Chronic Sinusitis: A Review and Update

Introduction

Chronic sinusitis is inflammation of the nasal passages that results in symptoms of drainage, facial pain, and decreased sense of smell and can greatly affect overall quality of life. This is a review, of and update on, assessing, diagnosing, and treating chronic sinusitis.

Definition

Chronic sinusitis, also called chronic rhinosinusitis, is inflammation of the nasal passages and paranasal sinuses that results in persistent symptoms. Specifically, the American Academy of Otolaryngology—Head and Neck Surgery defines chronic sinusitis as (1) more than 12 weeks of 2 or more symptoms of anterior or posterior mucopurulent drainage, nasal obstruction, facial pain, and decreased sense of smell and (2) evidence of inflammation, documented by either radiographic evidence, swelling in the middle meatus or ethmoid region, or observation of polyps in the nasal cavity.

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Epidemiology

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From 60% to 67% of chronic rhinosinusitis cases occur in women, and the prevalence increases with age, leveling off after 60 years

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Chronic rhinosinusitis is one of the most common reasons for ambulatory care visits, with a prevalence of 5% to 15% in the United States.

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Twenty-nine million individuals are diagnosed each year, resulting in significant health care expenditures, lost workdays, and antibiotic use.

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Risk Factors

Factors that likely increase the risk of chronic rhinosinusitis include the following

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:

• Active smoking
• Allergic fungal sinusitis
• Aspirin sensitivity
• Asthma, allergies, and atopy
• Chemical and particulate air pollutants such as nitrogen dioxide, ozone, and sulphur dioxide
• Cocaine use
• Gastroesophageal reflux disease
• Granulomatosis
• Humoral immunodeficiencies
• Impaired mucociliary clearance, such as due to
• Kartagener syndrome
• Innate immunodeficiencies, such as cystic fibrosis

Etiology

The etiology of chronic rhinosinusitis is not well understood but generally accepted as involving many factors, including a genetic predisposition, environmental factors, and infectious agents that, when combined, cause chronic inflammation of the upper airway.

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Bacterial infections, most commonly

Staphylococcus aureus

and

pseudomonas aeruginosa

, likely affect acute exacerbations.

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History

Patients with chronic rhinosinusitis will likely present with persistent symptoms—lasting more than 12 weeks—of nasal congestion, facial pressure, nasal blockage, anterior or posterior rhinorrhea, and a reduced sense of smell.

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They might also report ear pain, bad breath, and sleep difficulties.

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Warning signs of a more serious condition warranting immediate intervention include a severe headache and stiff neck (suggesting meningitis), intracranial or epidural abscess, or cavernous sinus thrombosis.

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Any ocular symptoms, such as pain, swelling, or visual changes, suggest orbital cellulitis or cavernous sinus thrombosis and should be investigated further.

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A medical history should be conducted to ask the patient about allergies, asthma, aspirin sensitivity, nasal trauma, and exposure to tobacco

smoke, as well as any previous treatments for rhinosinusitis.

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The practitioner should also assess for an immunocompromised state, a history of cystic fibrosis, and a personal or family history of Kartagener syndrome.

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Physical

An anterior rhinoscopy might reveal nasal mucosal erythema, nasal discharge from the middle meatal area, and nasal polyposis.

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It might also show an anatomic abnormality such as a septal deviation or evidence of prior surgery. Sinonasal inflammation should be assessed using either a rigid or flexible endoscope.

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This nasal endoscopy will give a detailed view of the sinus pathways and any polyposis, edema, mucosal obstruction, or purulent discharge.

Practitioners should consider using the Lund-Kennedy endoscopic scoring system, which helps assess the pathologic states of the sinuses by quantifying symptoms such as polyps, discharge, edema, scarring, adhesions, and crusting.

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Scores range from zero to 20, from least to greatest severity, with separate scores for each side of the nasal cavity.

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Diagnosis

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A diagnosis of chronic rhinosinusitis can be considered if 2 or more of the following symptoms have been present for at least 12 weeks:

• Decreased sense of smell

• Facial pain, pressure, or fullness

• Nasal blockage, obstruction, or congestion

• Nasal discharge

In addition, sinonasal inflammation should be documented by either nasal endoscopy or computed tomography (revealing paranasal sinus swelling).

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The differential diagnosis should include allergic, nonallergic, vasomotor, and eosinophilic nonallergic rhinitis. Facial pain could also be due to trigeminal neuralgia or cluster, tension, or migraine headaches.

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Treatment

Because chronic rhinosinusitis can negatively impair a patient’s day-to-day life, the practitioner might consider administering a quality-of-life questionnaire. The most common one used is the sinonasal outcome test.It asks patients to rate the severity of their symptoms, as well as social and emotional consequences. Other options include the rhinosinusitis outcome measure, thinosinituitis disability index, chronic sinusitis survey, and rhinosinusitis quality-of-life survey.

