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.
Chronic sinusitis manifests more subtly than acute sinusitis. However, it may start suddenly, as an upper respiratory tract infection or acute sinusitis that does not resolve, or emerge slowly and insidiously over months or years. At times, the initial symptoms may be acute in nature. 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. Fever, when present, may be low grade.
Patients with chronic sinusitis may present with the following symptoms:
-
Nasal obstruction, blockage, congestion, stuffiness
-
Nasal discharge (of any character from thin to thick and from clear to purulent)
-
Postnasal drip
-
Facial fullness, discomfort, pain, and headache (more with nasal polyposis)
-
Chronic unproductive cough (primarily in children)
-
Hyposmia or anosmia (more with nasal polyposis)
-
Sore throat
-
Fetid breath
-
Malaise
-
Easy fatigability
-
Anorexia
-
Exacerbation of asthma
-
Dental pain (upper teeth)
-
Visual disturbances
-
Sneezing
-
Stuffy ears
-
Unpleasant taste
-
Fever of unknown origin
In pediatric settings, halitosis is more commonly reported by parents of younger children. Nasal obstruction with mouth breathing and associated sore throat may be present. In some individuals with chronic sinusitis, parents may note occasional and painless morning eye swelling. Older children may complain of loss of taste due to associated nasal obstruction and anosmia. Nocturnal symptoms may include snoring and coughing due to associated postnasal drip.
The patient history should focus on the following key factors, beginning with consideration of major and minor diagnostic criteria:
-
The presence of major symptoms, including purulent anterior nasal drainage and/or purulent discolored posterior nasal drainage, nasal obstruction or blockage, facial congestion/fullness, facial pain/pressure, and hyposmia or anosmia (diagnosis of chronic sinusitis requires the presence of 2 of these symptom complexes of more than 3 months’ duration, 1 of which must be either obstruction or discharge [29] )
-
Duration of symptoms
-
Exacerbating and relieving factors
-
Current medications
-
Previous nasal or paranasal sinus surgery
-
Previous treatments and their duration
-
Previous imaging studies
-
Other confounding health problems (including asthma, allergy, and immunocompromising disorders)
-
Active or passive tobacco smoke
-
Exposure to allergens
Physical Examination
Physical examination in patients with chronic sinusitis may reveal various findings. It should include a complete head and neck examination (lymphadenopathy) to confirm the diagnosis and to rule out more serious disorders.
Sinus palpation is performed to evaluate tenderness or swelling. Pain or tenderness on palpation over frontal or maxillary sinuses may be noted. Transillumination of maxillary or frontal sinuses may be useful; it lacks sensitivity but may have value in experienced hands.
An oral cavity and oropharynx examination is used to evaluate the integrity of the palate and the condition of dentition and to look for evidence of postnasal drip. Oropharyngeal erythema and purulent secretions may be noted. Dental caries may be present.
Anterior rhinoscopy, with the use of a nasal speculum, is used 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.
The nasal examination can be supplemented with the use of nasal endoscopy (if available) and CT scanning. Endoscopic (rhinoscopic) examination findings include the following:
-
Nasal mucosal erythema, edema
-
Purulent secretions within the middle meatus
-
Nasal obstruction due to deviated nasal septum or hypertrophied turbinates
-
Nasal polyps
An endoscopic view of the nasal cavity can be seen below.
Endoscopic view right nasal cavity; lacrimal bone (L), uncinate process (U), ethmoid bulla (B), middle turbinate (MT), nasal septum (S).
Ear examination for the presence of middle ear fluid that may be the sign of a mass in the nasopharynx is indicated.
Ocular examination for spread of disease to the orbit and function of ocular musculature is indicated. Ophthalmic manifestations include the following:
-
Conjunctival congestion
-
Lacrimation
-
Proptosis, extraocular muscle palsies, and visual disturbances (when complicated by orbital extension)
Laryngeal examination is used to look for other confounding upper airway pathology including laryngeal-pharyngeal reflux (LPR). Lung examination is performed to determine if coexisting lower airway disease is present.
Cranial nerve examination is performed to look for underlying sinus malignancy or neurological disorder.
Manifestations of fungal sinusitis
Fungal sinusitis can manifest in different ways. [30] Unlike acute invasive fungal sinusitis, which is observed in patients who are immunosuppressed or who have diabetes, chronic fungal sinusitis is usually observed in immunocompetent patients. Mycetomas or fungus balls may be asymptomatic or may manifest as chronic sinusitis. Allergic fungal sinusitis usually manifests as nasal polyps and allergic sinusitis. Fungal elements in the sinuses are the inciting allergens.
Diagnostic Criteria
In 1996, the American Academy of Otolaryngology-Head & Neck Surgery convened a multidisciplinary Rhinosinusitis Task Force (RTF). This group defined adult rhinosinusitis diagnostic criteria. [3] These 1996 diagnostic criteria required 2 or more major factors or 1 major factor and 2 minor factors for the diagnosis of rhinosinusitis.
Major factors included facial pain or pressure, nasal obstruction or blockage, nasal discharge or purulence or discolored postnasal discharge, hyposmia or anosmia, purulence in nasal cavity, and fever (for acute rhinosinusitis only).
Minor factors were defined as headache, fever (for CRS), halitosis, fatigue, dental pain, cough, and ear pain, pressure, or fullness. Of note, facial pain requires another major factor associated with it for diagnosis (facial pain plus 2 minor factors is not deemed sufficient for diagnosis of rhinosinusitis).
In 2003, the RTF’s definition was amended to require confirmatory radiographic or nasal endoscopic or physical examination findings in addition to suggestive history. [4] The 2003 diagnostic criteria for CRS require the above criteria for longer than 12 weeks or more than 12 weeks of physical findings. In addition, one of the following signs of inflammation must be present:
-
Discolored nasal drainage from the nasal passages, nasal polyps, or polypoid swelling as identified on physical examination with anterior rhinoscopy after decongestion or nasal endoscopy
-
Edema or erythema of the middle meatus or ethmoid bulla on nasal endoscopy
-
Generalized or localized erythema, edema, or granulation tissue (If the middle meatus or ethmoid bulla is not involved, radiologic imaging is required to confirm a diagnosis.)
Imaging modalities confirming the diagnosis include the following:
-
Computed tomography (CT) scanning demonstrating isolated or diffuse mucosal thickening, bone changes, or air-fluid levels
OR
-
Plain sinus radiography revealing air-fluid levels or greater than 5 mm of opacification of one or more sinuses
-
Magnetic resonance imaging (MRI) not recommended for routine diagnosis because of its excessive sensitivity and lack of specificity
In general, plain radiography has low sensitivity and specificity. CT scanning is considered the imaging standard for evaluation of chronic sinusitis. [31]
The latest executive summary on adult sinusitis has altered the definition for CRS to read 12 weeks or longer of 2 or more of the following symptoms [32] :
-
Anterior or posterior mucopurulent drainage
-
Nasal obstruction
-
Facial pain-pressure-fullness
-
Decreased sense of smell
In addition, inflammation must be documented by demonstrating one of the following:
-
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 [29]
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.
Complications
The most serious complications of chronic sinusitis are neurological. Among these include subdural empyema, meningitis, venous sinus thrombosis, orbital cellulitis, and epidural abscess. [33]
-
Endoscopic view right nasal cavity; lacrimal bone (L), uncinate process (U), ethmoid bulla (B), middle turbinate (MT), nasal septum (S).
-
Air-fluid level (arrow) in the maxillary sinus suggests sinusitis.
