DIAGNOSIS AND MANAGEMENT OF
RHINOSINUSITIS
AIMS AND OBJECTIVES
1. Know the specific questions in the history i.e. nasal obstruction, sneezing,
rhinorrhoea, nasal discharge and post nasal drip, loss of sense of smell,
facial pain and epistaxis
2. Be able to examine the external nose, the internal nasal cavity and
identify the nasal septum, Little's area, nasal vestibule and the middle
and inferior turbinates
3. Be able to differentiate
a. between infective, allergic and non-allergic rhinosinusitis
b. rhinosinusitis and a structural nasal defect
4. Be able to recognise the complications of rhinosinusitis
5. Understand the principles of treatment for rhinosinusitis, a deviated nasal
septum and trauma to the external nasal skeleton
Introduction
Rhinosinusitis is an inflammatory process involving the mucosa of the nose and sinuses. It
is replacing the term sinusitis because inflammation of the mucosa is rarely confined to
the sinuses and frequently there is inflammation of the whole upper respiratory tract.
Rhinosinusitis can be classified into acute (symptoms for < 4 weeks), sub acute (4-12
weeks) and chronic (>12 weeks).
Chronic rhinosinusitis (CRS) is a multifactorial disease. Factors contributing can
be bacterial infection, allergy, mucociliary impairment, and swelling of the mucosa for
other reasons. Anatomical variations appear to play a minimal role. CRS has a significant
impact on quality of life even when compared with chronically debilitating diseases such as
diabetes and congestive heart failure.1 The disease causes significant physical symptoms,
as well as substantial functional and emotional impairment.2
The maxillary, frontal and anterior ethmoid sinuses drain into the middle meatus
between the inferior and middle turbinate. The posterior ethmoids drain into the superior
meatus whilst the sphenoid sinus drains into the sphenoethmoidal recess in the posterior
nasal cavity.
ACUTE RHINOSINUSITIS
Acute inflammation of one, some or all (pansinusitis) of the sinuses may occur. The
maxillary sinus is the most commonly affected, followed by the ethmoid, frontal and
sphenoid sinuses.
Pathology
The majority of cases follow a viral upper respiratory tract infection (URTI), which
involves all of the respiratory epithelium including the paranasal sinuses. Such
infections cause hyperaemia and oedema of the mucosa, which can block sinus
drainage. Stasis of secretions predisposes to secondary bacterial infection. It is
estimated that up to 2% of viral URTIs are complicated by a bacterial
rhinosinusitis.3 The most common causal organisms are Streptococcus
pneumoniae and Haemophilus influenzae.
Clinical features
Acute rhinosinusitis (ARS) is usually readily diagnosed clinically. It commonly
follows an acute viral URTI, with a severe, unilateral pain over the infected sinus,
malaise, and pyrexia. Other symptoms include nasal obstruction, mucopurulent
rhinorrhoea and poor smell. Acute facial pain without nasal symptoms is highly
unlikely to be due to ARS.
Pain developing in the cheek or upper teeth, usually indicates maxillary sinus involvement
and as mentioned, it tends to be unilateral. Frontal sinusitis produces pain above the eye
and tenderness of the supraorbital margin. Sphenoid infection may produce retro-orbital
pain or pain at the vertex of the head, but pain can be referred to the temporal region or
to the whole head. Tenderness on percussion of the upper first or second molar raises the
possibility of a rhinosinusitis of dental origin. If there is periorbital swelling then this may
be due to a periorbital cellulitis or abscess. This is a serious condition as the sight can be
in jeopardy and an urgent referral is warranted as intravenous antibiotics and drainage
may be required.
Anterior rhinoscopy using an auriscope (ask the patient to mouthbreathe to stop the lens
from misting up) may show inflamed or oedematous nasal mucosa and mucopurulent
secretions in the nasal cavity. Throat examination may reveal mucopurulent secretions in
the posterior oropharynx.
Investigations
Investigations are rarely necessary in uncomplicated cases. There is no clear evidence
that the culturing of purulent secretions contributes to the management of ARS. 4 Plain
sinus x-rays often show sinus opacification or a fluid level in the sinus but are rarely
necessary.
Treatment
Patients can try simple analgesics, steam inhalations, and a decongestant. The
decongestant may reduce nasal oedema and improve the natural drainage of the sinuses.
It can be given topically (xylometazoline spray), but not for more than 5 days in order to
avoid rhinitis medicamentosa (a condition where the nasal vasculature becomes
habituated and damaged by the sympathomimetic action of the drug resulting in rebound
congestion and chronic nasal obstruction). Patients often expect to be prescribed an
antibiotic but there is only a 3% difference in the cure rate even after just one week, in
patients with ARS whether they use antibiotics or not.5 Clinicians must weigh the benefits
of antibiotic treatment against the potential for adverse effects and antibiotic resistance.
