The first thing to note is that there is a poor correlation between symptoms and severity of the disease. Typical symptoms of chronic sinusitis include:

• Anorexia 
• Chronic unproductive cough common in children
• Dental pain often localized to the upper teeth
• Fatigue
• Exacerbation of asthma 
• Facial fullness, discomfort, pain, and headache (more with nasal polyposis) 
• Halitosis 
• Fever of unknown origin 
• Hyposmia or anosmia (more common with nasal polyposis) 
• Malaise 
• Nasal obstruction, blockage, congestion, stuffiness which may lead to mouth breathing
• Nasal discharge which may be watery of viscous. 
• Postnasal drip 
• Sneezing 
• Sore throat 
• Stuffy or blocked ears 
• Unpleasant taste 
• Visual disturbances including eye swelling

Obtain the following in the history:

• Duration of symptoms 
• Environmental living conditions and exposure to pollutants
• Factors which exacerbate the illness
• Factors that relive the symptoms
• Current use of medications, herbs and supplements
• Other medical problems (eg allergy, asthma, immunosuppression)
• Prior nasal and sinus surgery
• Prior treatments for sinusitis
• Results of previous imaging test
• Smoking

Physical examination

The physical exam is best performed with the use of a topical nasal decongestant like oxymetazoline as this can help with visualization. The exam must be done in a systemic manner and one needs to assess the turbinates, nasal septum, and middle meatus. Rhinoscopy should be conducted with and without a topical decongestant. During the exam one needs to identify the following?

• Abnormal features of nasal mucosa, like color or condition
• Any nasal mass or irregular surface
• Assess integrity of hard plate
• Bleeding, ulceration or diffuse areas of hemorrhage
• Dry crusts or nasal septum perforation should lead one to suspect Wegener granulomatosis
• Excessive secretion or dryness of nasal mucosa
• Hypertrophy of turbinates
• Look at condition of dentition and dental caries
• Look for evidence of purulent secretions and post nasal drip
• Palpation of the sinus for tenderness or swelling
• Presence of any anatomical obstruction, septal deviation
• Vascular malformations

Other organs systems to examine include the ears for otitis media or middle ear fluid collection and the eyes for cojunctival congestion, lacrimation, proptosis and visual acuity.

Criteria to make a diagnosis of chronic sinusitis include symptoms present for 12 weeks or longer, 2 or more symptoms and CT scan showing bony changes, diffuse mucosal thickening or air fluid levels. It is important to be aware that using CT scan signs of inflammation can be seen in more than 2/5th of patients with chronic sinusitis in the absence of symptoms. Thus, making a diagnosis of chronic sinusitis on a CT scan alone is not sufficient. The imaging test must be supported with presence of clinical symptoms. CT scan is usually done in patients who fail to respond to therapy to ensure that there is no other pathology. Both plain X-rays and MRI are not recommended in routine cases because they lack specificity. Routine blood work is usually not helpful. Routine culture is not recommended. Culture may be done during endoscopy in individuals with complications like orbital infection or intracranial extension. Biopsy, allergy testing, immunoglobulin levels and sweat test to rule out cystic fibrosis may aid in diagnosis.

The aim of treatment for chronic sinusitis is to enhance drainage, decrease mucosal edema and eradicate the bacteria that are present. When the diagnosis of chronic sinusitis is made, the first step in the management is to identify the contributing factors. Allergy is frequently associated with chronic sinusitis and it may also need treatment. Experts recommend that testing for allergy may identify a subset of patients whose symptoms may respond to allergy treatment. If the patient has failed successive treatments, check the immune system for defects.

There is no cure for chronic sinusitis and hence the goal is to decrease the symptoms and minimize the complications by controlling the infectious component of the disorder [7] [8] [9] [10]. In general the treatment of chronic sinusitis is use of intranasal corticosteroids. Antibiotics may be required if there are signs of an infection. In most patients with chronic sinusitis without the presence of nasal polyps, there is an underlying infection and hence the treatment is intranasal corticosteroids combined with an antibiotic. The initial therapy is with a broad spectrum antibiotic that will target Staphylococcus aureus, gram negative organisms and anaerobes. Rarely one may need antibiotics to cover for Haemophilus influenza, Streptococcus pneumoniae and Moraxella catarrhalis.

