Chronic Rhinosinusitis

star star star star star
based on 6 ratings

Last updated: May 7, 2022
Revisions: 24

Last updated: May 7, 2022
Revisions: 24

format_list_bulletedContents add remove

Introduction

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

Those with anatomical variations or mechanical obstruction, such as septal deviation, nasal polyps, or sinus hypoplasia, are also at increased risk of CRS

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

Clinical Features

Symptoms of chronic rhinosinusitis* include nasal blockage (either obstruction or congestion), nasal discharge (either anterior or posterior discharge, including nasal drip), facial pain or pressure (usually unilateral over the maxillary or frontal sinus), and an altered sense of smell. Symptoms must be present for ≥12 weeks.

On examination, there may be tenderness or swelling in the maxillofacial area over the affected sinus. Rhinoscopy will reveal generalised mucosal swelling, mucopurulent (green/yellow) discharge, or nasal polyps (Fig. 2)

*Current guidelines state patients must have 2 or more of these symptoms for a diagnosis of CRS

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*. The presence of mucosal swelling, mucosal occlusion of middle meatus, or nasal polyps (most commonly seen around the middle meatus) are often seen in patients with CRS.

*CT imaging is only required if complications of CRS are suspected and in pre-operative planning

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

Management

For mild disease, nasal saline douching and topical steroid spray should be trialled. Advice should be given to avoid any known triggers, smoking cessation (if relevant), and ensure good control of any associated conditions where possible (e.g. asthma.

Those with moderate to severe disease will require long term antibiotics with topical steroids and referral for consideration for surgery.

Functional Endoscopic Sinus Surgery

The aim of Functional Endoscopic Sinus Surgery (FESS) is to remove any polyps that have formed and to open up the sinuses. This all can be done via an endoscope.

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.

Figure 3 – Schematic demonstrating principles of FESS

Complications

A mucocoele can develop in cases of CRS, were a collection of mucus in an epithelial-lined cavity forms, most commonly in the frontal sinus. Mucocoeles can erode bone and invade local structures such as the orbit and the brain.

Key Points

  • Chronic rhinosinusitis which refers to inflammation of the mucosal linings of the nasal passage and paranasal sinuses with symptoms lasting longer than 12 weeks
  • Diagnosis is clinical however rhinoscopy should be performed to assess for any polyps
  • All cases of chronic rhinosinusitis should undergo nasal endoscopy
  • Treatment of chronic rhinosinusitis is dependant on the severity of symptoms