Definition & Epidemiology
Sinusitis is a clinical condition characterized by mucosal inflammation of the paranasal
sinuses. Acute sinusitis is a rapid-onset bacterial infection that has been present
for < 1 month and most commonly affects the maxillary sinus. Subacute sinusitis,
with symptoms present between 1 and 3 months, usually develops when an acute episode
of bacterial sinusitis has not been adequately treated. Chronic sinusitis has been
present for at least 3 months and is often associated with persistent mucosal changes.
Sinus disease is frequently encountered in general practice, and it has been estimated
that 0.5% of viral upper respiratory tract infection result in acute sinusitis.
Chronic sinusitis is also a very common condition and affects 31 to 35 million Americans.
The most frequent underlying cause is obstruction of the ostiomeatal complex (the
area in the nose where the paranasal sinuses drain to) due to allergic rhinitis.
In general, any one with recurrent disease (2 or more episodes of sinusitis for
2 or more years) should be evaluated for an underlying problem, which may predispose
to recurring infections. The commonest underlying causes of sinusitis are shown
Conditions that predispose to chronic sinusitis:
- Cystic fibrosis
- Ciliary dyskinesia
- Acquired immunodeficiency syndrome
Rhinitis medicamentosa (prolonged use of nasal decongestants,
to which the nose becomes readily addicted)
- Cocaine abuse
- Wegners granulomatosis
Relationship between Asthma and Sinusitis
The causal relationship between asthma and sinusitis and/or rhinitis is controversial.
What is clear is that these two conditions frequently co-exist. Consider the following
80% of patients with asthma have rhinitis symptoms, while 5-15% of patients with
perennial rhinitis will also have asthma.
Many patients with allergic rhinitis without a history of clinical asthma will nonetheless
show abnormal lung function tests
Approximately 40 to 60% of asthmatic patients will show radiographic evidence of
Whether the relation with recurrent sinusitis is causal or merely an epiphenomenon
of an infectious or immune-mediated disease affecting the entire respiratory tract
is still a matter of debate.
Although the aetiology may be murky, there are several empirical studies that suggest
that treatment of sinusitis or rhinitis may also improve asthma symptoms.
The following characteristics identify those patients in whom sinusitis may
play a role in the pathogenesis of asthma:
- Sinusitis preceding the development of asthma symptoms
Non-atopic patients (which implies that a fundamental change has occurred in the
sinus tissue and airway)
- Aspirin sensitivity
Corticosteroid dependency suggests that the underlying sinus disease may be a trigger
- Patients with asthma who are refractory to appropriate therapy
When a child with asthma becomes symptomatic while taking medication that was formerly
When a patient receives a short-term course of steroid therapy for an acute episode
of asthma and is still symptomatic after several days of treatment
The signs and symptoms of sinusitis
- Persistent nasal obstruction
- Purulent nasal and post nasal drip/discharge
- Hyposmia, anosmia (loss of smell)
- Throat clearing
- Facial pain
- Fatigue / malaise
- Bad breath (fetor oris)
- Persistent cold (> 7 days)
- Mucopurulent nasal discharge
- Facial pain
Diagnostic tests for sinusitis
- Careful history
Examination of the anterior aspect of the nose with an otoscope and the posterior
2/3 of the nose with flexible rhinoscopy
- CT scan of the sinuses (if patient fails to respond to initial treatment)
Skin Prick Tests to exclude Allergic Rhinitis (present
in 50-75% of chronic sinusitis) as possible predisposing cause
Immunologic assessment (to exclude an underlying immune deficiency) only when patient
has recurrent disease or there is bronchitis, IgG and IgA levels. If patient low
in IgG immunize with Pneumovax and obtain pre- and post-immunization IgG titre to
determine if patients are capable of rising new IgG2 antibody levels.
An approach to the treatment of chronic sinusitis
- Hydration (6-8 glasses of water per day)
Antibiotics 21 days or longer (until the patient is well plus 7 days). Choices:
Synermox (Augmentin), Ciproxin
- Topical long acting decongestants, twice daily for 7-14 days
- Nasal douche using saline and applied through an ear bulb syringe
Topical nasal steroids:
- 3 sprays twice daily, for 2 weeks
- 2 sprays twice daily, for 2 weeks
- 1-2 sprays 1-2 times per day until sinusitis resolves
Aim away from the nasal septum and towards the eye to reduce the risk of septal
About 60-80% of patients will improve and have long-lasting remissions.
Allergen immunotherapy can be used in appropriate patients
to try and reduce recurrent disease.
If the patient does not improve or the sinusitis continues to recur after initial
improvement, several options:
- Prophylactic antibiotics
- Oral steroids
- ENT consultation
Surgery for recurrent sinusitis
Surgery is usually reserved for those patients who have failed medical treatment
for 6 months. The surgical procedure (depends on the findings on CT scan) currently
recommended is endoscopic widening of the maxillary and ethmoid ostia. Prior to
surgery and immediately after the procedure, patients use topical steroids and extensive
lavages to reduce post-operative inflammation and reduce the likelihood of recurrence.
Useful link – JCAAI : Sinusitis