ACUTE & CHRONIC RHINOSINUSITIS

ACUTE & CHRONIC
RHINOSINUSITIS
Dr Harjitpal Singh
Assistant Professor(ENT),
Dr RKGMC, Hamirpur

DEFINITION
• Rhinosinusitis (RS) is an inflammation of the nose and
paranasal air sinuses.
• It accounts for about 5% of visits to primary care
physicians
• Its common causes include viral, bacterial and allergic.
• RS in children is a multifactorial disease and the
importance of predisposing factors changes with
increasing age.
• Acute sinusitis means acute infection or inflammation of
the paranasal sinuses of less than 4 weeks duration.

MICROBIOLOGY
•Viruses
• Rhinovirus
•Parainfluenzae I and II
•Coxsackie A21
• Respiratory syncitial
• Bacteria
• Pneumococci (29%)
• Streptococci
• Staphylococci (6.6%)
• H influenzae (48%)
• Escherichia coli
• Micrococcus catarrhalis
• Bacillus pfeiffer
• B. freidlander
• Specific Infections
•Fungi.
•Syphilis
•Tuberculosis
•Leprosy.

TYPES OF RHINOSINUSITIS
• Patients whose symptoms never disappear completely for more
than 12 weeks are termed chronic rhinosinusitis (CRS)
• While patients who have complete recovery between the
episodes of RS, which lasts for more than 7 days, are
considered to have recurrent rhinosinusitis.
• Pansinusitis is the term applied to inflammation of all the
paranasal sinuses, whereas individual sinus involvement is
named accordingly such as acute maxillary sinusitis, acute
ethmoiditis, acute frontal sinusitis or acute sphenoiditis.
• A sinusitis is termed open if pus can drain through its natural
ostium while it is not possible in close type.
• The commonly involved sinuses are maxillary and ethmoid.

TYPES OF RHINOSINUSITIS
1.Acute Rhinosinusitis (< 4 weeks duration)
a) Viral Rhinosinusitis (VRS)
b) Acute Bacterial Rhinosinusitis (ABRS)
2. Subacute Rhinosinusitis (4–12 weeks duration)
3. Chronic Rhinosinusitis (> 12 weeks duration)
a) With Polyps
b) Without Polyps
4. Recurrent Acute Rhinosinusitis (3 episodes in 6
months or 4 or > 4 episodes of acute RS in 1
year)

PATHOLOGY
• Sinusitis passes through five stages:
1. Catarrhal stage
2. Exudative stage
3. Suppurative stage
4. Stage of complications
5. Stage of resolution.

PATHOLOGY
• Inflammatory changes include hyperemia with
outpouring of serum and polymorphs associated
with local swelling, redness and edema (due to
obstruction of vein and lymphatics).
• If obstruction and edema persist for a long time, cell
degeneration with cloudy swelling and necrotic
changes will occur.
• Clinically, it may be:
 Catarrhal type
 Suppurative type.

ACUTE VIRAL RHINOSINUSITIS
(COMMON COLD)
• Approximately 20–30% cases of acute rhinosinusitis.
• The common viruses are: rhinovirus & parainfluenza.
• They spread by aerosolised droplets through coughing and
sneezing.
• Incubation period is 1-4 days.
• Complications are uncommon, as the disease is self limiting.
• Less than 2% in adults & 30% in children, it progress to
ABRS, & cause pharyngitis/bronchitis/pneumonia/OM
• Unless complicated by bacterial infection, the patient
improves within a week or 10 days.

Pathophysiology

CLINICAL FEATURES
• Usually AVRS begins with sore throat, which lasts for
1 or 2 days and then followed by cough and nasal
discharge.
• In beginning there may be burning sensation at the
back of nose, nasal stuffiness, rhinorrhea and
sneezing.
• Patient has chill and low-grade fever.
• Nasal watery discharge is profuse and may become
mucopurulent due to secondary bacterial invasion

TREATMENT
• There is no approved treatment, mainly symptomatic.
• Symptoms can be easily controlled with antihistaminics.
• Oral decongestants may cause insomnia and agitation.
• Analgesics are useful to relieve headache, fever & myalgia.
• Antibiotics have no role in AVRS.
• Nasal saline sprays/ nasal decongestants are useful.
• General: Bed rest and plenty of fluids are encouraged.

