Diagnosis

Chronic sinusitis

Etiology

Cause

• Viral sinusitis lasts up to 10 days and that completely resolves in 99% of cases

• Some patients may develop a secondary acute bacterial/fungal infection caused by:

  • Staphylococcus aureus

  • Coagulase-negative staphylococci

  • Haemphillus  influenzae

  • Moraxella catarrhalis

  • Streptococcus pneumoniae

  • Streptococcus intermedius

  • Pseudomonas aeruginosa

  • Nocardia species

  • Anaerobic bacteria ( Peptostreptococcus, Prevotella, Porphyromonas, Bacteroides, Fusobacterium species

  • Microaerophilic streptococci

  • Aspergillus species

  • Cryptococcus neoformans

  • Candida species

  • Sporothrix schenckii

  • Alternaria species

Pathophysiology

1. Inflammation (bacteria, virus, allergy)

2. Mucosal edema --> mechanical obstruction in the ethmoid, sphenoid, frontal, and/or maxillary sinus cavities

3. Mucous stagnation inside the sinuses --> rich medium for microbe growth

4. Unresolved acute sinusitis --> Chronic sinusitis

Classification [azw]

1. Chronic sinusitis without nasal polyps

2. Chronic sinusitis with nasal polyps

3. Allergic fungal rhinosinusitis

Epidemiology

Prevalence per 100.000 [msf][ips]

Incidence per 100.000 [msf][ips]

Approach

• Anterior rhinoscopy

• Nasal endoscopy

• Middle meatus culture

• Maxillary sinus aspiration

• CT caput

Diagnostic criteria: >12 week with 2 major or 1 major + 2 minor or nasal purulence [msf]

1. Major factors:

   • Fascial pain/pressure

   • Fascial congestion/fullness

   • Nasal obstruction/blockage

   • Nasal discharge

   • Hyposmia/anosmia

   • Purulence in the nasal cavity

2. Minor factors:

   • Headach

   • Fever

   • Hallitosis

   • Fatigue

   • Dental pain

   • Cough

   • Ear pain/pressure/fullness

Treatment

1. Medical treatment --> controlling predisposing factors, treating concomitant infections, reducing edema of sinus tissues, and facilitating the drainage of sinus secretions: [xeu]

   • Steam inhalation

   • Nasal saline irrigation

   • Topical or oral glucocorticoids (if allergy)

   • Antibiotics (if bacteria)

2. If the above measures fail --> Surgical treatment: re-establish sinus ventilation and to correct anatomical obstruction causing mucosal clearance:

   • Functional Endoscopic Sinus Surgery (FESS)

   • Balloon sinuplasty

   • Caldwell-Luc procedure

   • Inferior antrostomy (naso-antral window)

   • Nasal polyps and fungal sinusitis: surgical removal

3. Hospital admission:

   • Orbital and intracranial complications

   • Immunosuppressed patients

   • Pediatric patients

Differential diagnoses

Acute invasive fungal sinusitis, Acute laryngitis, Acute sinusitis, Allergic rhinosinusitis, Asthma, Bacterial tonsillitis, Brain abscess, Cancer, Cerebral venous sinus thrombosis, Meningitis, Nasal polyps, Osteomyelitis, Sarcoidosis, Subdural empyema, Wegener's granulomatosis