Acute & Chronic Rhinosinositus

Question 1

What is acute rhinosinusitis?

How is it diagnosed?

Answer 1

Symptomatic inflammation of the mucosal lining of the nasal cavity and paranasal sinuses.

Sudden onset of two or more symptoms, one of which should be either:

=> nasal blockage / obstruction / congestion

OR

=> nasal discharge (anterior or posterior nasal drip)

± facial pain / pressure worsen on bending forward

± reduction or loss of smell; for <12weeks

Question 2

What causes acute rhinosinusitis?

Answer 2

1. Viral (most common):
   => common cold caused by rhinovirus, coronavirus, parainfluenza virus, respiratory syncytial virus (RSV)
2. Bacterial:
   => Streptococcus pneumonia,
   => haemophilia influenzae
   => mortadella catarrhalis

Question 3

What are the signs and symptoms of acute rhinosinusitis?

Answer 3

1. Main symptoms: nasal obstruction and coloured discharge
2. Facial pain / tenderness worsen on bending forward - more common in acute presentation of rhinosinusitis
3. Hyposmia / anosmia
   (reduced / absent smell)
4. Pain elsewhere i.e. dental infections can spread to sinus
5. Fever and malaise (systemic features)
6. Double sickening (deterioration after an initial milder phase of illness) => may indicate acute post-viral rhinosinusitis or bacterial rhinosinusitis
7. Anterior rhinoscopy - inflammation and discharge
8. Nasendoscopy - pus discharging from sinus openings e.g. middle meatus

Question 4

What are the complications of an acute rhinosinusitis?

Answer 4

1. Intracranial:

=> meningitis,

=> cavernous sinus thrombosis,

=> intracranial abscess (rare)

2. Associated with severe, sudden onset headache, vomiting and photophobia
3. Extracranial:

=> osteomyelitis,

=> orbital or pre-septal cellulitis,

=> orbital abscess

*intraorbital complications = surgical emergencies as vision at risk with infraorbital sepsis

Question 5

What are the investigations for acute rhinosinusitis?

Answer 5

1. Bloods:
   => FBC for WBC
   => CRP
   => Blood cultures if very ill / co-morbidity
2. If complicated rhinosinusitis / not responding

=> swab for microscopy, culture and sensitivity

=> CT with contrast of sinuses and brain if complications occur

Question 6

What is the treatment for acute rhinosinusitis?

1. If symptoms <5d & mild?
2. If symptoms >10d or worsening after 5d?
3. If severe with at least 3 of discoloured discharge, severe local pain, fever, elevated ESR/CRP, double sickening?
4. If recurrent or chronic symptoms?

Answer 6

1. If symptoms <5 days and mild:

=> Analgesia & nasal saline irrigation

=> Fluid dehydration

=> Nasal decongestant e.g. xylometazoline or pseudo-ephedrine for 1 week only

2. If symptoms persistent after 10 days or worsening after 5 days:

=> Treat as above

=> Topical intranasal steroids

3. If severe (at least 3 of discoloured discharge, severe local pain, fever, elevated ESR/CRP, double sickening)

=> Broad spectrum antibiotics for 7d e.g. phenoxymethylpenicillin (first line), amoxicillin

=> Co-amoxiclav if systemically very unwell, high risk of complications

=> Topical intranasal steroids

4. If recurrent or chronic symptoms, refer to ENT for management + possible endoscopic sinus surgery

Question 7

What is acute sinusitis?

Answer 7

Inflammation of mucous membranes of the paranasal sinuses

=> sinuses are usually sterile

Most common pathogen in acute sinusitis:
=> Streptococcus pneumonias
=> Haemophilus influenzae
=> Rhinoviruses

Question 8

What are the predisposing factors for acute sinusitis?

Answer 8

1. Nasal obstruction e.g. septal deviation or nasal polyps
2. Recent local infection e.g. rhinitis or dental extraction
3. Swimming/diving
4. Smoking

Question 9

What is chronic rhinosinusitis?

Answer 9

Inflammation of the nasal mucosa and paranasal sinuses for >12weeks

It can be divided into:

=> chronic rhinosinusitis with polyps

OR

=> chronic rhinosinusitis without polyps

Question 10

Chronic rhinosinusitis is very common - accounts for 85% of outpatient visits for rhinosinusitis in adults.

What are the predisposing factors of chronic rhinosinusitis?

Answer 10

1. Atopy: hay fever, asthma
2. Nasal obstruction e.g. septal deviation or nasal polyps
3. Recent local infection e.g. rhinitis or dental extraction
4. Swimming/diving
5. Smoking
6. Secondary to medication / cocaine abuse

Question 11

What are the signs and symptoms of chronic rhinosinusitis?

Answer 11

Inflammation of the nose & sinuses causing 2 or more symptoms:

1. Nasal blockage / obstruction / congestion e.g. mouth breathing
2. Nasal discharge (anterior / posterior nasal drip)
   * post. nasal drip may cause chronic cough

=> clear if it’s due to an allergy or vasomotor

=> thicker, purulent discharge if secondary infection

3. ± facial pain/frontal pressure - worse on bending forward
4. ± hyposmia/anosmia

And either:

=> Endoscopic signs of polyps, middle meatus oedema or mucopurulent discharge

=> CT scan - mucosal changes of the ostiomeatal complex/sinuses

Question 12

What are the non-operative management options?

Answer 12

1. Saline nasal irrigation
2. Nasal decongestants (short course only)
3. Anti-histamines (if an allergic component)
4. Oral steroids with chronic rhinosinusitis with polyps + topical therapy

=> Drops i.e. betamethasone or fluticasone for 4-6week

=> Switch to maintenance intra-nasal corticosteroids spray i.e. fluticasone or mometasone for 3 months until review

Question 13

What choice of oral antibiotics are used in chronic rhinosinusitis?

Answer 13

1. Macrolides e.g. clarythromycin

=> in non-polyp chronic rhinosinusitis

=> used when IgE levels aren’t raised

=> cardiac hx taken into account due to effects on QT prolongation

2. Doxyclycline

=> in polyp chronic rhinosinusitis

Question 14

What is the surgical management for chronic rhinosinusitis?

Answer 14

Functional endoscopic sinus surgery (FESS)

=> removes diseased tissue, relieves obstruction and restores normal function + anatomy of paranasal sinuses

*surgery used as an adjunct when medical treatment has failed