ACUTE BACTERIAL RHINOSINUSITIS
• This usually follows viral upper respiratory
infection.
• The most common bacteria responsible for ABRS
are Streptococcus pneumoniae, Haemophilus
influenzae, Moraxella catarrhalis and
Staphylococcus aureus

Predisposing Factors are following:
1. Viral rhinosinusitis
2. Allergic rhinosinusitis
3. Trauma
4. Physical stigmata such as DNS
5. Swimming and diving
6. Barotraumas.
7. Dental infections and extraction of upper molars and premolars:
They involve maxillary sinus.
a. Periapical dental abscess may burst into the sinus.
b. The root of a tooth, during extraction, may be pushed into
maxillary sinus.

PREDICTORS OF ABRS
• Best predictors of ABRS, which differentiate it from VRS,
include: i. Maxillary toothache
ii. Poor response to decongestants
iii. Colored/purulent nasal discharge
vi. Abnormal transillumination
• Other predictors include unilateral facial pain, pain with
bending and mildly elevated ESR.
• Findings having little predictive value include headache,
difficulty in sleeping, sore throat, sneezing, malaise,
itchy eyes, fever or sweats and painful chewing.
• Severe symptoms include both high-grade fever and
purulent nasal discharge for 3–4 consecutive days.

EXTERNAL SIGNS
1. Flushing of cheek with swelling of cheek, which
may spread to lower lid in maxillary sinusitis.
2. Upper lid may be swollen in frontal sinusitis.
3. Ethmoiditis may give rise to swelling at the inner
canthus of same eye.
4. Tenderness over the affected sinus.
a. Cheek: Maxillary sinusitis.
b. Floor of sinus: Frontal sinusitis.
c. Inner canthus: Ethmoids.

PAIN IN SINUSITIS
• Antral Pain: It is along the infraorbital margins and
referred to upper teeth or gums on affected side.
• Ethmoidal Pain: It is localized over bridge of nose and
inner canthus of eye and is referred to parietal
eminence.
• Frontal Sinus Pain: It is localized to forehead and pain is
periodical in nature, i.e. starts an hour or two after
getting up from bed and vanishes during afternoon.
• Sphenoidal Pain: It gives rise to occipital or vertical
headache and sometimes is referred to mastoid
process. Pain may be felt behind the eyeball due to
close proximity with Vth nerve.

ACUTE ETHMOID SINUSITIS WITH
ORBITAL CELLULITIS

INVESTIGATIONS
1. Hematology: TLC DLC are increased.
2. Culture sensitivity test.
3. Transillumination test.
a. Maxillary sinus—absence of infraorbital crescent of
light and pupillary glow indicate sinusitis.
b. Frontal sinus transillumination:not very informative.
1. X-ray paranasal sinuses (PNS) to demonstrate fluid level,
pus or opacity.
2. Computed tomography (CT) scan—coronal CT may show
thickening of mucosa or opacification with occlusion of
maxillary infundibulum.

TRANSILLUMINATION TEST
It is performed in a darkroom using a bright light with a
special torch in a darkened room. They are 15 percent
less accurate than X-rays.
For maxillary sinuses light is placed in oral cavity and light
transmission is compared over maxillary sinuses.
For frontal sinuses light is placed in the superior medial
corner of the anterior orbit. Frontal sinuses often develop
asymmetrically.
Interpretations:
a. Normal: Typical light transmission
b. Dull: Reduced light transmission
c. Opaque: No light transmission

CT PARANASAL SINUSES
CHRONIC
ETHMOIDOMAXILLARY
SINUSITIS

Treatment can be discussed under three headings:
Prophylactic Treatment
1. Strengthen the first line of defence, i.e.
mucous/ciliary blanket.
2. Sunshine, good ventilation, and proper
humidity.
3. Good diet rich in vitamins.
4. Avoid flying and swimming with cold.

Medical Treatment
• Antibiotics Amoxicillin 500 mg three-times daily (TDS) or any other
broad spectrum antibiotic (BSA) for 10 to 14 days and not one
week to avoid recurrence. If there is no response in 3 to 5 days,
change over to clarithromycin/azithromycin/ cefixime.
• Local decongestants: Ephedrine in saline nasal drops or
oxymetazoline/xylometazoline nasal drops followed by steam
inhalation (which liquefies the thick viscid secretions).
• Analgesics: Aspirin and codeine preparation.
• Local application of heat by hot water bottle for about 10 minutes,
three times a day is comforting, relieves pain and promotes
drainage.