Treatment of chronic sinusitis depends on duration and severity of symptoms plus any objective features of inflamed paranasal sinuses or the nasal mucosa. Presence of nasal polyps leads to slightly different treatment. Chronic rhinosinusitis with nasal polyps is treated with intranasal corticosteroids. Antibiotics are recommended when symptoms indicate infection (pain or purulence).

Control risk & trigger factors

• Treat upper respiratory tract infections and gastroesophageal reflux disease  
• Avoid exposure to tobacco smoke and environmental pollutants
• Allergic patients should be treated with antihistamines, cromolyn or immunotherapy
• Get control of asthma with prophylactic leukotriene inhibitors
• Symptoms may be relieved with topical decongestants, topical steroids, antibiotics, nasal saline, topical cromolyn, or mucolytics.
• Steam inhalation and nasal saline irrigation may help by moistening dry secretions, reducing mucosal edema, and reducing mucous viscosity. Patients who have facial pain, and documented purulence should be suspected of having a concomitant bacterial infection and antibiotics should be considered.

Steroids

Most trials have shown a benefit from use of steroids in chronic sinusitis. In patients with severe sinusitis with polyps which has failed to respond to intranasal steroid, a 2 week course of oral prednisone may help improve symptoms. Steroids have also been used before and after endoscopic sinus surgery with effectiveness. When starting steroids, the minimal dose of the drug must be started and the patient must be told of all the potential adverse effects.

Adjunct therapies

• Saline irrigation
• Mucolytics
• Antihistamines
• Nasal decongestant

No solid evidence that any of the above therapies work. In addition, prolonged use of nasal decongestants can lead to development of rhinitis medicmentosa.

Antimicrobial therapy

• At least 4-6 weeks of antibiotic treatment is required. Antibiotics selected should have broad spectrum coverage until culture results are available. Antibiotic therapy is continued until patient is asymptomatic, otherwise a relapse can occur. In refractory cases or in people with poor IV access, nebulized antibiotics can be administered.
• Typical antibiotics used include amoxicillin plus clavulanate, macrolide plus metronidazole, 3rd generation cephalosporin or a quinolone. MRSA coverage is essential.
• Experts recommend tailoring therapy to the clinical presentation. Patients with chronic sinusitis without nasal polyps are usually treated with a short course of prednisone and intranasal steroid.
• Patients with chronic sinusitis and nasal polyps need relief from the obstruction and improved sinus drainage. This is achieved with use of systemic steroids and sometimes surgery.

If patient fails to respond, consider other disorders like:

• Invasive fungal rhinosinusitis
• Vasomotor rhinitis
• Migraine
• Atypicla facial pain
• Trigeminal neuralgia
• TMJ syndrome

Surgical care

• Surgery is never the first choice treatment for chronic sinusitis. It is reserved for cases that have failed to respond to medical therapy and in patients with obstruction. The aim of surgery is allow for ventilation of the sinuses and correct mucosal opposition so that mucociliary clearance can be reestablished. Surgery can help remove thick and viscid secretions, and polys.
• Fungal sinusitis (with fungal balls) is resistant to medical care and usually requires surgical debridement. Role of antifungal agents in chronic sinusitis is not clear. Allergic fungal sinusitis that presents with nasal polys is treated with systemic steroids followed by surgical removal of the polyps.

Consultations

All recurrent cases of chronic sinusitis should be referred to an otolaryngologist. In addition, any ocular involvement requires consultation with an ophthalmologist. If there is poor dental hygiene or dental caries, a consultation with a dentist is recommended.

Chronic sinusitis is associated with high morbidity because of its chronicity. Despite treatment, relapses are common. The patients usually have a poor quality of life. The disorder can exacerbate asthma and if left untreated can lead to osteomyelitis, meningitis, brain abscess and ocular complications. Even though medical and surgical treatment is available, the outcomes are not always predictable or consistent. Some patients do obtain relief from symptoms, but the treatment if often for prolonged time periods.

Complications

• In children chronic sinusitis may result in the adenoiditis, purulent otitis media, laryngitis and dacryocystitis
• Orbital cellulitis
• Subperiosteal abscess
• Orbital abscess
• Cavernous sinus thrombosis
• Epidural abscess
• Meningitis
• Brain abscess
• Subdural abscess
• Sinus wall may develop osteomyelitis and mucocele formation

Finally the cost of medical care for chronic sinusitis is prohibitively expensive. Absenteeism from work is frequent leading to low productivity.

