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Chronic Rhinosinusitis

Chronic Rhinosinusitis and Sinus Infections

CHRONIC RHINO-SINUSITIS OVERVIEW

  • The sinuses are hollow air pockets in the bones of the face and head that probably exist to cushion the brain during trauma
  • The sinuses are lined with a thin layer of tissue that normally makes a small amount of mucus to keep the sinuses healthy and lubricated and flush away germs.
  • Rhinosinusitis occurs when the lining of the sinuses gets infected or irritated, become swollen, and create extra mucus.
  • The swollen lining may also interfere with drainage of mucus.

 

SINUSES OF THE FACE

  • Chronic rhinosinusitis refers to a condition that lasts at least 12 weeks despite being treated and causes at least TWO of the following symptoms:
  • Nasal congestion
  • Mucus discharge from the nose or mucus that drips down the back of the throat
  • Facial pain, pressure, or “fullness”
  • A decreased sense of smell. Read information about Anosmia or decreased sense of smell.
  • Chronic rhinosinusitis is different from the more common form of rhinosinusitis (called acute rhinosinusitis), which is a temporary infection of the sinuses that often occurs following colds. Chronic rhinosinusitis is a more persistent problem that requires a specific treatment approach.
  • It is sometimes overlooked by both patients and healthcare providers because the symptoms are lower grade and chronic
  • If you have been treated for rhinosinusitis with antibiotics multiple times within a single year, or if you have two or more of the symptoms listed above much of the year, Talk to an ENT DOCTOR IN DUBAI regarding the condition about whether you might have chronic rhinosinusitis.

 

 

CHRONIC RHINO-SINUSITIS CAUSES

Unlike acute rhinosinusitis, which is usually caused by infection, chronic rhinosinusitis often has more complicated and elusive causes. Infections can certainly contribute to or worsen chronic rhinosinusitis, but people with chronic conditions usually have longstanding inflammation that cannot be explained by infection alone

Healthcare providers often divide chronic rhinosinusitis into three different categories, depending upon the features that are present.

  1. Chronic rhinosinusitis without nasal polyposis
  • Chronic rhinosinusitis without nasal polyposis is the most common type of rhinosinusitis.
  • In this form of rhinosinusitis, the swelling and irritation of the sinus lining may be caused by different factors, such as allergies to things in the air, irritation from things in the air, and infections.
  • The factors are different in different people.

 

Development of Sinusitis – the sinuses become swollen due to inflammation, blocking
the passage, and leading to mucus build-up

  1. Chronic rhinosinusitis with nasal polyposis
  • Some people with chronic rhinosinusitis have abnormal soft, jelly-like growths inside their nose or sinuses called nasal polyps.
  • The polyps can become large and numerous enough to clog the sinuses, causing symptoms.
  • Scientists do not fully understand why some people form nasal polyps. Treatment involves medications to shrink the polyps or surgery to remove them. Some people need both.

 

 

Example of Sinuses with nasal polyps

  1. Chronic rhinosinusitis with fungal allergy (“allergic fungal rhinosinusitis”)
  • Some people with chronic rhinosinusitis develop a strong allergic response to fungi (the plural of fungus) inside their sinuses.
  • It is normal for air to contain small amounts of fungi (airborne spores), and most people can breathe in air containing fungal spores without problems.
  • However, in some people, the allergy to fungi causes the sinus lining to make thick, dense mucus that fills the sinuses.
  • To diagnose this type of chronic rhinosinusitis, a healthcare provider must find thick mucus in the sinuses, see fungi in the mucus under the microscope, and show (with allergy testing) that patients are allergic to fungi. (See “Allergic fungal rhinosinusitis”.)

 

CHRONIC RHINO-SINUSITIS RISK FACTORS

Several factors can increase your risk of chronic rhinosinusitis or worsen your symptoms once you have the disorder. These include:

  • Allergies: Allergies are much more common among people with chronic rhinosinusitis than they are among people in the general population. This is especially true of allergies that are present year-round, such as dust mites, animal dander, moulds, and cockroaches. Allergies that are poorly controlled can worsen the symptoms of chronic rhinosinusitis. 
  • Exposure to tobacco smoke or airborne irritants: Exposure to cigarette smoke or certain environmental toxins, such as formaldehyde, can increase the risk of chronic rhinosinusitis.
  • Immune system disorders: Most people with chronic rhinosinusitis have normal immune systems. However, people with certain immune system problems are at increased risk of chronic rhinosinusitis. They may also have recurrent problems with other infections, such as ear and chest infections
  • Viral infections: Some people develop chronic rhinosinusitis after having repeated viral infections (such as the common cold), although it is not clear that the infections actually cause chronic rhinosinusitis.
  • Deviated septum & enlarged turbinates: The piece of cartilage that runs down the midline of the nose and separates the nostrils, called the septum, is not entirely straight in many people. This is a condition called a deviated septum. This may be present from birth or develop later in life as the result of injury to the nose. A deviated septum may cause one nostril to be blocked, but it usually does not cause chronic rhinosinusitis.

 

CHRONIC RHINO-SINUSITIS SYMPTOMS:

  • As noted above, the symptoms of chronic rhinosinusitis must include two or more of the following:
  • Nasal congestion
  • Mucous discharge from the nose or mucus that drips into the back of the throat
  • Facial pain, pressure, or “fullness”
  • A decreased sense of smell (which is especially common among people who have polyps)
  • Many people with chronic rhinosinusitis also experience fatigue, although this symptom is not used to diagnose chronic rhinosinusitis, because there are many other causes of fatigue unrelated to conditions of the sinuses. Still, fatigue is a prominent feature of chronic rhinosinusitis, and it can be the most difficult symptom for some people to manage.

