Chronic rhinosinusitis

For many, however, the symptoms last for weeks or months, or even years. These people suffer from chronic rhinosinusitis, infection or inflammation of the sinuses. They may take over-the-counter medications for relief, and antibiotics to fight the infection, but again and again the symptoms return, resulting in substantial morbidity and time off work. Rhinosinusitis is one of the commonest reasons why a general practitioner prescribes antibiotics.

After three months, says Dr Eric Holbrook, assistant professor at Harvard Medical School and a sinus expert in the Department of Otolaryngology at Massachusetts Eye and Ear Infirmary, “we tend to think of it more as an inflammatory problem.”

Many physicians assume recurring sinus problems are caused by an infection and automatically prescribe antibiotics, says Holbrook. But many of these prescriptions are unnecessary and potentially harmful. More often than not, the recurring symptoms are caused by a structural problem or an over-responsive immune system, which may make the patient more susceptible to infection but which require a different treatment.

Undeniably, sinus membranes can become inflamed by bacterial infection. But there are alternative causes of inflammation such as allergies, bacterial super antigens, or even fungus. There may be a deviated septum. Or a patient may have scar tissue, nasal tumors, or polyps causing obstruction. Any of these conditions, or a combination of them, can permanently block sinuses and their drainage openings, causing a buildup that does not resolve. These myriad causes for the symptoms lead Holbrook to call chronic rhinosinusitis a “spectrum” rather than a single entity. While there’s no cure for the condition, he adds. “It is our job to provide patients the most relief we can.”

Defining rhinosinusitis

Rhinosinusitis is a long-term inflammation or infection of at least one of the four paranasal sinuses (frontal, maxillary, ethmoid or sphenoid) characterised by two or more of the following symptoms; blockage or congestion; discharge (anterior or postnasal drip); facial pain or pressure; reduction or loss of smell lasting less than 12 weeks. Chronic rhinosinusitis is defined by nasal congestion or blockage lasting more than 12 weeks and accompanied by one of the following sets of symptoms; facial pain or pressure, discoloured nasal discharge or postnasal drip, and/or reduction or loss of smell.

In adults, chronic rhinosinusitis most often is linked to blockage of the sinus ostium, typically the maxillary sinus ostium located under the middle turbinate. The obstruction, and accompanying mucus retention and infection, causes the signs and symptoms characteristic of rhinosinusitis. The rising prevalence of rhinosinusitis may be reflective of the rise in allergies, particularly allergies to inhaled dust, mould, pollen, or the spores of fungi. The allergies trigger the release of histamine and other chemicals that cause the inner lining of the nose to swell and block sinus drainage.

There’s a lot of overlap between rhinosinusitis and asthma, says Holbrook. Studies show that as many as 75% of people with asthma also get sinusitis, and some state that up to 80% of adults with chronic sinusitis also have allergic rhinitis. Studies have suggested that allergic inflammation affects the entire respiratory tract, supporting the higher incidence of comorbid allergic rhinitis in asthmatics. Both diseases can be caused by an immune system response, notes Holbrook, so treating one often helps relieve symptoms of the other.

Diagnosis

One of the most common symptoms of chronic rhinosinusitis is painful pressure in the upper parts of the face, especially the forehead behind the nose, between or behind the eyes, or in the cheek. Sinus pain may be accompanied by toothache in the upper teeth, pain on stooping and fever. Additional symptoms include nasal congestion, hyposmia, rhinorrhoea, halitosis and, on occasion, ear symptoms. “Usually on physical exam you should be able to document thickened or discolored drainage by looking in the nose,” says Holbrook.

If diagnosis is not clear, additional investigations may help. X-ray examination of the sinuses, ultrasonography, computed tomography, sinus puncture and culture of aspirate can give a

better definition of the clinical picture. However, few of these methods are universally available in primary care.

Pharmacologic treatment

It is becoming increasingly recognised that there are two types of chronic rhinosinusitis: those with nasal polyps, and those without. If a patient has nasal polyps or other structural blockages, topical steroids are usually effective. However, if the polyp disease is very aggressive, and topical steroids don’t provide enough benefit, an otolaryngologist can determine whether the patient requires surgery. Traditional open sinus procedures have been replaced with endoscopic surgery to widen the openings and restore sinus ventilation and drainage. Endoscopic sinus surgery is now the mainstay of surgical treatment for chronic rhinosinusitis, and should be reserved for refractory or complicated cases.

If a patient does not have polyps, the condition could be caused by an overactive immune system. In these patients, the chronic rhinosinusitis is caused by inflammation – in the same way asthma and allergies are. Therefore, leukatrine inhibitors, which interfere with the inflammation cascade, can often help.

Antihistamines too may provide relief, and corticosteroids, either taken orally or topically in nasal sprays, can relieve nasal swelling and sinus inflammation. Caution should be taken when prescribing oral steroids to at-risk groups, such as patients with diabetes.

Many of the recommendations for treating chronic rhinosinusitis also include long, sustained (4- to 6-week) treatment with antibiotics. “There are theories about whether or not you get enough medication into the sinuses with routine one- or two-week courses,” says Holbrook, pointing to one avenue of research investigating the role of biofilms. Biofilms are a collection of bacteria surrounded by the slime they secrete, attached to the surface. The theory is that certain patients with rhinosinusitis have a chronic infection because the bacteria are able to form colonies that build a protective layer, which the microorganisms hide in while a patient is taking antibiotics. When the patient stops taking the medication, the bacteria leave hiding and once again invade. “So the antibiotics are not eradicating it. They just keep it calm for awhile,” said Holbrook.

For penicillin-resistant sinusitis, second-line antibiotics such as amoxicillin/clavuanic acid, clarithromycin, and levafloxacin are required. A comprehensive list of first- and second-line treatments can be found in the guidelines published in the December 2004 supplement to the Archives of Otolaryngology – Head and Neck Surgery.

If a patient’s allergies are difficult to treat and manage, a referral to an allergy specialist might be appropriate, to test for specific allergies and potentially administer immunotherapy.

Because of the complicated nature of chronic rhinosinusitis, it is appropriate for most patients to be referred to a specialist, Holbrook says. Failure to respond to a three month period of initial medical treatment should certainly prompt referral to a ear, nose and throat specialist.

Non-pharmacologic treatment

Saline irrigation is an ancient therapy that works well for people with chronic rhinosinusitis. Holbrook recommends a product called Sinus Rinse, from a US-based company called NeilMed. In addition, he says doctors should caution patients against long-term use of topical nasal decongestants (neosynephrine sprays), which can cause a “rebound effect” that is hard to treat. Other at-home remedies include inhaling steam from a vaporizer or a hot cup of water to soothe inflamed sinus cavities and heat applied over the inflamed area for comfort.

Prevention

Patients with allergies can help prevent episodes of rhinosinusitis by identifying and avoiding triggers and taking measures at home to remove indoor airborne allergens, including:

• Keep windows closed.

• Use a HEPA filter (high-efficiency particulate air filter) on the air conditioner.

• Drive with the external vents closed and air conditioning on.

• Take a shower or wash hair before going to bed at night to remove pollutants or airborne allergens that accumulated during the day.

• Dry clothes inside, either in a dryer or on a line.

• Inhale steam and rinse the nose with a saline solution regularly.

• Drinking enough fluids.

In summary, sinus symptoms recurrent or persisting beyond three months signify a chronic condition that requires a more detailed work-up and evaluation. An otolaryngologist can assist in making recommendations for medications and evaluate the patient for surgical intervention.