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First-line treatment for mild and severe chronic rhinosinusitis with or without nasal polyps includes intranasal corticosteroids.Research demonstrates that these drugs can reduce symptoms overall and reduce polyp recurrence. Options include fluticasone, mometasone, and triamcinolone. Patients should be instructed to use 2 sprays per nostril once daily.¹

Patients with severe nasal polyps might benefit from having oral corticosteroids administered for 2 weeks prior to using intranasal steroids.

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Short-term antibiotic treatment might help a patient experiencing repeated exacerbations. However, long-term antibiotic treatment does not appear to be effective.

Although less effective than intranasal corticosteroids, nasal saline irrigation can help relieve symptoms in adults both with and without polyps. Patients should use at least 200 mL of isotonic or hypertonic saline per side.

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Finally, patients who smoke should be counseled to discontinue.

Complications

Although severe complications are rare, ongoing rhinosinusitis can negatively affect the surrounding nasal bone, causing osteitis, bone erosion, metaplastic bone formation, mucocele formation, and optic neuropathy.

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An untreated bacterial infection can lead to additional complications, including bacterial meningitis, orbital cellulitis, and cavernous sinus thrombosis.

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Journal of Otolaryngology

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Prognosis

Chronic rhinosinusitis can also lead to clinical depression, particularly in patients whose symptoms disturb sleep. According to the results of a 2017 study published in the, patients with sleep problems were 82% more likely to report moderate or severe depression than those without troubled sleep.

For most patients, chronic sinusitis cannot be cured, so treatment focuses on symptom relief. In fact, about 25% of those who have surgery for chronic rhinosinusitis do not experience clinically significant improvement.

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ICD-10Codes

When symptoms are relieved, however, depression appears to be reduced, as well.

International Classification of Diseases, Tenth Revision

lists these codes for chronic sinusitis:

• J32.0—chronic maxillary sinusitis

• J32.1—chronic frontal sinusitis

• J32.2—chronic ethmoidal sinusitis

• J32.3—chronic sphenoidal sinusitis

• J32.4—chronic pansinusitis

• J32.8—other chronic sinusitis

• J32.9—chronic sinusitis, unspecified

• B95-B97—additional code, if desired, to identify infectious agent

Melissa DeCapua, DNP, PMHNP-BC

, is a psychiatric nurse practitioner with a clinical background in psychosomatic medicine. She is a design researcher in the technology industry, guiding

product development by combining her clinical expertise and creative thinking. She is a strong advocate for empowering nurses and fiercely believes that nurses should play a pivotal

role in shaping modern health care. To learn more, visit her website at melissadecapua.com and follow her on Twitter @melissadecapua.

References

1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis executive summary.Otolaryngol Head Neck Surg.2015;152(4):598-609. doi: 10.1177/0194599815574247.

2. Ah-See KL, MacKenzie J, Ah-See KW. Management of chronic rhinosinusitis.BMJ.2012; (345):e7054. doi: 10.1136/bmj.e7054.

3. Centers for Disease Control and Prevention. Chronic sinusitis.cdc.gov/nchs/fastats/sinuses.htm. CDC website. Updated March 31, 2017. Accessed September 17, 2017.

4. Settipane RA, Peters AT, Chandra R. Chapter 4: chronic rhinosinusitis.Am J Rhinol Allergy.2013;27(suppl 1):S11-15. doi: 10.2500/ajra.2013.27.3925.

5. Psaltis AJ, Li G, Vaezeafshar R, Cho KS, Hwang PH. Modification of the Lund-Kennedy endoscopic scoring system improves its reliability and correlation with patient-reported outcome measures.Laryngoscope. 2014;124(10):2216-2223. doi: 10.1002/lary.24654.

6. Alobid I, Bernal-Sprekelsen M, Mullol J. Chronic rhinosinusitis and nasal polyps: the role of generic and specific questionnaires on assessing its impact on patient’s quality of life.Allergy. 2008;63(10):1267-1279. doi: 10.1111/j.1398-9995.2008.01828.x.

7. Hanna BM, Crump RT, Liu G, Sutherland JM, Janjua AS. Incidence and burden of comorbid pain and depression in patients with chronic rhinosinusitis awaiting endoscopic sinus surgery in Canada.J Otolaryngol Head Neck Surg. 2017;46(1):23. doi: 10.1186/s40463-017-0205-3.

8. DeConde AS, Smith TL. Classification of chronic rhinosinusitis—working toward personalized diagnosis.Otolaryngol Clin North Am. 2017;50(1):1-12. doi: 10.1016/j.otc.2016.08.003.