SURGERY
• The surgery is reserved for patients with threatened
intraorbital or intracranial complications.
• The reported success of endoscopic sinus surgery is
about 80–90%.
• It is indicated in following conditions:
– Persistent disease despite medical therapy.
– Recurrent RS with identifiable and related
anatomical or acute pathological
abnormalities in the osteomeatal complex.

CHRONIC RHINOSINUSITIS
• It is a chronic inflammatory disease of nasal and
paranasal sinus mucosa where symptomatology
has continued beyond 12 weeks and which has
resulted in irreversible degenerative changes.
• It usually follows acute sinusitis, which has not been
treated adequately or it may also follow a cold or
tooth infection.
• It occurs when the self cleansing mechanism of nose
and paranasal sinuses gets impaired.
• Maxillary sinus is most commonly involved.
• Organisms isolated in CRS are Staphylococcus aureus,
Pseudomonas aeruginosa, Klebsiella pneumoniae and
Escherichia coli. Anaerobic organisms are also found.

For clinical purposes, it is divided into two categories:
1. CRS without polyps
2. CRS with polyps
CRS WITHOUT POLYPS
• It is bacterial in origin
• Some cases are due to progression of acute →
subacute → chronic rhinosinusitis.
• Organisms isolated in CRS are Staphylococcus aureus,
P aeruginosa, K pneumoniae and E coli.
• Anaerobic organisms are also found.

CRS WITH POLYP
• Polyp formation in the nose and sinuses can be
due to infectious processes or systemic
disorders such as
(i) primary ciliary dyskinesia,
(ii) cystic fibrosis,
(iii) Samter triad (aspirin sensitivity,
nasal polypi and asthma),
(iv) asthma (7% of patients with asthma
have polypi)

FACTORS ASSOCIATED WITH
• Environmental Exposures
• Anatomical factors
• Allergy
• Ciliary impairment
• Primary Cilia Dyskinesia
• Smoking
• Laryngopharyngeal reflux

Environmental Exposures
• Exposure to individual with respiratory
complaints was risk factor for RS
infection(adjusted OR = 3.7).
• Increased levels of dampness in home has been
associated with sinusitis.
• Exposure to air pollution, irritants used in

Anatomical factors
• Anatomical variations including Haller cells and
septal deviation, nasal polyps, and choanal
obstruction by benign adenoid tissue, or
odontogenic sources of infections.

Ciliary impairment
• Ciliary function diminished during viral and
bacterial rhinosinusitis.
• Exposure to cigarette smoke and allergic
inflammation has been shown to impair
ciliary function.
• Impaired mucociliary clearance in AR

Smoking
• Active smokers with on-going allergic inflammation
have increased susceptibility to ARS compared to
non-smokers with on-going allergic inflammation,
suggesting that exposure to cigarette smoke and
allergic inflammation is mediated via different and
possibly synergistic mechanisms.

Laryngopharyngeal reflux
• Pacheco-Galvan et al. 1997-2006 have shown
significant associations between GERD and
sinusitis.
• Recent systematic review, Flook and Kumar showed
only poor association between acid reflux, nasal
symptoms, and ARS

Anxiety and depression
• Poor mental health, anxiety, or depression is
associated with susceptibility to ARS
• Mechanisms are unclear.

Concomitant Chronic Disease
• Concomitant chronic disease (bronchitis,
asthma, CVS disease, DM, CA) in children
has been associated with increased risk of
developing ARS secondary to influenza.

.BIOFILM
• It is a protective mechanism by which
microorganisms form a polysaccharide film
around their colonies.
•The film, though permitting nutrients to
organisms and providing an exit for
excretions, is impervious to antibiotics,
leading to bacterial resistance, chronicity
and refractoriness to treatment.

Causative Factors And
Pathophysiology Of Chronic
Sinusitis.

