Rhinosinusitis and Sinusitis

Question 1

What is rhinosinusitis?

Answer 1

Inflammation in the nose and paranasal sinuses.

Question 2

How does rhinosinusitis present?

Answer 2

Diagnosis based on having 2 or more symptoms of: nasal blockage/obstruction/congestion, nasal discharge, facial pain or pressure, reduction of loss of smell and endoscopic or CT findings.

Question 3

Describe acute rhinosinusitis?

Answer 3

Common cold, almost always self-limiting, if lasting longer than 5 days can consider intranasal corticosteroids (fluticasone or mometasone). If symptoms worsen after 5 days then likely acute post-viral sinusitis.

Question 4

Describe chronic rhinosinusitis?

Answer 4

Symptoms for >12 weeks. Can be with or without nasal polyps.

Question 5

What are the common causes of chronic rhinosinusitis without polyps?

Answer 5

Causes without polyps
•	Allergy (see below)
•	Chronic bacterial infections 
•	Ciliary impairment e.g. CF
•	Anatomical abnormalities e.g. septal deviation 
•	Hormonal – pregnancy and hypothyroid 
•	Trauma – nasal sinus fracture 
•	Foreign body 
•	Swimming and diving

Question 6

Describe rhinosinusitis with polyps - when do they require further investigation?

Answer 6

With polyps – inflammatory polyps that cause a CRS representing the extreme end of the disease. Normally found bilaterally but don’t require biopsy unless suspicious. (All unilateral polyps require biopsy).

Question 7

How is rhinosinusitis managed?

Answer 7

Intranasal corticosteroids and nasal saline irrigation are key to management. If no improvement after 4 weeks and endoscopic examination reveals moderate to severe disease, consider cultures and add long term antibiotics (>12 weeks).

Surgical – nasal polypectomy, functional endoscopic sinus surgery, septoplasty, reduction of inferior turbinates.

Question 8

Describe the presentation of allergic rhinosinusitis

Answer 8

Seasonal symptoms and associated with hay fever. Other symptoms include sneezing, pruritis, nasal discharge and bilateral itchy eyes.

Strong association with Asthma.

Question 9

What is seen on endoscopy for rhinosinusitis?

Answer 9

Endoscopy shows inflamed turbinates, pale mucosa and nasal polyps.

Question 10

How is allergic rhinosinusitis classified?

Answer 10

Classified based on its impact on Asthma (ARIA)
Duration
Intermittent – symptoms < 4 days per week and less than 4 weeks
Persistent – symptoms < 4 days per week and more than 4 weeks.

Question 11

What defines the severity of allergic rhinosinusitis

Answer 11

Severity
Mild – no change to normal life
Moderate to severe – impairment of daily activities

Question 12

How should suspected allergic rhinosinusitis be investigated?

Answer 12

Skin prick tests to common triggers – pollens, moulds, house dust mites and animal epithelia
RAST blood test if skin prick not possible

Question 13

What is the management of allergic rhinosinusitis?

Answer 13

Management is by avoidance of trigger, nasal saline irrigation and oral or intranasal antihistamines for prevention (preferably non-sedating such as oral loratadine and cetirizine or intranasal azelastine and olopatadine).
If moderate, severe, or persistent then intranasal corticosteroid sprays – beclomethasone.
Short course of prednisolone can help rapid resolution for example during exams.

Question 14

What other causes of rhinorrhoea are there aside from acute, chronic and allergic rhinosinusitis?

Answer 14

Foreign body, CSF after head injury, bacteria, CF, pregnancy and decongestant overuse.

Question 15

What other causes of congestion are there aside from acute, chronic and allergic rhinosinusitis?

Answer 15

Child – large adenoids, choanal atresia, foreign body and post nasal space tumour
Adult – deflected nasal septum, granuloma (from TB, syphilis or leprosy), topical vasoconstrictors and tricyclics.

Question 16

What are nasal polyps?

Answer 16

Swelling of the nasal or sinus mucosa into the nasal cavity. Note nasal polyps are rare in children <10yrs – must rule out neoplasm, cystic fibrosis and meningocele.

Question 17

What is the typical presentation of nasal polyps?

Answer 17

Typical presentation – male >40yrs, usually bilateral, middle meatus most common, watery anterior rhinorrhoea, sneezing, purulent postnasal drip, nasal obstruction, sinusitis, mouth breathing, snoring and headaches.

Question 18

How should nasal polyps be investigated?

Answer 18

Anterior rhinoscopy or nasal endoscopy showing pale and mobile mucosal nodules that are insensitive to gentle palpation. Compared with turbinates which are pink, mobile and sensitive.

Note unilateral polyps or bleeding require urgent investigation

Question 19

How are nasal polyps managed?

Answer 19

Medical – topical steroid drops can shrink the polyp e.g. betamethasone for 2 weeks followed by fluticasone for 3 months. Consider long term antibiotics such as doxycycline. Note must advise how to give nose drops – head forward not back.

Surgical – endoscopic sinus surgery, only consider if maximal medical treatment fails and ongoing severe symptoms. Complications are rare but can include damage to the optic nerve. After surgery don’t blow nose until better and be wary epistaxis.

Question 20

What differentials should be considered before a diagnosis of sinusitis can be made?

Answer 20

• Migraine
• TMJ dysfunction
• Dental pain
• Neuropathic pain
• Temporal arteritis
• Herpes zoster

Question 21

How does sinusitis present?

Answer 21

Sinus/facial pain
Nasal congestion and discharge (if blood stained and late presentation think cancer)
Fever >38
Elevated inflammatory markers
Double sickening – worsening after initial milder phase of illness.
Unilateral predominance

Question 22

What can lead to a bacterial sinusitis?

Answer 22

Mostly follow a viral infection
Direct spread from dental root, diving or swimming
Odd anatomy e.g. septal deviation, polyps
ITU causes – mechanical ventilation, recumbency and use of NG tubes

Question 23

Which organisms are often involved in bacterial sinusitis?

Answer 23

Common organisms – S. pneumoniae, H influenza, S Aureus, Moraxella Catarrhalis and various fungi.

Question 24

How should suspected bacterial sinusitis be investigated?

Answer 24

Clinical diagnosis
Examine nose for mucosal inflammation, oedema and nasal discharge
CT if recurrent or acute
Nasal endoscopy

Question 25

How is sinusitis managed?

Answer 25

Acute/Single episode – 98% are viral and self-limiting taking 2.5 weeks to resolve so treat with simple analgesia, decongestants, and nasal saline irrigation

Intranasal corticosteroids if symptoms present for more than 10 days
Antibiotics if bacterial causes suspected – amoxicillin or doxycycline

Chronic – treat as above but send for imaging/surgery.
Surgery is endoscopic sinus surgery tailored to the particular sinus.
Cessation of smoking

Question 26

What potential complications can occur in bacterial sinusitis?

Answer 26

Complications to be aware of orbital cellulitis/abscess (emergency), meningitis, cerebral abscess, cavernous sinus thrombosis and osteomyelitis.

Question 27

What is Samter’s triad?

Answer 27

Samter’s triad – association between asthma, nasal polyps and aspirin sensitivity