk RP. Management of recurrent and chronic sinusitis in children. Am J Otolaryngol. Nov-Dec 1995;16(6):367-82. [Medline].
Druce HM. Adjuncts to medical management of sinusitis. Otolaryngol Head Neck Surg. Nov 1990;103(5(Pt 2)):880-3. [Medline].
Druce HM. Diagnosis and medical management of recurrent and chronic sinusitis in adults. In Gershwin, M. Eric and Incaudo, Gary : Diseases of the Sinuses A Comprehensive Textbook of Diagnosis and Treatment. Humana press,Totowa, NJ, USA. 1996;215-31.
Eloy P, Bertrand B, Rombaux P. Medical and surgical management of chronic sinusitis. Acta Otorhinolaryngol Belg. 1997;51(4):271-84. [Medline].
Friedman WH, Katsantonis GP, Bumpous JM. Staging of chronic hyperplastic rhinosinusitis: treatment strategies. Otolaryngol Head Neck Surg. Feb 1995;112(2):210-4. [Medline].
Gold SM, Tami TA. Role of middle meatus aspiration culture in the diagnosis of chronic sinusitis. Laryngoscope. Dec 1997;107(12 Pt 1):1586-9. [Medline].
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Lund VJ. Maximal medical therapy for chronic rhinosinusitis. Otolaryngol Clin North Am. Dec 2005;38(6):1301-10, x. [Medline].
Marshall KG, Elhamy A. Chronic sinusitis. In: Disorders of the Nose and Paranasal Sinuses: Diagnosis and Management. PSG Publishing: Littleton, Mass; 1987.
Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol. Dec 2004;114(6 Suppl):155-212. [Medline].
Nagi MM, Desrosiers MY. Algorithms for management of chronic rhinosinusitis. Otolaryngol Clin North Am. Dec 2005;38(6):1137-41, vii. [Medline].
Pang YT, Willatt DJ. Do antral washouts have a place in the current management of chronic sinusitis?. J Laryngol Otol. Oct 1996;110(10):926-8. [Medline].
Parsons DS. Chronic sinusitis: a medical or surgical disease?. Otolaryngol Clin North Am. Feb 1996;29(1):1-9. [Medline].
Stafford CT. The clinician's view of sinusitis. Otolaryngol Head Neck Surg. Nov 1990;103(5 (Pt 2)):870-4; discussion 874-5. [Medline].
Weir NA. Infective rhinitis and sinusitis. In: Scott-Brown WG, Kerr AG, eds. Scott-Brown's Otolaryngology. Vol 3. 6^th ed. Boston, Mass: Butterworth-Heinemann Medical; 1997:8, 23-5.
Witsell DL, Stewart MG, Monsell EM, et al. The Cooperative Outcomes Group for ENT: a multicenter prospective cohort study on the effectiveness of medical and surgical treatment for patients with chronic rhinosinusitis. Otolaryngol Head Neck Surg. Feb 2005;132(2):171-9. [Medline].

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Keywords

sinusitis, chronic sinusitis, chronic rhinosinusitis, recurrent sinusitis, chronic rhinitis, recurrent rhinitis, runny nose, sinus congestion, chronic congestion, chronic sinus congestion, recurrent sinus congestion, chronic cold, recurrent cold

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Contributor Information and Disclosures

Author

Seth M Brown, MD, MBA, Assistant Clinical Professor, Department of Surgery, Division of Otolaryngology, University of Connecticut School of Medicine; Director, The Connecticut Sinus Institute
Seth M Brown, MD, MBA is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Rhinologic Society, and North American Skull Base Society
Disclosure: Nothing to disclose.

Coauthor(s)

Marvin P Fried, MD, FACS, Professor and University Chairman, Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine
Marvin P Fried, MD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Rhinologic Society, American Society for Head and Neck Surgery, American Society for Laser Medicine and Surgery, American Society of Plastic and Reconstructive Surgery, Massachusetts Medical Society, Phi Beta Kappa, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Entrigue Consulting fee Board membership

Babak Sadoughi, MD, Resident Physician, Department of Otorhinolaryngology-Head and Neck Surgery, Montefiore Medical Center, Albert Einstein College of Medicine
Babak Sadoughi, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Association for Research in Otolaryngology, and Medical Society of the State of New York
Disclosure: Nothing to disclose.

Osama A Abdel Razek, MB, BCh, MSc, Research Fellow, Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard University Medical School
Disclosure: Nothing to disclose.

Dennis Poe, MD, Clinical Assistant Professor, Departments of Otology and Laryngology, Harvard University Medical Center, Boston University School of Medicine
Dennis Poe, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Otological Society, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Lanny Garth Close, MD, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Columbia University College of Physicians and Surgeons
Lanny Garth Close, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physicians, American Laryngological Association, American Society for Head and Neck Surgery, and New York Academy of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists
Stephen G Batuello, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American Medical Association, and Colorado Medical Society
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position

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