Chronic

• Chronic rhinosinusitis = inflammation of nasal cavities and paranasal sinuses lasting >12 weeks

  • Is not simply as chronic infection lasting over 12 weeks
  • Due to chronic inflammation that is often due to multiple contributing factors
  • Inflammatory factors - allergy, irritants
  • Structural factors - deviated septum
• Demographics:

  • Can occur in adults and children
  • But most common in 4th decade of life
  • More common in women
• Predisposing conditions/risk factors:

  • Allergic rhinitis
  • Allergic fungal rhinosinusitis - thick mucus in sinuses, fungi in mucus, allergy testing will confirm diagnosis
  • Environmental irritants - smoking
  • Chronic pulmonary conditions - asthma and COPD
  • Systemic disease affecting mucosa/mucociliary clearance - CF, primary ciliary dyskinesia, Churg Strauss disease
  • Immunodeficiency and recurrent URTIs
  • Irritation from local pathology - tumour, dental infection
  • Abnormal anatomy
• Classification:

  • New classification - primary and secondary - further classified by anatomic distribution, endotype dominance and clinical phenotypes
  • Sometimes chronic inflammation can result in nasal polyps but not always - not clear why some people get polyps and others don't
• Presentation:

  • 4 cardinal features =
  • Nasal congestion
  • Nasal discharge - typically mucopurulent and white/light yellow - anteriorly through nostril or posteriorly through nasopharynx
  • Facial pain or pressure - vague pain across zygomatic arches
  • Anosmia - more common if nasal polyps
  • Other features: polyps, fatigue, malaise, poor sleep, halitosis, dental pain, dysphonia
• Uncomplicated vs complicated (extension beyond nasal cavity) and red flags are the same as for acute rhinosinusitis
• Variable presentation:

  • Patients can present in early stages and it will only become apparent that it is chronic not acute when it does not clear in 12 weeks
  • Might present having had symptoms for a few weeks but not clearing
  • May present with a more insidious slow progressive illness with symptoms worsening over months/years
  • Can have acute exacerbation - infection on top of chronic inflammation - sudden worsening of symptoms
• Chronic rhinosinusitis can significant impact QOL:

  • Poor sleep
  • Depression
  • Reduced social functioning
  • Impact on employment
  • Address these issues as part of history and management
• Overall treatment aims = reduce symptom burden and improve QOL by:

  •Improving mucosal inflammation

  •Improving and maintaining adequate sinus drainage
• General advice:

  • Avoid smoking
  • Use OTC intranasal saline as an irrigation device
  • Control any coexistent conditions that can worsen symptoms
• Medical management:

  • Intranasal corticosteroids to decrease inflammation for up to 3 months - budesonide, fluticasone, mometasone
  • Refractory or more complex cases often need ENT referral:
  • Leukotriene receptor antagonists - add on therapy with steroids, especially if history of allergy or nasal polyps
  • Advanced options - biologic agents, oral steroids
  • Antibiotics have limited role except in acute bacterial exacerbations - co-amoxiclav for 5-7 days
• Diagnosis:

  To diagnose chronic rhinosinusitis you need:

  1. Clinical features lasting >12 weeks: (≥2) Nasal congestion, nasal discharge, facial pain or pressure, absent or reduced smell, AND

  2. Objective evidence of mucosal inflammation: (≥1): Mucopurulent mucus, oedema or polyps in the nasal cavity on examination; sinonasal inflammation on nasal endoscopy or CT

  •Once diagnosis made can then investigate for the specific cause e.g. sinus surgery to get samples to look for signs of fungal rhinosinusitis etc
• Surgical options:

  • Those who fail to respond to medical therapy may require functional endoscopic sinus surgery (FESS) - restore the ventilation and drainage of the paranasal sinuses
  • Does not target underlying cause so if used in conjunction with medical therapy
• Admit patients to hospital if they have:

  • Severe systemic infection and/or signs of sepsis
  • Intraorbital/periorbital complications
  • Intracranial complications
• Urgent outpatient referral if:

  • Concerned sinusitis is due to cancer causing blockage
  • Persistent unilateral symptoms:
  • Obstruction (including polyps)
  • Discharge
  • Nosebleeds
  • Crusting
  • Facial swelling
• Cases that need referral (urgency depending on judgement):

  • No improvement after 3 months of treatment
  • Significantly impacting quality of lives
  • Doubt about diagnosis
  • Immunocompromised
  • Underlying cause that needs specialist input - allergic or immunological, anatomical defect, unusual or resistant bacteria
  • Comorbidity complicating management e.g. polyps or asthma