eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Nasal & Sinus Diseases

Sinusitis, Chronic, Medical Treatment

Author: Seth M Brown, MD, MBA,, Clinical Assistant Professor, Department of Surgery, Division of Otolaryngology, University of Connecticut; Consulting Physician, Department of Surgery, Division of Otolaryngology, Connecticut Children's Medical Center
Coauthor(s): Marvin Peter Fried, MD, University Chairman, Department of Otorhinolaryngology, 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 25, 2008

Introduction

Background

Chronic sinusitis is an inflammatory process that involves the paranasal sinuses and persists for 12 weeks or longer. Recently, literature has supported that chronic sinusitis is almost always accompanied by concurrent nasal airway inflammation and is often preceded by rhinitis symptoms; thus, the term chronic rhinosinusitis (CRS) has evolved to more accurately describe this condition. The latest executive summary published in Otolaryngology - Head and Neck Surgery on adult sinusitis (2007) has altered the definition for chronic rhinosinusitis (CRS) to read: 12 weeks or longer of two or more of the following symptoms:

  • Anterior or posterior mucopurulent drainage
  • Nasal obstruction
  • Facial-pain-pressure-fullness
  • Decreased sense of smell

In addition, inflammation must be documented by demonstrating either:

  • Purulent mucus or edema in the middle meatus or ethmoid region
  • Polyps in the nasal cavity or middle meatus
  • Imaging showing inflammation of the paranasal sinuses

This is in contrast to recurrent acute sinusitis, which is present when 4 or more episodes per year of acute bacterial rhinosinusitis without signs and symptoms of rhinosinusitis between episodes.1

Pathophysiology

The pathophysiology of this disorder is poorly defined. Current thinking supports that chronic rhinosinusitis (CRS) is predominantly an inflammatory disease. Confounding factors that may contribute to inflammation include the following:

  • Persistent infection (including biofilms and osteitis)
  • Allergy and other immunologic disorders
  • Intrinsic factors of the upper airway
  • Superantigens
  • Colonizing fungi that induce and sustain eosinophilic inflammation
  • Metabolic abnormalities such as aspirin sensitivity

All of these factors can play a role in disruption of the intrinsic mucociliary transport system. This is because an alteration in sinus ostia patency, ciliary function, or the quality of secretions leads to stagnation of secretions, decreased pH levels, and lowered oxygen tension within the sinus. These changes create a favorable environment for bacterial growth that, in turn, further contribute to increased mucosal inflammation.

Frequency

United States

The overall prevalence of chronic rhinosinusitis (CRS) in the United States is 146 per 1000 population. This involves nearly 30 million US adults yearly, making chronic rhinosinusitis (CRS) more common than any other chronic condition. For unknown reasons, the incidence of this disease appears to be increasing yearly. This results in a conservative estimate of 18-22 million physician visits in the United States each year and a direct treatment cost of $3.4-5 billion annually.

Mortality/Morbidity

Chronic sinusitis is rarely life-threatening, although serious complications can occur because of the proximity to the orbit and cranial cavity.

  • Approximately 75% of all orbital infections are directly related to sinusitis.
  • Intracranial complications remain comparatively rare, with 3.7-10% of intracranial infections related to sinusitis.

Age

Rhinosinusitis is more common in the pediatric population because this term includes both acute and chronic infection and both viral and bacterial disease. This is likely secondary to an increased frequency of exposure to upper respiratory tract infections in the pediatric population.

Clinical

History

Patient history is extremely important in chronic rhinosinusitis (CRS) because of the broad overlap between sinus symptoms and other disease processes, as well as poor correlation between symptoms and endoscopic and radiographic findings. Consequently, a number of key factors in the patient's history should be discerned. They are as follows:

  • The presence of major symptoms (including purulent anterior nasal drainage, purulent-discolored posterior nasal drainage, nasal obstruction or blockage, facial congestion or fullness, facial pain or pressure, and hyposmia or anosmia)
  • The presence of minor symptoms (including headache, ear pain or fullness, halitosis, dental pain, cough, fever, fatigue)
  • Duration of symptoms
  • Exacerbating and relieving factors
  • History of previous nasal or paranasal sinus surgery
  • Current medications
  • Previous treatments and their duration
  • Other confounding health problems (including asthma, allergy, and immunocompromising disorders)
  • Active or passive tobacco smoke

Physical

The physical examination should include a complete head and neck examination to confirm the diagnosis and to rule out more serious disorders.