ANATOMICAL STRUCTURAL FACTORS
WHICH BLOCK OSTIA
• Concha bullosa
• Paradoxical middle turbinate
• Concha bullosa of contralateral side
• Septal deviation pushing the middle turbinate
• Haller cell obstructing the maxillary sinus
• Inversion of uncinated process
• Pneumatization of uncinated process

• The sign and symptoms may be divided into two types:
1)Major and
2)Minor.
• The presence of two or more major factors or one major
factor and two minor factors or purulent nasal discharge
make the diagnosis of CRS.

MAJOR FACTORS:
• Facial pain/pressure
• Facial congestion/fullness
• Nasal obstruction/blockage
• Nasal discharge/purulence/discolored postnasal drip
• Hyposmia / anosmia
• Purulence in nasal cavity on examination
• Fever (acute rhinosinusitis only)

MINOR FACTORS:
• Headache
• Fever
• Halitosis
• Fatigue
• Dental pain
• Cough
• Ear pain/pressure/fullness

DIFFERENTIAL DIAGNOSES
1. Cystic fibrosis or primary ciliary dyskinesia: If the polyps are
present in children then cystic fibrosis or primary ciliary
dyskinesia syndrome must be ruled out.
2. Fungal infection: In cases of very sticky, rubbery, yellow, tan or
green mucus, special stains for fungus should be performed.
3. Systemic diseases: In cases of antibiotic and surgical failure
cases, systemic diseases (sarcoid, Wegener’s granulomatosis)
and mucosal and ciliary abnormalities should be considered.
4. Gastroesophageal reflux disease: If the presenting complaint is
postnasal discharge then patient must be evaluated for
GERD.

Medical Treatment
• Treat the cause with particular attention to tonsils, adenoids,
allergy, personal habits (smoking or alcohol indulgence),
environment or work situation (smoky or dusty
surroundings).
• Antibiotics
• Saline nasal douching.
• Allergy, if present must be managed.
• Nasal decongestants relieve nasal obstruction and improve
sinus ventilation.
• Nasal steroid spray.

INDICATIONS FOR SINUS SURGERY
• Nasal polyposis
• Anatomic blockage—deviated septum, enlarged turbinate,
concha bullosa
• Mucocele
• Orbital abscess
• Fungal sinusitis—allergic vs. invasive (mucor)
• Tumor of nasal cavity or sinus
• Chronic, recurrent sinusitis
• Failure to respond to maximal medical therapy
• Obtain cultures

Surgical Treatment
• Endoscopic Sinus Surgery
• In antibiotic failures when CT scan is positive, endoscopic
sinus surgery (ESS) is considered.
• Massive polyps are usually not cured with antibiotics and
recurrence usually occurs after surgery.
• Long term NSS and oral steroids (especially perioperative) do
prevent or delay recurrence after the removal.
• Noninclusion of sinus ostium, postoperative scarring and
systemic diseases (sarcoid, Wegener’s granulomatosis),
mucosal and ciliary abnormalities can result in failure.

Surgical Treatment
Maxillary Sinus
• Antral puncture and irrigation.
• Intranasal antrostomy is done if antral puncture and
sinus irrigations fail. A window, which provides aeration
and free drainage, is made in the inferior meatus.
• Caldwell-Luc operation: The antrum is approached
through the anterior wall with sublabial incision. After
removing the irreversible diseases, another window is
created between the antrum and inferior meatus.

Surgical Treatment
Frontal sinusitis
• External frontal operation (Howarth’s)
• Osteoplastic flap operation
• Obliterative operation on frontal sinus.
Ethmoid sinusitis
• Intranasal ethmoidectomy
• Transantralethmoidectomy(Jansen-Horganprocedure)
• External ethmoidectomy (Lynch-Howarth procedure)
• Transorbital ethmoidectomy (Patterson operation)
Sphenoid sinusitis
• Intranasal drainage
• Via external ethmoidectomy

LONG-TERM MANAGEMENT
• May be a lifelong disease
• Allergy control - antiihistamines, nasal steroids, immunotherapy
• Oral steroids - judiciously
• Antibiotics for acute exacerbations
• Environmental control—avoid carpet, damp, mold, older homes, smog
• Saline irrigations
• Alternative therapies—acupuncture, stress management, herbal remedies
• Pain management
• Multi-disciplinary effort—work with allergy, infectious disease,
neurology/pain management services

ACUTE & CHRONIC RHINOSINUSITIS

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