Sinusitis

The term “sinusitis” has now been officially replaced by “rhinosinusitis” in the Otolaryngology literature. Rhinosinusitis is divided into two main categories: acute (sinus infection lasting less than four weeks) and chronic (sinus infection lasting greater than twelve weeks). Sub-acute rhinosinusitis refers to a sinus infection lasting between four and twelve weeks.

Rhinosinusitis usually begins after obstruction of the sinus drainage pathways secondary to a viral URTI, or some other cause, resulting in stagnation of secretions within the sinus. Bacteria from the nasal cavity invade the mucus filled sinuses if the obstruction does not resolve within a few days. If the infection does not resolve within a few weeks, the mucus membrane will undergo polypoid change causing further obstruction. The flora will gradually change from one of acute sinusitis (S. pneumo, H.influenzae and Moraxella) to one of chronic sinusitis (anaerobes, gram negative enterococci). Once the infection has lasted greater than four weeks, it becomes increasingly difficult to treat because of increasingly resistant bacteria as well as a significant reduction of ciliary activity within the obstructed drainage pathways.

It is therefore imperative to treat an established acute rhinosinusitis aggressively to avoid the development of chronic sinusitis.

Symptoms of rhinosinusitis include facial congestion/fullness, nasal obstruction, nasal discharge / purulence / discoloured PND, hyposmia, purulence, facial pain and pressure. Other symptoms include headache, fatigue, halitosis, dental pain, cough and ear pain.

CT scanning remains the modality of choice and should be obtained in the coronal plane ONLY if medical therapy has failed. It’s purpose is NOT to detect acute sinusitis but to reveal underlying chronic pathology. Plain films are the least accurate imaging technique with high false positive and false negative rates.

Treatment for acute rhinosinusitis should include non-medical management i.e. saline irrigation, steaming, increased water intake/hydration. Medical management should include topical or systemic decongestants, antimicrobial and topical nasal steroids. Mometasone (Nasonex) is currently the only nasal steroid indicated for the treatment of acute sinusitis. It reduces the number of basophils and eosinophils in the mucosa and inhibits the late-phase reaction after exposure to allergens. Antimicrobial therapy for acute sinusitis should include amoxicillin-clavulanate or macrolide antibiotics. For chronic rhinosinusitis systemic decongestants, topical nasal steroids and occasionally systemic steroids are used. Antimicrobial therapy should include amoxicillin-clavulanate, clindamycin, cefuroxime and or quinolones. Endoscopically guided culture directed treatment is far superior to empiric therapy for choosing the appropriate antibiotic. Patients with recalcitrant chronic sinusitis non-responsive to medical management should be referred to a sinus centre.

Case studies

Acute Sinusitis: Diagnosis and Treatment

A 39 yo mother of two young children presents with a 10 day history of a worsening cold and nasal congestion that is not getting better. She states that it all started with a cold that got somewhat better after the first five days but has now become worse again. She is getting colored nasal discharge, pain and pressure in both her cheek sinuses. She finds that her nasal passages are congested and her sense of smell is compromised. She feels tired and does not have the energy to get out of bed and drop her kids to school in the morning. She denies fevers.

As her symptoms have worsened and continue past 7 days, she now has moderate to severe acute rhinosinusitis. She meets the Canadian Guidelines criteria for acute sinusitis as she complains of the PODS (pain and pressure, obstruction, discharge and smell loss) symptoms lasting more than five days.

Treatment: She needs to be started on a nasal steroid spray, two sprays to each nostril twice daily, nasal irrigations with saline once to twice daily and encouraged hydration. If her symptoms do not start to turn around within 48 hours, she should be started on an antibiotic regimen with the first line of treatment being amoxicillin 500mg po tid.

Chronic Sinusitis

A 50 yo male presents with an eight year history of nasal congestion, anterior and posterior nasal discharge, reduced sense of smell and feeling generally fatigued but still managing to continue to function at a reduced level than before. He remembers exactly when this started after a bad cold and can almost give you the exact date. He has been on several courses of antibiotics than only help him partially and only for a short time. The symptoms almost always return. He has also been put on prednisone for short bursts of two to three weeks during which time he feels great, his sense of smell and energy return and he feels back to normal for a short time. Also, he has over the last year been told he has developed asthma, which he never had before.

On endoscopic examination of his nasal passage he has nasal polyps in both middle meatie with colored discharge going down the back of his throat.

Adult onset asthma with symptoms of sinusitis lasting more than three months is classic for Chronic Sinusitis. These patients will not get better on medical management and will invariably require endoscopic sinus surgery and superb post op care for successful management and cure of their symptoms.

Sinusitis and Asthma

Chronic rhinosinusitis (CRS) is characterized by long-standing inflammation of the nose and paranasal sinuses. Chronic rhinosinusitis can be subdivided into CRS without nasal polyposis (CRSsNP) and CRS with nasal polyposis (CRSeNP). The prevalence of CRS in Canada is 5.7%, and ranges from 2% to 16% in the United States.

Asthma is a chronic inflammation of the lower airways involving episodic breathlessness and wheezing, with airway hyperresponsiveness to environmental stimuli, with a prevalence of 5%–10% in the general population. Coexistence of asthma and rhinosinusitis has been noted in the medical literature for centuries. The current one-airway or united airway concept is supported by anatomical links and similarities in histology, pathophysiology, and immune mechanisms.

Forty percent of CRS patients have been shown to have asthma, and sinus x-ray or computed tomography (CT) showed that 93% of those with asthma also had sinusitis. A recent study examining the effect of CRS on development of Asthma over 12 years found that CRS patients were significantly more likely to develop asthma than non-CRS counterparts and one in 13 individuals with CRS will be subsequently diagnosed with asthma.

The full case study on sinusitis and asthma is located here: Sinusitis and Asthma