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chronic sinusitis

Clinical manifestations: - sinusitis for >= 12 weeks - see acute sinusitis - despite symptoms suggesting chronic sinusitis, sinus inflammation & sinus infection are often absent on endoscopy. [1] Laboratory: 1) nasal cytology a) modified Wright-Giemsa or Hansel stain b) > 5 neutrophils per high-power field - 85% sensitivity, 40% specificity c) >5 eosinophils per high-power field - allergic rhinitis, nasal polyposis 2) sinus aspiration (endoscopy) & culture is the gold standard 3) cultures of nasal secretions are useless Special laboratory: 1) rhinoscopy - used by otolaryngologists & allergists - check for nasal polyps [2] 2) endoscopy a) sinus aspiration & culture b) useful for draining sinus c) useful for ruling out vs making diagnosis [1] 3) allergen testing Radiology: 1) computed tomography (coronal sinus CT) a) visualization of ethmoid sinuses b) 90-100% sensitivity, 60% specificity c) method of choice 2) magnetic resonance imaging Complications: - sinonasal inflammation associated with decreased brain connectivity within a major functional hub with a central role in modulating cognition [7] Differential diagnosis: - migraine Management: 1) non-pharmaceutical measures: - drink plenty of fluids - adequate rest & sleep - self-administered daily nasal irrigation with a neti pot with modest reduction in symptoms; NNT = 13 [5] - inhaling steam of no benefit - consider other diagnoses [1] 2) pharmaceutical agents a) nasal corticosteroids plus saline irrigation 1st line [3] b) sinusitis with nasal polyps - leukotriene antagonists as maintenance - nasal glucocorticoids 1st line [10] - systemic glucocorticoids as rescue therapy [3] c) sinusitis without nasal polyps - antibiotics guided by sinus aspiration & culture - 4-6 weeks of macrolide therapy - shorter duration of other antibiotics [3] d) antifungal agents not recommended [2] except in cases of allergic fungal sinusitis with polyposis [9] 3) referral to otolaryngologist - endoscopic sinus surgery (also see patient information) - improves sleep & quality of life in patients with chronic rhinosinusitis [4] - good short-term relief, but minimally effective at 1 year for patients with chronic rhinosinusitis with nasal polyps [8] - chronic invasive fungal sinusitis generally requires surgery

Related

causes of persistent or recurrent sinusitis

Specific

chronic ethmoidal sinusitis chronic frontal sinusitis chronic hyperplastic sinusitis chronic maxillary sinusitis chronic sphenoidal sinusitis

General

sinusitis chronic otorhinolaryngologic disease; chronic ear, nose & throat (ENT) disease chronic upper respiratory tract infection

References

  1. Ferguson BJ et al. Prospective observational study of chronic rhinosinusitis: Environmental triggers and antibiotic implications. Clin Infect Dis 2012 Jan 1; 54:62. PMID: 22114094
  2. Rosenfeld RM et al Clinical Practice Guideline (Update). Adult Sinusitis Executive Summary. Otolaryngol Head Neck Surg April 2015 vol. 152 no. 4 598-609 PMID: 25833927 http://oto.sagepub.com/content/152/4/598.full
  3. Rudmik L, Soler ZM. Adult Chronic Sinusitis. JAMA. 2015 Sep 1;314(9):964 PMID: 26325574 - Rudmik L, Soler ZM Medical Therapies for Adult Chronic Sinusitis. A Systematic Review. JAMA. 2015;314(9):926-939 PMID: 26325561 http://jama.jamanetwork.com/article.aspx?articleID=2432168
  4. Alt JA et al. Quality of life in patients with chronic rhinosinusitis and sleep dysfunction undergoing endoscopic sinus surgery: A pilot investigation of comorbid obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg 2015 Sep 10 PMID: 26356240
  5. Little P, Stuart B, Mullee M et al Effectiveness of steam inhalation and nasal irrigation for chronic or recurrent sinus symptoms in primary care: a pragmatic randomized controlled trial. CMAJ July 18, 2016 PMID: 27431306 http://www.cmaj.ca/content/early/2016/07/18/cmaj.160362
  6. Bachert C, Han JK, Desrosiers M et al. Efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis with nasal polyps (LIBERTY NP SINUS-24 and LIBERTY NP SINUS-52): Results from two multicentre, randomised, double-blind, placebo-controlled, parallel-group phase 3 trials. Lancet 2019 Sep 19; S0140-6736(19)31881-1; PMID: 31543428 - Stevens WW. A new treatment for chronic rhinosinusitis with nasal polyps. Lancet 2019 Sep 19; S0140-6736(19)32133-6; PMID: 31543427
  7. Jafari A, de Lima Xavier L, Bernstein JD et al Association of Sinonasal Inflammation With Functional Brain Connectivity. JAMA Otolaryngol Head Neck Surg. 2021;147(6):534-543 PMID: 33830194 PMCID: PMC8033506 (available on 2022-04-08) https://jamanetwork.com/journals/jamaotolaryngology/fullarticle/2778439
  8. Lourijsen ES et al. Endoscopic sinus surgery with medical therapy versus medical therapy for chronic rhinosinusitis with nasal polyps: A multicentre, randomised, controlled trial. Lancet Respir Med 2022 Apr; 10:337. PMID: 35012708 https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(21)00457-4/fulltext
  9. Archer SM, Meyers AD Nonsurgical Treatment of Nasal Polyps.. Medscape. April 1, 2021 https://emedicine.medscape.com/article/861353-treatment
  10. NEJM Knowledge+