Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU
Nasal physiology
Mucociliary clearance can be tested by placing saccharin on the inferior turbinate and timing the onset of sweet taste in the mouth. The normal range is 7-11 minutes.
There is normal asymmetry of nasal mucosa swelling, with one side of nose swollen as a result of dilatation of veins in the inferior turbinate and the other side "open" - 80% of the population exhibits a nasal cycle, with reciprocal changes in airflow over 1-2 hours.
Anatomy
Sinus is a Latin word for “fold” or “pocket”. Paranasal sinuses have an embryogenic origin from the nasal passage and are an integral component of the airway. Drainage pathways of the sinuses are complex and can be blocked during inflammation. Ostia are the sinus openings in the nasal cavity. They are 2-6 mm wide.
Location of the openings of the sinuses
- Inferior meatus - opening of nasolacrimal duct.
- Middle meatus - frontal, maxillary and anterior ethmoids
- Superior turbinate - posterior ethmoids and sphenoid sinuses
Mnemonic
Sinuses listen to the following radio channels: FM AM / PS SS
Frontal sinus, Maxillary sinus, and
Anterior ethmoids drain into Middle meatus
Posterior ethmoids and Sphenoid sinus drain into
Sphenoethmoidal recess above Superior turbinate
Sinusitis
Approximately 31-35 million Americans are affected by sinusitis every year (15% of the population).
Sinusitis of less than 4 weeks’ duration is considered acute. Chronic sinusitis persists for more than 4 weeks.
Recurrent sinusitis is defined as 4 or more episodes of sinusitis per year. Each episode lasting 7-10 days and no symptoms during intervening periods.
Acute Exacerbation of Chronic Sinusitis is the sudden worsening of chronic sinusitis that returns to baseline with treatment.
The term sinusitis is often interpreted as reflecting simply a bacterial sinus infection but the disease can have a significant allergic component.
Sinusitis is mostly preceded by rhinitis and is rarely found without rhinitis.
The 1997 Rhinosinusitis Task Force thus proposed the term Rhinosinusitis instead of Sinusitis (reiterated in 2007 guidelines).
Acute Sinusitis
Symptoms for up to 4 weeks. Viral most of the time. Bacterial in less than 5%. Patients with allergic rhinitis (AR) are more susceptible to acute sinusitis.
Duration of symptoms and definition
Less than 4 weeks - acute sinusitis
4-12 weeks - subacute sinusitis
Longer than 12 weeks - chronic sinusitis
Complications of acute sinusitis
Orbital cellulitis
Subperiostal, intraorbital or eyelid abscess
Cavernous sinus thrombosis
Meningitis
Subdural, epidural or brain abscesses
Osteomyelitis of frontal bone (Potts puffy tumor)
Chronic Sinusitis
Symptoms for more than 12 weeks. Not an "infection."
Eosinophilic Sinusitis
Allergic Fungal Sinusitis (click to read the article)
Complications of acute sinusitis
Orbital cellulitis
Subperiostal, intraorbital or eyelid abscess
Cavernous sinus thrombosis
Meningitis
Subdural, epidural or brain abscesses
Osteomyelitis of frontal bone (Potts puffy tumor)
Chronic Sinusitis
Symptoms for more than 12 weeks. Not an "infection."
Eosinophilic Sinusitis
Allergic Fungal Sinusitis (click to read the article)
Noneosinophilic Sinusitis
Noneosinophilic sinusitis is considered to have an infectious basis and is treated with antibiotics. Organisms found are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. If a patient has Pseudomonas aeruginosa or Staphylococcus aureus, cystic fibrosis should be considered in differential diagnosis.
Diagnosis
A limited CT of sinuses costs about the same as a standard plain film sinus series but is much more useful.
CT scan findings do not correlate well with symptoms.
Upper airway endoscopy can identify anatomic or mechanical disorders of the upper airway. Anterior rhinoscopy is an examination of the nasal cavity performed with a nasal speculum under good illumination. Usually done with a rigid rhinoscope.
The gold standard for diagnosis of bacterial sinusitis is sinus puncture and culture.
Treatment
Treatment of Acute Sinusitis
Over 70% of patients with acute rhinosinusitis improve after 7 days, with or without antimicrobial therapy.
NNT = 7: 7 patients must be treated to achieve one additional positive outcome at 7 to 12 days.
More adverse effects in treated group, number needed to harm (NNH) = 9.
