- Chronic sinusitis is defined by (2 or more of) nasal obstruction, mucopuluent discharge, decreased smell or facial pain with CT or endoscopic evidence of sinus disease
- Consider other differential diagnoses
- Nasal obstruction, a post-nasal drip, headaches or loss of smell as sole individual symptoms are rarely due to sinusitis.
- Once the diagnosis is made, commence a trial of maximal medical management
- An ENT specialist will organise further investigation, medical and possibly surgical management as well.
- Removal of the adenoids is helpful in paediatric chronic rhinosinusitis.
Chronic sinusitis is a common condition that typically has a complex multifactorial pathophysiology. It is important to consider other conditions that can masquerade as sinusitis when making the diagnosis. Initial diagnosis and treatment begins in the general practice but may require further specialist assistance. Some symptoms dictate more urgent referral.
Chronic sinusitis (chronic rhinosinusitis, CRS) is a common condition which is often challenging to treat successfully. Many patients require long term treatment to reduce inflammation within the sinuses and reduce the impact their symptoms have on their quality of life. The diagnosis can sometimes be confusing, particularly when patients presents with symptoms such as “sinus pain” or headaches, loss of smell, chronic cough and post-nasal drip – all of which can be caused by conditions other than sinusitis.
With the availability of information online, many patients will make their own diagnosis and may request specific treatments or a specialist referral. Many will struggle with the compliance necessary to use the medical therapy for the length of time needed for effectiveness. Unfortunately a small group of patients need indefinite medical therapy and may still have exacerbations of their symptoms that require additional treatments from time to time.
Chronic sinusitis is defined in the literature by 12 weeks or longer of two or more of:
- mucopurulent discharge (rhinorrhoea or post-nasal drip)
- nasal obstruction
- decreased sense of smell
- facial pain
As well as either:
- CT scan evidence of sinusitis or
- Evidence of visible pus coming from the sinuses on endoscopy
In clinical practice the symptoms of CRS are more diverse can be divided into 4 symptoms:
- Nasal (obstruction, discharge, impaired smell)
- Facial (pressure, pain, headaches)
- Oropharyngeal (ear pain, halitosis, post-nasal drip, dental pain, cough)
- Systemic (General malaise, fatigue)
The most common symptom is nasal obstruction followed by post-nasal drip. Most patients presenting only with facial pain or headaches (particularly unilateral) without other symptoms of sinusitis generally do not have sinusitis. We divide CRS into two broad groups – CRS with polyps and CRS without polyps.
Differential diagnoses for specific symptoms
It is important to try and establish what symptoms are the primary concern for patients. Not only does it help guide treatment but it also assists in not overlooking alternative diagnoses.
- Nasal obstruction
Most patients with chronic sinusitis have some degree of nasal obstruction. This is frequently one of their chief complaints. The presence of nasal obstruction in the absence of other symptoms of sinusitis should raise suspicion for other causes. They may include a deviated nasal septum, large adenoids, allergic rhinitis or nasal valve collapse. Nasal valve collapse is a frequently overlooked condition that causes nasal obstruction due to collapse of the soft tissues of the nose with inspiration.
- Post-nasal drip
The sensation of post-nasal drip, frequently felt as a kind of throat irritation is common and is not always due to chronic sinusitis. It may also be caused by gastroesophageal reflux, laryngopharyngeal reflux or by chronic laryngeal irritation from a throat clearing habit. Increased production of mucus which is felt in the throat can also be caused by allergic rhinitis and non-allergic rhinitis (such as vasomotor rhinitis).
- Headaches and facial pain
Headaches that present in the midface, around the orbits or in the frontal area are also common. Patients will usually present these symptoms as a “sinus pain” or as “sinus”. Be wary of attributing chronic facial pain, especially with an episodic history, to sinus pathology. It is uncommon for sinusitis to present with pain in the absence of other symptoms. A CT scan during an episode of pain can be helpful in ruling out sinus pathology. Periorbital and frontal headaches which are episodic in nature and unilateral are usually caused by migraines.
- Loss of smell (anosmia)
Chronic rhinosinusitis particularly with nasal polyps is one cause of a decline in the sense of smell. Essentially polyps block the transmission of smells to the olfactory receptors. There are many other causes of anosmia that should be considered, particularly if a change in smell is the patient’s only symptom. These include old age, certain medications, Alzheimer’s and Parkinson’s Disease, nutritional and hormonal disturbances. Progressive or sudden loss of smell warrants a CT scan (brain and sinuses) to rule out primary olfactory tract pathology. New sudden anosmia warrants treatment with a course of prednisone.