In severe cases, or where symptoms are persisting or progressing, antibiotics are
recommended.4 In acute maxillary sinusitis there is limited evidence, but this supports the
use of Penicillin or Amoxicillin for 7 to 14 days. 6 If there is no improvement after 3 to 5
days or in areas where penicillin resistance is high, alternatives such as amoxycillinclavulanate, cefuroxime7, or doxycycline4 may be considered.
When to refer and Surgical Treatment
ARS usually responds to medical treatment. However, if there is progressive pain
the sinuses may need draining with either a maxillary sinus washout or trephining
of the frontal sinus and an urgent referral to an ENT surgeon is needed.
Symptoms and signs of potential complications requiring immediate referral
include periorbital cellulitis, severe headaches, focal neurological signs and
symptoms of meningitis.
CHRONIC RHINOSINUSITIS
Chronic inflammation of the sinuses may follow an ARS or have a more insidious onset.
The condition is over diagnosed as facial pain is often incorrectly thought to be sinogenic,
the sinuses can only be examined using a nasendoscope, and sinus x-rays are not specific.
The incidence of chronic infective rhinosinusitis in the U.K. has decreased because of the
improvements in the general health of the population, diet, hygiene and the introduction
of antibiotics. However the incidence of chronic non-infective rhinosinusitis due to
eosinophilic inflammation has increased.
CRS can be debilitating for patients and has been shown to significantly impair quality of
life but this can be rectified with treatment. The disease imposes a major economic cost
on society in terms of direct cost as well as decreased productivity.8
Pathology
The microbial pathogens present in chronic infective rhinosinusitis are significantly
different to those in ARS. Staphylococcus aureus, coagulase-negative staphylococcus,
anaerobic and gram-negative bacteria predominate. In the majority of patients with CRS
frank purulent infection cannot be found although mucosal hyper-reactivity to
staphylococcal superantigens has been proposed as the cause in the subgroup who
develop nasal polyps. Many patients have hypertrophic mucosa with tenacious secretions
and at histology the lining is replete with eosinophils yet there is no evidence of allergy as
we understand it (Type I IgE mediated hypersensitivity). Very occasionally, sinusitis can
be secondary to dental disease and the organisms are anaerobic producing a foul smelling
discharge.
Clinical features
Patients with chronic rhinosinusitis have nasal obstruction and commonly a discoloured
discharge (nasal or post-nasal) for longer than 12 weeks. They may also experience a
smell disturbance (anosmia or cacosmia = unpleasant smell) or intermittent frontal pain.
Many patients, with facial pain or headaches incorrectly believe they have sinus trouble.
This is often reinforced by the medical profession. However, CRS is usually painless. Key
points in the history of sinogenic pain are: an exacerbation of pain during an URTI, an
association with rhinological symptoms, pain that is worse when flying and a response to
medical treatment.9 Facial pain or pressure on its own without nasal symptoms or signs is
highly unlikely to be due to rhinosinusitis and an alternative diagnosis such as midfacial
segment pain, migraine, cluster headaches and atypical facial pain should be considered.
Vascular pain, such as in cluster headaches, can be associated with autonomic rhinological
symptoms such as nasal congestion and clear rhinorrhoea due to vasodilatation of the
lining of the nose, and this can lead to an incorrect diagnosis. Traditionally, an increase in
the severity of pain on bending forward has been considered diagnostic of sinusitis, but
this finding is non-specific and can occur with many other types of facial pain.9
Patients should have a history of purulent secretions around the clock. Some discoloured
nasal or post-nasal discharge in the mornings can occur with snorers whose clear nasal
secretions (we all produce about half a cup a day) collect in the nasopharynx and become
discoloured with the commensals that collect there. This is common and not indicative of a
CRS.
The diagnosis of CRS is largely based on the history, but physical signs such as mucosal
swelling, inflammation and discharge are needed to make the diagnosis. Anterior
rhinoscopy using an auriscope can be performed but viewing the middle meatus is
difficult. Nasendoscopy achieves much better visualization but is not readily available in
general practice. Signs such as inflammation, mucopus, or the presence of nasal polyps
help confirm the diagnosis. Inferior turbinates are often mistaken as a nasal polyp but are
red and sensitive rather than the pale, pendulous, opalescent painless swellings
characteristic of a polyp. Patients can also be asked to blow their nose to look for evidence
of mucopurulent secretions in their tissue.
Patients with an allergic rhinitis have nasal obstruction and may have hyposmia, nasal
irritation, and sneezing. They often have a slightly yellow nasal mucus due to staining with
