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Sinusitis

Last updated: April 1, 2021

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Rhinosinusitis is a mucosal inflammation of both the paranasal sinuses and adjacent nasal cavities. Viral infections are the most common cause of acute rhinosinusitis, with bacterial and fungal infections occurring less often. The primary symptoms are purulent rhinorrhea, nasal obstruction, and facial pain. Acute rhinosinusitis (ARS) is often self-limiting, but antibiotic therapy may be indicated if a bacterial superinfection is suspected. Imaging and endoscopy are reserved for cases of treatment failure, recurrent rhinosinusitis, and chronic rhinosinusitis, as well as in patients with certain risk factors. Complications arise if the infection spreads and may involve the soft tissues, bone, vascular system, and/or central nervous system. Chronic rhinosinusitis (CRS) lasts at least 12 weeks and is viewed as a chronic inflammatory state similar to asthma, which may become complicated by bacterial exacerbations and chronic fungal infections.

  • Pansinusitis: inflammation of all sinuses on one or both sides
  • Acute sinusitis: inflammation of the sinuses for < 4 weeks
  • Subacute sinusitis: progressive symptoms of sinus inflammation occurring over 4–12 weeks; represents a transition from acute to chronic infection
  • Chronic sinusitis: persistent symptoms of sinus inflammation > 12 weeks
  • Recurrent acute sinusitis: four or more separate episodes of acute sinusitis that occur within 1 year, with at least 8 weeks of symptom resolution between episodes
  • Rhinosinusitis: simultaneous inflammation of the nasal mucosa and sinuses

References:[1][2]

  • Incidence: Sinusitis is one of the most commonly diagnosed conditions in the USA, affecting an estimated 35 million individuals per year.
  • Peak incidence: early fall to early spring
  • Sex: >

References:[3]

Epidemiological data refers to the US, unless otherwise specified.

References:[4]

  • Sinusitis is triggered by three factors: obstruction of sinus drainage pathways (sinus ostia), ciliary impairment, and altered mucus quantity and quality → stasis of secretions inside the sinuses → proliferation of various pathogens → sinusitis
  • Recurrent, untreated/complicated acute sinusitis may lead to chronic sinusitis.

References:[5]

Condition Sinusitis Rhinitis Additional features
Acute viral rhinosinusitis
Acute bacterial rhinosinusitis
  • Persistent symptoms ≥ 10 days without clinical improvement OR
  • ≥ 3 initial days of severe symptoms, fever (> 39°), facial pain, or purulent nasal discharge OR
  • Symptoms initially improve and then worsen after 5–6 days (double worsening)

Fungal rhinosinusitis

  1. Noninvasive
    • Allergic fungal: features of asthma and other atopic manifestations
    • Fungal mycetoma: unilateral complaints; usually involves the maxillary sinus
  2. Invasive
Chronic rhinosinusitis
  1. Allergic fungal: See “Fungal rhinosinusitis” above.
  2. Chronic rhinosinusitis with nasal polyps: See “Nasal polyps.”
  3. Chronic rhinosinusitis without nasal polyps: anatomical abnormalities (septal deviation, tumors), dental disease

Acute bacterial rhinosinusitis should be suspected in patients with symptoms of acute rhinosinusitis that do not improve after 10 days or worsen after initial improvement!

References:[2][4][6][7]

Nasal polyps [8][9]

Primary ciliary dyskinesia [11][12]

You can memorize the cause of Kartagener syndrome by thinking of Kartagener's restaurant that only has 'take-out' service because there is no dine-in (dynein).

Kartagener syndrome is a subtype of primary ciliary dyskinesia characterized by the triad of situs inversus, chronic sinusitis, and bronchiectasis.

Fungal rhinosinusitis (FRS) [13][14]

Acute invasive fungal rhinosinusitis is a life-threatening diagnosis with a mortality rate of 50–80%. If suspected, immediately admit the patient and consult ENT. [14]

Diagnostic criteria for acute rhinosinusitis (ARS) [7]

  • Purulent nasal drainage with at least one of the following:
    • Nasal obstruction
    • Facial pain or pressure
  • Duration: ≤ 4 weeks

Classification of acute rhinosinusitis [7]

Diagnostic criteria for chronic rhinosinusitis [7]

Approach [1][7][15]

Imaging [7][15][17]

Imaging is the initial diagnostic tool for suspected complications.