- Chronic cough
A chronic cough has many cause. Sinusitis presents more commonly in children with a persistent cough. Look for other more specific upper airway symptoms in the history and for examination or CT evidence of sinus disease before concluding that sinusitis is causing the chronic cough. Chronic throat irritation, throat clearing, coughing and a sense of post-nasal drip in the absence of any diagnostic clinical findings is also a common presenting which falls under the diagnoses of globus pharyngeus. This condition has a strong psychological component and often requires a multi-disciplinary approach to treatment.
Differential diagnosis for nasal polyps
Several space-occupying lesions in the nasal cavity can appear like polyps (clinically and radiologically) and must be considered. These include normal structural variants such as a concha bullosa, medialised uncinated process or a very large inferior turbinate. Benign nasal tumours include inverted papillomas, haemangiomas and schwannomas. Malignant tumours include squamous cell carcinomas, salivary gland tumours, olfactory neuroblastomas and lymphomas. Tumours tend to be unilateral, may lack sinus inflammation and may display surface features such as easy bleeding and ulceration.
Other masses in the nasal cavity can include encephaloceles, antrochoanal polyps and foreign bodies.
What investigations are needed?
A CT scan rather than an MRI scan is the best initial investigation to make the diagnosis of chronic sinusitis. A CT will also be helpful to diagnose anatomical variants which may be contributing to the disease (accessory ostia, conchae bullosae etc) Once the diagnosis is known, it is often helpful to perform a repeat CT scan after a period of “maximal medical management” (see below). This will help to evaluate for treatment response and residual disease. For patients presenting primarily with episodic headaches, encourage the patient to have their scan on a day when headaches are severe.
It may be appropriate to consider further investigation of the host immune system and to evaluate for chronic diseases. This may include assessment for vitamin D deficiency, sarcoidosis (serum ACE), complement levels, immunoglobulin levels (IgA, IgM, IgG subtypes) and hypothyroidism (TSH). Consider evaluating for asthma and allergic rhinitis.
What is the initial treatment?
Once the diagnosis has been made, initial treatment should consist of a combination of therapies. If polyps are present, the treatment is different. Consider continuing medical therapy for up to 3 months to assess for a benefit as it can take time to reverse the inflammatory process of established CRS. We refer to this initial treatment period as “maximal medical management”.
Maximal medical management in CRS without polyps (3-4 weeks)
In patients without nasal polyps, this should consist of a macrolide antibiotic for a minimum of 3 weeks, a topical steroid nasal spray and a high volume saline irrigation. High volume solutions are superior to low-volume spray products.
Maximal medical management in CRS with polyps (3-4 weeks)
For patients with polyps, a course of oral prednisone over 2 weeks should be combined with a steroid nasal rinse. Budesonide 1mg/mL ampules one daily in a high volume saline rinse product are an excellent choice. An alternative is betamethasone cream dissolved in a saline rinse product.
When should patients with chronic sinusitis be referred to a specialist?
Failure of “maximal medical management” should trigger a referral to an ENT specialist. Failure should be dictated by persistence of symptoms or the presence of persistent radiological or endoscopic disease. Although persistent radiological or endoscopic disease do not in themselves define failure of treatment, they may be predictive for subsequent relapse.
Are there any symptoms that require more urgent referral?
Be on the lookout for symptoms and signs suggestive of complications of rhinosinusitis. These include:
– Clear fluid rhinorrhoea (skull base erosion)
– Cranial nerve palsies (invasive fungal infection)
– Orbital/ocular symptoms including diplopia, blurred vision (orbital wall erosion)
– Sudden loss of smell (idiopathic, tumour)
– Severe progressive pain (tumour)
What will an ENT Specialist do?
Our understanding of the pathophysiology of chronic rhinosinusitis evolves every year as new research is presented and published. The aetiology of an individual patient’s CRS is usually multifactorial with host and environmental factors both playing a part. Once a chronic inflammatory process has begun it is necessary to try and roll back this inflammation often by targeting it in multiple ways.
- Confirm the diagnosis and rule out differential diagnoses
- Ensure an adequate treatment period of “maximal medical therapy” has occurred.