  • Anterior rhinoscopy, with the use of a nasal speculum, to evaluate the condition of the nasal mucosa and to look for purulent drainage or evidence of polyps or other nasal masses (Other contributing factors to CRS that can be evaluated are nasal septal deviation and turbinate hypertrophy. The nasal examination should be carried out both before and after the use of a topical decongestant. If available, this portion of the examination can be supplemented with the use of nasal endoscopy.)
  • Ear examination for the presence of middle ear fluid that may be the sign of a mass in the nasopharynx
  • Neck examination for lymphadenopathy
  • Cranial nerve examination for underlying sinus malignancy or neurological disorder
  • Oral cavity and oropharynx examination to evaluate the integrity of the palate, the condition of dentition, and to look for evidence of postnasal drip
  • Sinus palpation for evaluation of tenderness or swelling
  • Ocular examination for spread of disease to the orbit and function of ocular musculature
  • Laryngeal examination to look for other confounding upper airway pathology including laryngeal-pharyngeal reflux (LPR)
  • Lung examination to determine if co-existing lower airway disease is present

Causes

A number of factors often contribute to the inflammatory process that causes chronic rhinosinusitis (CRS). Please see Pathophysiology for a discussion on etiology.

  • Any disease process or toxin that affects cilia has a negative effect on chronic rhinosinusitis (CRS).
  • The bacteria presumed to be involved in chronic rhinosinusitis (CRS) differ from those in acute rhinosinusitis. Those most commonly isolated in chronic rhinosinusitis (CRS) include Staphylococcus aureus, coagulase-negative Staphylococcus, anaerobic bacteria, and gram-negative bacteria.
  • The reflux of gastric contents may play a contributing role in some cases of chronic rhinosinusitis (CRS). This relationship still needs to be better defined.

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
References
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References

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  2. 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].

  3. 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].

  4. 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].

  5. Bhattacharyya N. Radiographic stage fails to predict symptom outcomes after endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope. Jan 2006;116(1):18-22. [Medline].

  6. Arjmand EM, Lusk RP. Management of recurrent and chronic sinusitis in children. Am J Otolaryngol. Nov-Dec 1995;16(6):367-82. [Medline].

  7. Druce HM. Adjuncts to medical management of sinusitis. Otolaryngol Head Neck Surg. Nov 1990;103(5(Pt 2)):880-3. [Medline].

  8. 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.

  9. Eloy P, Bertrand B, Rombaux P. Medical and surgical management of chronic sinusitis. Acta Otorhinolaryngol Belg. 1997;51(4):271-84. [Medline].

  10. Friedman WH, Katsantonis GP, Bumpous JM. Staging of chronic hyperplastic rhinosinusitis: treatment strategies. Otolaryngol Head Neck Surg. Feb 1995;112(2):210-4. [Medline].

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  12. Gwaltney JM Jr, Jones JG, Kennedy DW. Medical management of sinusitis: educational goals and management guidelines. The International Conference on sinus Disease. Ann Otol Rhinol Laryngol Suppl. Oct 1995;167:22-30. [Medline].

  13. Lund VJ. Maximal medical therapy for chronic rhinosinusitis. Otolaryngol Clin North Am. Dec 2005;38(6):1301-10, x. [Medline].

  14. Marshall KG, Elhamy A. Chronic sinusitis. In: Disorders of the Nose and Paranasal Sinuses: Diagnosis and Management. PSG Publishing: Littleton, Mass; 1987.

  15. 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].

  16. Nagi MM, Desrosiers MY. Algorithms for management of chronic rhinosinusitis. Otolaryngol Clin North Am. Dec 2005;38(6):1137-41, vii. [Medline].

  17. 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].

  18. Parsons DS. Chronic sinusitis: a medical or surgical disease?. Otolaryngol Clin North Am. Feb 1996;29(1):1-9. [Medline].

  19. Stafford CT. The clinician's view of sinusitis. Otolaryngol Head Neck Surg. Nov 1990;103(5 (Pt 2)):870-4; discussion 874-5. [Medline].

  20. Weir NA. Infective rhinitis and sinusitis. In: Scott-Brown WG, Kerr AG, eds. Scott-Brown's Otolaryngology. Vol 3. 6th ed. Boston, Mass: Butterworth-Heinemann Medical; 1997:8, 23-5.

  21. 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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Further Reading

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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, orbital infection, orbit infection, sinus pain, sinus pressure, postnasal discharge, sinus obstruction, purulent rhinorrhea, rhinorrhea, post-nasal drip, postnasal drip, maxillary sinusitis, ethmoid sinusitis, frontal sinusitis, anaerobic cocci infection, bacteroid infection, streptococcal infection, Staphylococcus aureus, Bacteroides, Streptococcus, S aureus, Staphylococcus

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Contributor Information and Disclosures

Author

Seth M Brown, MD, MBA,, Clinical Assistant Professor, Department of Surgery, Division of Otolaryngology, University of Connecticut; Consulting Physician, Department of Surgery, Division of Otolaryngology, Connecticut Children's Medical Center
Seth M Brown, MD, MBA, is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Rhinologic Society, and North American Skull Base Society
Disclosure: Nothing to disclose.

Coauthor(s)

Marvin Peter Fried, MD, University Chairman, Department of Otorhinolaryngology, Montefiore Medical Center, Albert Einstein College of Medicine
Marvin Peter Fried, MD 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: GE Navigation Consulting fee Board membership; 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: Nothing to disclose.

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

 
 
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