CHRONIC RHINO-SINUSITIS DIAGNOSIS:

  • Chronic rhinosinusitis is likely if a person has had two or more symptoms listed above for a period of at least three months
  • In addition, there should be evidence of sinus disease that can be seen on:
  • Sinus Computed Tomography (CT) scan
  • A sinus CT scan is a procedure that takes about 15 minutes and involves a series of radiographs of the head and face. The radiographs give a detailed picture of the linings of the sinuses and any mucus or polyps within the space of the sinuses.
  • or with a procedure called sinus endoscopy
  • Sinus endoscopy is an office procedure in which a clinician uses a thin tube attached to a camera to see inside the sinuses (figure 4).
  • Endoscopy also allows the clinician to take a sample of mucus from inside the sinuses to examine under the microscope, and identify bacteria, fungi, and other contributing factors.
  • Samples of mucus from the front of the nasal cavity (which are easier to obtain) are not representative of what is found in the sinuses.

 

CONDITIONS RELATED TO CHRONIC RHINO-SINUSITIS:

  • The linings of the nose and sinuses are similar to the linings of the lungs.
  • Asthma: About one in five people with chronic rhinosinusitis also has asthma. The people most likely to have asthma are those who have chronic rhinosinusitis and nasal polyps.
  • Aspirin Exacerbated Respiratory Disease (AERD): Some patients with chronic rhinosinusitis, nasal polyps, and asthma also have a condition called aspirin intolerance, or Aspirin Exacerbated Respiratory Disease (AERD). Previously commonly referred to as Samter’s Triad. The symptoms of aspirin intolerance consist of a noticeable worsening in nasal or chest symptoms in the first few hours after taking aspirin, ibuprofen, naproxen sodium, or other nonsteroidal anti-inflammatory drugs (NSAIDs). Worsening of symptoms may involve sudden nasal congestion, pain and pressure in the sinuses, wheezing, chest tightness, and cough. These reactions can be severe and even life threatening. In contrast, Paracetamol usually does not aggravate sinus and asthma symptoms. If you think you may have aspirin intolerance, you should avoid aspirin and other similar medications and talk to an ENT DOCTOR IN DUBAI regarding the condition.
      

CHRONIC RHINO-SINUSITIS TREATMENT

  • Potential treatments for chronic rhinosinusitis include:
  • Lifestyle modifications
     
    1. Smoking Cessation: People with chronic rhinosinusitis who smoke cigarettes should stop. 
    2. Environmental Allergies: People who have environmental allergies as a contributing factor to their sinus problems may be able to change things in their home or work conditions to reduce exposure to the specific allergens that bother them.
    3. Daily nasal saline washing: Most people with chronic rhinosinusitis find that washing their nasal passages daily with saline (salt water) helps reduce symptoms. Washing the nose before applying medications also clears away mucus and reduces its interference with medications.
    4. Glucocorticoid nasal sprays, washes, and drops: Because all forms of chronic rhinosinusitis involve some degree of inflammation i.e. irritation and swelling), most people with the condition need medications to reduce inflammation. Glucocorticoids (commonly called “steroids”) are very effective anti-inflammatory drugs. They also decrease mucus production and help shrink any polyps that may be present. Using glucocorticoids in form of nasal sprays or drops has the advantage of putting the medicine right where it is needed, and also of not treating the rest of the body, where the drug is not needed.
    5. Glucocorticoid Nasal Sprays: Your healthcare provider will probably ask you to try a glucocorticoid spray initially, as sprays are easy to use. Sprays however do not reach deep into the cavities of the sinuses, but they reduce swelling in the nasal passages and open up the areas through which the sinuses drain.
    6. Nasal drops or washes: Helps to get the glucocorticoid solution higher up into the sinuses. If drops are prescribed, you must put them into the nose while lying in specific positions. This allows the liquid to move into the different sinuses (See MEG Information pamphlet on Nasal Sprays).
    7. Antibiotics: Although chronic rhinosinusitis is often caused by inflammation rather than infection, infection of the sinuses can develop and aggravate symptoms. As a result, some people need to take antibiotics. It is not unusual to need long courses of antibiotics, lasting several weeks, to fully treat a sinus infection in a person with chronic rhinosinusitis.
    8. Leukotriene modifiers: Healthcare providers occasionally prescribe a group of medications called leukotriene modifiers to people with chronic rhinosinusitis. These treatments work by reducing inflammation in a different way than glucocorticoids. These medications are not used for all types of chronic rhinosinusitis, and they appear to be most helpful for people with chronic rhinosinusitis with nasal polyposis who also have asthma +/- allergic rhinitis


  • Biologics for Nasal Polyposis
  • “Biologics” are synthetically prepared “monoclonal” antibodies designed to block a key element in the body’s immune system that contributes to inflammation.
  • In Chronic Rhinosinusitis, these ‘blocking’ antibodies usually target a very focal part of the inflammatory pathway that is responsible for the changes in chronic rhinosinusitis and associated conditions such as asthma.
  • These medications reduce the size of nasal polyps and improve the symptoms of chronic rhinosinusitis, when used in conjunction with a nasal steroid spray.
  • The represent a significant advance in the treatment of nasal polyps, especially for patients who have had recurrence of nasal polyps despite sinus surgery.
  • In Australia, most of these drugs currently require a co-diagnosis of significant asthma or eczema is required as a pre-requisite for patients to ‘qualify’ for the injection.
  • There are numerous other biologics, currently in trial, that may become available in the years to come