- Further medical therapy
- Allergy testing and treatment (avoidance, medication, immunotherapy)
- Culture directed antimicrobial therapy
- Further topical and oral corticosteroid therapy
- Aspirin desensitisation
Surgery for chronic rhinosinusitis
Surgery for CRS is generally indicated when symptoms persist despite an appropriate trial of medical therapy. There have been dramatic advances in sinus surgery techniques over the past 3 decades. Modern sinus surgery emphasises mucosal preservation and enlargement of natural sinus drainage pathways. Endoscopic approaches are standard.
Surgery has a number of primary aims: (1) to establish a patent nasal airway and relieve sinus outflow obstruction; (2) to decrease the overall inflammatory load and (3) to open the sinuses to allow for postoperative topical medication delivery.
Paediatric Chronic Rhinosinusitis
Most children with rhinorrhoea, nasal congestion and a cough lasting more than 12 weeks have chronic rhinosinusitis.
Paediatric CRS is thought be multifactorial possibly involving bacteria, biofilms, adenoiditis and inflammatory cellular changes. In children the adenoids are believed act as a reservoir of bacteria. In some children adenoiditis is the primary problem but this can be difficult to differentiate from sinusitis without a CT scan of the sinuses. It is not believed that the actual size of the adenoids matters in children with rhinosinusitis.
Asthma can be closely linked to paediatric CRS. Asthma not responding to medical therapy can be the only presenting symptom of paediatric CRS. Asthma symptoms can return when sinusitis episodes recur. Helping to control CRS in children with asthma will also help to control their asthma.
The association between allergic rhinitis and paediatric chronic rhinosinusitis is controversial. Allergic rhinitis may be a contributing factor in some patients but generally the cause is multifactorial.
Immunodeficiency has also been reported to be a factor in several studies. Abnormalities commonly seen include IgG subclass deficiencies, IgA deficiency and poor responses in pneumococcal titres. Intravenous immunoglobulin can help to reduce episodes of chronic rhinosinusitis.
Cystic fibrosis has a high incidence of paediatric CRS and nasal polyposis. All children who have nasal polyps should be tested for cystic fibrosis. Primary ciliary dyskinesia is a rare cause of paediatric CRS. This is an autosomal recessive disorder involving the dysfunction of cilia. The diagnosis is considered in children not responding to medical and surgical treatment.
Controversy exists regarding the role of GERD in paediatric CRS. At this stage empiric treatment is not indicated.
Making the diagnosis
Paediatric CRS is defined as the symptoms of nasal congestion, coloured nasal discharge, facial pressure or pain, or cough that has been present for 12 or more weeks. Two or more symptoms are needed. Purulent discharge and mucosal oedema should be evident on examination. Nasal endoscopy is useful in making the diagnosis, assessing for adenoid involvement and checking for polyps.
Plain X-rays have no role in the diagnosis and do not correlate with CT scan findings. A CT scan is the only available mechanism to distinguish whether CRS is present in addition to chronic adenoiditis. CT is reserved for when surgery is being considered.
Management of paediatric chronic sinusitis
The initial management of paediatric CRS is medical. Nasal saline irrigations are beneficial although compliance can be poor. Intranasal corticosteroids are also recommended. Oral antibiotics are indicated and oral corticosteroids should be considered. Oral antihistamines and decongestants are not indicated.
Antibiotic therapy is recommended for 3 to 12 weeks. Amoxicillin/clavulanate or a second or third generation cephalosporin are first line antibiotics. If allergic to penicillin and cephalosporins a macrolide or clindamycin is appropriate. 2
If these medical measures fail, consideration is then given for surgical intervention. In children up to 12 years of age an adenoidectomy alone can be very effective. The adenoids are believed to be obstructive or serve as a reservoir for bacterial growth. Research suggests 70% of children with CRS will improve after an adenoidectomy. Maxillary sinus irrigation at the time of the adenoidectomy may be helpful. Persistence of symptoms despite an adenoidectomy may justify endoscopic sinus surgery.
Final thoughts on chronic sinusitis
Chronic rhinosinusitis in children and adults can be a challenging condition to successfully treat. Even when symptoms are successfully treated, relapses are common. Many new treatments not mentioned in this summary are under investigation but care must be taken to evaluate these further for efficacy and safety before recommending them. A strong partnership between the patient’s GP and specialist is often needed over a long period to successfully manage this disease.