  • Sinus CT: standard imaging modality
    • Findings may include signs of:
      • Rhinosinusitis: opacification, mucosal thickening, air-fluid levels, soft tissue swelling [16]
      • Complications: spread beyond the sinuses
      • Underlying causes of CRS: e.g., anatomic abnormalities, osteomeatal obstruction, polyposis
      • Aggressive fungal infection or neoplasm: e.g., osseous destruction, extrasinus extension, local invasion [7][14]
  • MRI: can be used to evaluate for intracranial or intraorbital involvement or to differentiate polyps from tumors [15]
  • Sinus x-ray
    • No longer recommended due to limited sensitivity and specificity
    • May show sinus opacification and air-fluid levels

Endoscopy

Pale or dark necrotic mucosa with crusting or ulcers indicates acute invasive fungal rhinosinusitis, which is a medical emergency. [18]

Additional studies

A clinical diagnosis of chronic sinusitis should be confirmed with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography. [7]

Approach [7]

Symptomatic treatment [1][7]

The following options may be offered to all patients with rhinosinusitis.

Antibiotic treatment [7]

Antibiotic treatment in acute bacterial rhinosinusitis (ABRS) [1][7][23]
Adults Children (< 18 years)
First-line treatment

Penicillin allergy

Inpatient treatment

Surgical treatment [1][22][25]

Orbital and intracranial necrotic spread is especially common in invasive fungal sinusitis.

References:[26][27]

We list the most important complications. The selection is not exhaustive.

