Chronic Rhinosinusitis

Rhinosinusitis (sinusitis) is a relatively common condition, characterised by inflammation of the mucosal linings of the nasal passage and paranasal sinuses.

This article will focus on chronic rhinosinusitis (CRS), which refers to symptoms lasting longer than 12 weeks. Its pathophysiology is complex, involving interactions between the dysfunctional nasal mucosa and environmental factors.

In this article, we shall look at the risk factors, clinical features and management of chronic rhinosinusitis.


Risk Factors

The main risk factors for chronic rhinosinusitis include:

  • Asthma or atopy
  • Aspirin sensitivity
  • Ciliary impairment (e.g. cystic fibrosis or primary ciliary dyskinesia)
  • Smoking
  • Immunosuppression

Fig 1 – The location of the paranasal sinuses (1) Frontal sinuses (2) Ethmoid sinuses (3) Sphenoid sinuses (4) Maxillary sinuses


Clinical Features

According to the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS), chronic rhinosinusitis can be diagnosed if two or more of the following symptoms are present for >12 weeks:

  • Nasal obstruction
  • Discoloured nasal discharge (either anterior or posterior discharge)
  • Facial pain or pressure (usually unilateral over the maxillary or frontal sinus)
  • Altered sense of smell

Rhinoscopy will reveal generalised mucosal swelling, mucopurulent (green/yellow) discharge, and/or polyps. Nasal polyps are overgrowths of swollen mucosa which prolapse into the airway or sinuses.


Differential Diagnosis

The main differential diagnoses for chronic rhinosinusitis include:

  • Recurrent acute rhinosinusitis – consider if there is resolution of symptoms between episodes.
  • Malignancy – consider in cases of unilateral nasal polyposis, the presence of bloodstained discharge, or eye signs.
  • Foreign bodies – more common in children, and typically presents with nasal obstruction and discoloured unilateral discharge.

Investigations

To make a formal diagnosis of chronic rhinosinusitis, nasal endoscopy is required. At least one of the following signs should be present:

  • Mucosal swelling
  • Mucopurulent discharge
  • Mucosal occlusion of middle meatus
  • Nasal polyps (most commonly seen around the middle meatus).

Occasionally, severe nasal polyps can be observed directly by anterior rhinoscopy.

Fig 2 – A nasal polyp, as observed on anterior rhinoscopy


Management

The treatment of chronic rhinosinusitis is dependant on the severity of symptoms. This can be assessed via a severity Visual Analogue Score (VAS) score (VAS CRS), in addition to examination of the nasal cavity.

  • Mild disease (VAS 0-3 with no significant mucosal disease) – treated with nasal saline douching and topical steroid spray or drops.
  • Moderate to severe disease (VAS >3 with significant mucosal disease) – requires long term antibiotics with topical steroids and a CT scan of the sinuses.
    • Refractory cases should be considered for surgical intervention (FESS). After surgery, it is important that topical treatments are continued.

Functional Endoscopic Sinus Surgery (FESS)

The aim of Functional Endoscopic Sinus Surgery (FESS) is to remove any polyps that have formed and open up the sinuses. This will reduce obstruction, drain any collections of mucus, and allow topical treatments to reach all areas to prevent recurrence.

Complications of FESS include bleeding, infection, need for nasal packing, recurrence, injury of the orbit, and cerebrospinal fluid leak.


Complications

One complication of chronic rhinosinusitis is a mucocoele – a collection of mucus in an epithelial-lined cavity.  They are rare, most common in the frontal sinus, and usually present with a lump on the forehead.

Long term, the mucocoele can erode bone and invade local structures such as the orbit and the brain.

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