Start antibiotics if no improvement by day 7 or patient has worsening at any time.
Amoxicillin should be first choice based on safety, efficacy, cost, and narrow spectrum. A 10-14 day course is commonly used (7 days beyond clinical improvement).
Treatment of Chronic Sinusitis
Saline lavage (Ann Fam Medicine, July 2006).
Intranasal steroids (INS)
Antihistamines – not useful, may worsen by drying mucosa. Only consider if significant allergic component.
Itraconazole (Sporanox) for fungal sinusitis (most commonly seen in the Southern states). Itraconazole use requires a close follow-up due to the risk of CHF, cardiac arrhythmias, liver dysfunction and peripheral neuropathy (foot drop). It has a "black box" warning for CHF patients.
Refer to ENT for chronic sinusitis. Balloon sinuplasty is a procedure gaining wider acceptance.
Nasal Polyps
Nasal polyps can be considered a form of chronic hyperplastic sinusitis and usually originate in the ethmoid sinuses. Malignant transformation is uncommon. Polyps can occupy the entire nasal cavity, thus producing a total blockage.
Nasal polyposis can be associated with allergic fungal sinusitis, cystic fibrosis (CF) and the triad of asthma, aspirin intolerance, and nasal polyps (Samter's triad in AERD). In cystic fibrosis, polyps show neutrophilic inflammation.
CF should always be considered in children with nasal polyps.
What is the triad of aspirin-exacerbated respiratory disease (AERD)?
Samter's triad include asthma, aspirin sensitivity, and nasal/ethmoidal polyposis:
ASPirin
Asthma
Sensitivity to aspirin
Polyps
Approximately 9% of the U.S. population has asthma - 9% of adult asthmatics have aspirin-exacerbated respiratory disease (AERD) (http://goo.gl/FIeE9).
Noneosinophilic sinusitis is considered to have an infectious basis and is treated with antibiotics. Organisms found are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. If a patient has Pseudomonas aeruginosa or Staphylococcus aureus, cystic fibrosis should be considered in differential diagnosis.
Diagnosis
A limited CT of sinuses costs about the same as a standard plain film sinus series but is much more useful.
CT scan findings do not correlate well with symptoms.
Upper airway endoscopy can identify anatomic or mechanical disorders of the upper airway. Anterior rhinoscopy is an examination of the nasal cavity performed with a nasal speculum under good illumination. Usually done with a rigid rhinoscope.
The gold standard for diagnosis of bacterial sinusitis is sinus puncture and culture.
Treatment
Treatment of Acute Sinusitis
Over 70% of patients with acute rhinosinusitis improve after 7 days, with or without antimicrobial therapy.
NNT = 7: 7 patients must be treated to achieve one additional positive outcome at 7 to 12 days.
More adverse effects in treated group, number needed to harm (NNH) = 9.
Start antibiotics if no improvement by day 7 or patient has worsening at any time.
Amoxicillin should be first choice based on safety, efficacy, cost, and narrow spectrum. A 10-14 day course is commonly used (7 days beyond clinical improvement).
Treatment of Chronic Sinusitis
Saline lavage (Ann Fam Medicine, July 2006).
Intranasal steroids (INS)
Antihistamines – not useful, may worsen by drying mucosa. Only consider if significant allergic component.
Itraconazole (Sporanox) for fungal sinusitis (most commonly seen in the Southern states). Itraconazole use requires a close follow-up due to the risk of CHF, cardiac arrhythmias, liver dysfunction and peripheral neuropathy (foot drop). It has a "black box" warning for CHF patients.
Refer to ENT for chronic sinusitis. Balloon sinuplasty is a procedure gaining wider acceptance.
Nasal Polyps
Nasal polyps can be considered a form of chronic hyperplastic sinusitis and usually originate in the ethmoid sinuses. Malignant transformation is uncommon. Polyps can occupy the entire nasal cavity, thus producing a total blockage.
Nasal polyposis can be associated with allergic fungal sinusitis, cystic fibrosis (CF) and the triad of asthma, aspirin intolerance, and nasal polyps (Samter's triad in AERD). In cystic fibrosis, polyps show neutrophilic inflammation.
CF should always be considered in children with nasal polyps.
What is the triad of aspirin-exacerbated respiratory disease (AERD)?