The causes of chronic sinusitis include the following:

• Dental disorders
• Immunodeficiency states
• Nasal obstruction
• Polyps
• Allergies

Common types of bacteria involved include:

• Staphylococcus aureus including MRSA
• Haemophilus influenza
• Streptococcus pneumoniae
• Streptococcus intermedius
• Pseudomonas aeruginosa
• Anaerobes

The exact role of these bacteria in chronic sinusitis is not known. Even with proper techniques of isolation, bacteria are isolated in only about 50% of patients with chronic sinusitis. The only thing certain is that bacteria can exacerbate the symptoms. Fungal agents involved include Aspergillus, Cryptococcus and Candida.

Risk factors

• Anatomical defects in the sinuses and nasal cavity
• Allergic rhinitis
• Asthma
• Nasal polyps
• Prior nasal or orotracheal intubation
• Presence of a nasal mass
• Immune defects like AIDS, deficiency of IgA [4]
• Non-allergic rhinitis
• Cystic fibrosis
• Wegener granulomatosis
• Smoking
• Environmental pollutants
• Gastroesophageal reflux disease (GERD)
• Dental disease

Chronic sinusitis is a common global medical disorder. In the US alone it is estimated that nearly one out of every seven individuals are affected. The disorder occurs in both genders and requires multiple visits to the emergency room and outpatient clinics. The chronicity of symptoms adds to a significant financial burden to the individual and the healthcare system.

In most cases, chronic sinusitis is seen in late adulthood and is now being reported in countries with high pollution like China. Damp and wet climates and places associated with higher pollen concentration also have a high prevalence. In children chronic sinusitis is more common and most likely related to prior upper respiratory tract infections [5] [6].

The pathophysiology of chronic sinusitis is not well understood. It is widely believed that presence of a bacterial infection or bacterial biofilms contribute to chronic or persistent sinus disease. The problem is exacerbated in the presence of antibiotic resistant strains of bacteria. However, the contribution of bacteria, fungi, other immunological deficits, susceptibility factors and role of environment remains unknown. It is now accepted that there is a spectrum of chronic sinusitis with various subtypes which present different pathological mechanism.

Chronic sinusitis is difficult to prevent because the actual cause is not known. However, once diagnosed patients should avoid triggers like allergens, environmental pollutants, discontinue smoking and stress. The individual should follow up with a healthcare provide to ensure that the asthma is well controlled. The earlier the symptoms are controlled, the better is the quality of life.

Chronic sinusitis is a very common medical disorder not only in the US, but globally. This inflammatory disorder affects the paranasal sinuses and is usually accompanied by varying degrees of nasal inflammation. When the condition lasts more than 12 weeks, it is considered chronic. Chronic sinusitis is classified as:

• Chronic sinusitis without presence of nasal polyps 
• Chronic sinusitis with nasal polyps 
• Allergic fungal rhinosinusitis

In the majority of cases, chronic sinusitis evolves from an acute sinusitis, but the symptoms are much intense in chronic sinusitis. Even though bacterial involvement can occur in chronic sinusitis, there are medical disorders which can present with chronic sinusitis in the absence of bacteria. These include cystic fibrosis, allergies, gastroesophageal reflux disease (GERD) or exposure to environmental agents. Fungal sinusitis can present in the same way as bacterial sinusitis but most patients tend to be diabetic, immunosuppressed or are on a prolonged course of corticosteroids. Allergic fungal sinusitis may present with nasal polyps. Chronic sinusitis is a disorder difficult to treat. Even with current day treatment, relapses are common the quality of life is poor [1] [2] [3].

Chronic sinusitis is a disorder of the nasal passages and the sinuses. It is a condition whose exact cause is unknown and it can present with a variety of symptoms that include a runny node, facial pain, fever, blocked nose, polyps, cough, and loss of weight. The diagnosis is made from a physical exam and use of a CT scan. Some people may need a endoscopy for biopsy. The treatment involves use of intranasal steroids and antibiotics. People who fail to respond need endoscopic surgery. The results of treatment are not always consistent and not everyone benefits. If left untreated, chronic sinusitis can extend to the eyes, brain and other facial areas.

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