eosinophils but this is not indicative of active infection. On examination they classically
have pale and swollen turbinates though the mucosa can be red. Patients with an
idiopathic rhinitis (non-infective, non-allergic) also complain of nasal obstruction and clear
rhinorrhoea or post-nasal discharge but itching and sneezing are less common than in
allergic rhinitis. CRS, allergic rhinitis and idiopathic rhinitis can occur concurrently.
Investigations
Plain sinus x-rays are insensitive and of limited usefulness for the diagnosis of
rhinosinusitis due to the number of false positive and negative results. Guidelines from the
Royal College of Radiologists recommend that plain films of the sinuses are not routinely
indicated.
Treatment
The principle aims of treatment are to ventilate the sinuses and restore mucociliary
clearance. If a diagnosis of CRS is made, a trial of medical therapy should be tried. 4 A
course of broad-spectrum oral antibiotics, such as amoxycillin-clavulanate, clindamycin or
a combination of metronidazole and a penicillin is given for at least 3 weeks. 7 Topical nasal
steroids such as betamethasone drops (2 drops, left+right tds) should be given for 2
months followed by a steroid nasal spray. Nasal drops are best taken whilst the patient is
lying on the bed with the head upside down over the edge. In addition, instructions on
nasal douching (see below) should be given. It is unusual for patients’ symptoms not to
respond to medical treatment. Other co-existing pathologies such as allergic rhinitis or
nasal polyps should be treated accordingly e.g. allergen avoidance, antihistamines, and
oral steroids. Topical steroid therapy can be continued beyond eight weeks if there is an
improvement.
When to refer and Surgical Treatment
If there is no improvement after eight weeks medical therapy, consider referring the
patient to an ENT specialist (Fig. 7). Patients should undergo nasendoscopy to confirm the
diagnosis. In persistent cases that have not responded to maximum medical treatment, a
CT scan of the paranasal sinuses with a view to surgery may be considered. In Functional
Endoscopic Sinus Surgery (FESS), the natural drainage pathways of the sinuses are
cleared, to allow adequate drainage and resolution of the CRS. Treatment outcomes show
a mean 91% improvement rate10 and it is now the preferred technique in sinus surgery
rather than the classical 'open' surgical approach. Patients are advised that they will often
need to continue to take topical nasal medication after surgery as many of the causes of
CRS are due to a systemic disease affecting the nasal lining. It is like ‘asthma of the nose’
and indeed many of the patients have co-existing late onset asthma.
Summary
Chronic infective rhinosinusitis tends to be over diagnosed. Many patients do not have an
active infection but have developed a persistent allergic rhinitis due to perennial allergens.
Other common causes of CRS are patients with mucosal hypertrophy or polyps associated
with late onset asthma who often have hyposmia and yellow stained secretions due to
eosinophils. Chronic infection is associated with green secretions throughout the day along
with nasal obstruction and this usually responds to the correct anti-bacterial treatment.
Patients with facial pain or pressure without any nasal symptoms rarely have CRS, and
their pain is usually neurological in origin. The commonest cause of facial pain is midfacial
segment pain, a symmetrical sensation of pressure, sometimes described as ‘blockage’ but
without any airway impairment that affects the face and/or forehead. It is like tension
type headache except that it affects the midface. It responds to low dose amitriptyline,
taking 6 weeks to work and needs 6 months of treatment.11
Nasal Douching
Mix ½ teaspoon of salt, ½ teaspoon of sugar and ½ teaspoon of bicarbonate of soda in 2
pints of boiled water, which has been left to cool. Place some of the mixture into a saucer,
or draw some mixture up with a syringe. Block off one nostril with one finger and then
sniff or squeeze up the solution into the other nostril, letting it run out afterwards. Topical
sprays and drops should be taken after douching.
COMPLICATIONS OF INFECTIVE SINUSITIS
Can be serious and life threatening
They include:
Chronic sinusitis
Osteomyelitis
Peri-orbital cellulitis and orbital abscess
Commonest serious complication
Direct or blood-borne spread
Ethmoid sinuses separated from orbit by thin plate of bone (lamina
papyracea)
Ethmoiditis can be associated with:
 cellulitis i.e. inflammation of skin anterior to orbital septum
‘pre-septal cellulitis’
 orbital abscess whereby pus is subperiosteal (confined by
periosteum of lamina papyracea) but posterior to orbital septum
Management
Peri-orbital cellulitis is treated by high dose antibiotics and careful
observation
An orbital abscess puts the vision at risk from pressure on the optic
nerve and requires urgent drainage
 This can be prevented by careful monitoring of:
 colour vision (this is the first sign of danger)
 visual acuity
 eye movements
 If in doubt a CT scan of the sinuses should be requested
urgently
Facial cellulitis