Samter's triad include asthma, aspirin sensitivity, and nasal/ethmoidal polyposis:
ASPirin
Asthma
Sensitivity to aspirin
Polyps
Approximately 9% of the U.S. population has asthma - 9% of adult asthmatics have aspirin-exacerbated respiratory disease (AERD) (http://goo.gl/FIeE9).
Pediatric sinusitis (click the link to continue).
Surgical treatment of chronic sinusitis
References
Allergy and Immunology MKSAP, 3rd edition.
Acute and Chronic Rhinosinusitis: Practical Clinical Treatment Strategies. Nancy Otto, PharmD. Medscape, 11/2008.
Acute Sinusitis: A Cost-Effective Approach to Diagnosis and Treatment. AFP, 1998.
Sinusitis Practice Guideline Aims to Improve Diagnosis, Cut Antibiotic Use. AFP, 2007.
Related Reading
FIT Corner Questions. Chapter 78 of the 6th edition of Middleton’s Allergy Principles and Practice, edited by N. Franklin Adkinson, et al. September 27, 2006. Chapter 78: Nasal Polyps and Sinusitis.
Allergic Fungal Sinusitis. Photoclinic. Consultant. Vol. 48 No. 9, August 1, 2008.
JAMA Patient Page: Acute Sinusitis, 2009.
Surgical treatment of chronic sinusitis
Functional Endoscopic Sinus Surgery (FESS) is the surgical standard of care. FESS restores sinus drainage and provides some symptom improvement in close to 90% of selected patients.
References
Allergy and Immunology MKSAP, 3rd edition.
Pediatric sinusitis. Ellen R. Wald, MD. Audio-Digest Pediatrics, Volume 55, Issue 14, July 21, 2009.
Acute Bacterial Rhinosinusitis in Adults: Part II. Treatment. AFP, 2004.Acute and Chronic Rhinosinusitis: Practical Clinical Treatment Strategies. Nancy Otto, PharmD. Medscape, 11/2008.
Acute Sinusitis: A Cost-Effective Approach to Diagnosis and Treatment. AFP, 1998.
Sinusitis Practice Guideline Aims to Improve Diagnosis, Cut Antibiotic Use. AFP, 2007.
Related Reading
FIT Corner Questions. Chapter 78 of the 6th edition of Middleton’s Allergy Principles and Practice, edited by N. Franklin Adkinson, et al. September 27, 2006. Chapter 78: Nasal Polyps and Sinusitis.
Allergic Fungal Sinusitis. Photoclinic. Consultant. Vol. 48 No. 9, August 1, 2008.
JAMA Patient Page: Acute Sinusitis, 2009.
Humming increases airflow between the sinus and nasal cavities, which could protect against sinus infections. NYTimes, 2010.
Multi-symptom Asthma is Closely Related to Nasal Blockage, Rhinorrhea and Symptoms of Chronic Rhinosinusitis http://goo.gl/sU4AU
Nucleotide-binding oligomerization domain (NOD)-like receptors (NLRs) have a potential role in chronic rhinosinusitis/polyps http://goo.gl/QAS4r
Atrophic Rhinosinusitis: Progress Toward Explanation of an Unsolved Medical Mystery. Medscape, 2011.
SNOT-16 Assessment Tool for Acute Sinusitis takes 5 minutes - copyright protected by Washington University. Medscape, 2011.
Staphylococcus aureus biofilm and and superantigens are associated with chronic sinusitis, cause T-helper 2 skewing http://bit.ly/ngnxBe
Intranasal antinuclear autoantibodies (ANA) in patients with chronic rhinosinusitis with nasal polyps. JACI, 2011.
Chronic Sinusitis - JAMA Patient Page (PDF), 2011.
Mnemonics for sinusitis: PODS and C-PODS (end of PDF here)
Published: 07/10/2007
Updated: 04/29/2012
SNOT-16 Assessment Tool for Acute Sinusitis takes 5 minutes - copyright protected by Washington University. Medscape, 2011.
Staphylococcus aureus biofilm and and superantigens are associated with chronic sinusitis, cause T-helper 2 skewing http://bit.ly/ngnxBe
Intranasal antinuclear autoantibodies (ANA) in patients with chronic rhinosinusitis with nasal polyps. JACI, 2011.
Chronic Sinusitis - JAMA Patient Page (PDF), 2011.
Mnemonics for sinusitis: PODS and C-PODS (end of PDF here)
Published: 07/10/2007
Updated: 04/29/2012
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