  1. Chow AW, Benninger MS, Brook I et al. IDSA Clinical Practice Guideline for Acute Bacterial Rhinosinusitis in Children and Adults. Clin Infect Dis . 2012; 54 (8): p.e72-e112. doi: 10.1093/cid/cis370 . | Open in Read by QxMD
  2. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical Practice Guideline (Update), Adult Sinusitis Executive Summary. Otolaryngol Head Neck Surg. 2015; 152 (4): p.598-609. doi: 10.1177/0194599815574247 . | Open in Read by QxMD
  3. Summary Health Statistics for U.S. Adults: National Health Interview Survey, 2001.
  4. Raz E, Win W, Hagiwara M, Lui YW, Cohen B, Fatterpekar GM. Fungal Sinusitis. Neuroimaging Clin N Am. 2015; 25 (4): p.569-576. doi: 10.1016/j.nic.2015.07.004 . | Open in Read by QxMD
  5. Morcom S, Phillips N, Pastuszek A, Timperley D. Sinusitis.. Aust Fam Physician. 2016; 45 (6): p.374-7.
  6. Hwang PH, Patel ZM. Acute sinusitis and rhinosinusitis in adults: Clinical manifestations and diagnosis. In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/acute-sinusitis-and-rhinosinusitis-in-adults-clinical-manifestations-and-diagnosis.Last updated: November 8, 2016. Accessed: February 16, 2017.
  7. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS et al. Clinical practice guideline (update): Adult sinusitis. Otolaryngol Head Neck Surg. 2015; 152 (2S): p.S1-S39. doi: 10.1177/0194599815572097 . | Open in Read by QxMD
  8. Stevens WW, Schleimer RP, Kern RC. Chronic Rhinosinusitis with Nasal Polyps. The Journal of Allergy and Clinical Immunology: In Practice. 2016; 4 (4): p.565-572. doi: 10.1016/j.jaip.2016.04.012 . | Open in Read by QxMD
  9. Hulse KE, Stevens WW, Tan BK, Schleimer RP. Pathogenesis of nasal polyposis. Clinical & Experimental Allergy. 2015; 45 (2): p.328-346. doi: 10.1111/cea.12472 . | Open in Read by QxMD
  10. Aspirin-exacerbated respiratory disease (AERD). https://www.aaaai.org/conditions-and-treatments/library/asthma-library/aspirin-exacerbated-respiratory-disease. . Accessed: February 24, 2021.
  11. Lucas JS, Burgess A, Mitchison HM, et al. Diagnosis and management of primary ciliary dyskinesia. Arch Dis Child. 2014; 99 (9): p.850-856. doi: 10.1136/archdischild-2013-304831 . | Open in Read by QxMD
  12. Shapiro AJ, Davis SD, Polineni D, et al. Diagnosis of Primary Ciliary Dyskinesia. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2018; 197 (12): p.e24-e39. doi: 10.1164/rccm.201805-0819st . | Open in Read by QxMD
  13. Chakrabarti A, Denning DW, Ferguson BJ, et al. Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Laryngoscope. 2009; 119 (9): p.1809-1818. doi: 10.1002/lary.20520 . | Open in Read by QxMD
  14. Singh V. Fungal Rhinosinusitis: Unravelling the Disease Spectrum. J Maxillofac Oral Surg. 2019; 18 (2): p.164-179. doi: 10.1007/s12663-018-01182-w . | Open in Read by QxMD
  15. Frerichs N, Brateanu A. Rhinosinusitis and the role of imaging. Cleve Clin J Med. 2020; 87 (8): p.485-492. doi: 10.3949/ccjm.87a.19092 . | Open in Read by QxMD
  16. DelGaudio JM, Swain RE, Kingdom TT, Muller S, Hudgins PA. Computed Tomographic Findings in Patients With Invasive Fungal Sinusitis. Archives of Otolaryngology–Head & Neck Surgery. 2003; 129 (2): p.236. doi: 10.1001/archotol.129.2.236 . | Open in Read by QxMD
  17. Kirsch CFE, Bykowski J, Aulino JM, et al. ACR Appropriateness Criteria ® Sinonasal Disease. J Am Coll Radiol. 2017; 14 (11): p.S550-S559. doi: 10.1016/j.jacr.2017.08.041 . | Open in Read by QxMD
  18. Silveira MLC, Anselmo-Lima WT, Faria FM, et al. Impact of early detection of acute invasive fungal rhinosinusitis in immunocompromised patients. BMC Infect Dis. 2019; 19 (1). doi: 10.1186/s12879-019-3938-y . | Open in Read by QxMD
  19. Chiarella SE, Grammer LC. Immune deficiency in chronic rhinosinusitis: screening and treatment. Expert Rev Clin Immunol. 2016; 13 (2): p.117-123. doi: 10.1080/1744666x.2016.1216790 . | Open in Read by QxMD
  20. Jiang N, Kern RC, Altman KW. Histopathological Evaluation of Chronic Rhinosinusitis: A Critical Review. Am J Rhinol Allergy. 2013; 27 (5): p.396-402. doi: 10.2500/ajra.2013.27.3916 . | Open in Read by QxMD
  21. Barshak MB, Durand ML. The role of infection and antibiotics in chronic rhinosinusitis.. Laryngoscope Investig Otolaryngol. 2017; 2 (1): p.36-42. doi: 10.1002/lio2.61 . | Open in Read by QxMD
  22. Sedaghat AR. Chronic Rhinosinusitis.. Am Fam Physician. 2017; 96 (8): p.500-506.
  23. Wald ER, Applegate KE, Bordley C, et al. Clinical Practice Guideline for the Diagnosis and Management of Acute Bacterial Sinusitis in Children Aged 1 to 18 Years. Pediatrics. 2013; 132 (1): p.e262-e280. doi: 10.1542/peds.2013-1071 . | Open in Read by QxMD
  24. Rosenfeld RM. Acute Sinusitis in Adults. N Engl J Med. 2016; 375 (10): p.962-970. doi: 10.1056/nejmcp1601749 . | Open in Read by QxMD
  25. Brietzke SE, Shin JJ, Choi S, et al. Clinical Consensus Statement. Otolaryngol Head Neck Surg. 2014; 151 (4): p.542-553. doi: 10.1177/0194599814549302 . | Open in Read by QxMD
  26. Levy DA, Pecha PP, Nguyen SA, Schlosser RJ. Trends in complications of pediatric rhinosinusitis in the United States from 2006 to 2016. Int J Pediatr Otorhinolaryngol. 2020; 128 : p.109695. doi: 10.1016/j.ijporl.2019.109695 . | Open in Read by QxMD
  27. Carr TF. Complications of sinusitis. American Journal of Rhinology & Allergy. 2016; 30 (4): p.241-245. doi: 10.2500/ajra.2016.30.4322 . | Open in Read by QxMD
  28. Bergström SE. Primary Ciliary Dyskinesia (Immotile-cilia Syndrome). In: Post TW, ed. UpToDate. Waltham, MA: UpToDate. https://www.uptodate.com/contents/primary-ciliary-dyskinesia-immotile-cilia-syndrome.Last updated: January 19, 2018. Accessed: February 20, 2018.