May be an extension of:
 orbital cellulitis
 frontal sinusitis or where the pus spreads into the soft
tissues of the forehead ‘Pott’s puffy tumour’
 maxillary sinusitis or osteomyelitis

Is treated with high dose antibiotics and sinus drainage as
necessary


Usually form as a late complication of acute sinusitis
Collections of sterile mucus occupying an obstructed sinus
(especially frontal and ethmoidal)
Present with facial swelling, visual disturbances due to
displacement of eye or secondary infections
Treatment is by surgical drainage (usually endoscopic)
Mucoceles


Intracranial complications
 Can occur by direct spread, by venous thrombophlebitis or
along the perineural tissue of the olfactory nerve
 Meningitis is the commonest complication
 Cavernous sinus thrombosis
o Due to spreading thrombophlebitis from the frontal,
ethmoidal and sphenoid sinuses
o There is decreased venous return from the eye causing
the orbit to swell and congestion of the retinal vessels
o Symptoms include high fever with rigors, severe
headache, reduced level of consciousness and cerebral
irritation
o Signs include IIIrd, IVth, VIth nerve palsies causing
opthalmoplegia in addition to paraesthesia of the upper
two divisions of the Vth (due to the close proximity of
these nerves to the cavernous sinus)
o Frequently the symptoms become bilateral
o Treatment is with high dose antibiotics but there is still a
high associated mortality

Brain abscesses secondary to frontal sinusitis
o occur most commonly in the frontal lobe
o may cause subtle changes in personality, headaches a
grand mal convulsion or may be found incidentally on a
CT scan
o treatment requires neurosurgical drainage or aspiration

Extradural abscess secondary to frontal sinusitis
o May be found on CT scan and is usually due to a
dehiscence of the posterior wall of the frontal sinus
o Are usually drained into the frontal sinus and hence
externally

Subdural abscess secondary to frontal sinusitis
o Is difficult to diagnose in early stages
o Patients have general malaise, headache and some neck
stiffness and signs of raised intracranial pressure
o The diagnosis is generally made on the examination and
CT scan
o The prognosis of this rare complication is poor
Acknowledgements
We would like to thank Dr Ko, Dr Poon and Mr Foundling-Miah for their comments and
suggestions.
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