Chronic or Frequently Recurring Sinusitis
For acute maxillary sinusitis, see Acute Maxillary Sinusitis
Essentials
- Chronic sinusitis is divided into two types: inflammation with and without nasal polyps.
- The diagnosis, conservative treatment and examination of any underlying factors can be done in an outpatient setting.
- An ENT specialist should be consulted if inflammatory symptoms are prolonged despite treatment or if the patient has had at least 3 separate episodes of sinusitis within one year.
- Asthma tests should be performed for patients with lower respiratory tract symptoms, as necessary.
Definition and aetiology
- There are maxillary, frontal, sphenoidal and ethmoidal sinuses.
- Sinusitis means inflammation of one or more of these. The most common form of sinusitis is maxillary sinusitis.
- Sinusitis is defined as chronic if the symptoms continue for more than 12 weeks.
- If acute purulent sinusitis recurs at least 3-4 times a year, it is called frequently recurring sinusitis.
- There are several causes for sinusitis becoming chronic, such as:
- anatomy obstructing the middle nasal meatus
- nasal polyposis
- allergic rhinitis
- smoking
- dental infection
- tumour or foreign body
- fungal infection.
Symptoms and diagnosis
- The diagnosis of chronic or frequently recurring sinusitis is based on history, clinical examination, imaging and microbial culture of purulent discharge.
- The most common symptoms suggesting chronic sinusitis are persistence of the following for more than 12 weeks:
- oedema of the nasal mucosa and blocked or stuffy nose
- increased nasal discharge or postnasal drip
- facial pain or feeling of pressure
- impaired sense of smell.
- On clinical examination, the following findings may be made:
- erythematous nasal mucosa with profuse secretion and oedema
- dry, crusty mucosa that bleed easily
- secretions in the middle nasal meatuses
- congested nasal breathing
- polyps, which are nearly always bilateral.
- In the case of a polyp or polyps on one side, only, consult an ENT specialist to exclude tumours.
- Acute exacerbations of infections may also occur.
- Retention of secretions in the sinus may be detected by sinus x-ray or ultrasound examination.
- In the case of prolonged sinus symptoms maxillary puncture may provide additional information.
- Bacterial culture is recommended because microbes inconsistent with the microbial aetiology of acute maxillary sinusitis, such as Pseudomonas or Staph. aureus, may be present.
- Irrigation may produce only mucous secretions, in which case bacterial culture will be negative.
- Examinations performed in specialized health care additionally include nasal endoscopy and often CT of the sinuses.
Treatment in primary health care
- Treatment depends on the severity of symptoms.
- Glucocorticoid drops or sprays
- Fluticasone drops are recommended, particularly in the beginning of treatment.
- In long-term use, most patients benefit from a glucocorticoid leading to alleviation of nasal congestion, reduction of secretions and improvement of impaired sense of smell Topical Steroids for Chronic Rhinosinusitis.
- Regular use is usually indicated in patients with polyposis and often also after maxillary sinus surgery.
- Glucocorticoids may cause excessive drying of the nasal mucosa. If so, a nasal irrigator or moistening nasal sprays should be added to the regimen and/or the dose of glucocorticoid should be reduced.
- Moistening of the nasal mucosa
- Saline- or oil-based moistening sprays alleviate the symptoms of chronic sinusitis and prevent the glucocorticoid spray from drying the mucosa excessively.
- Moistening sprays should be used several times a day in courses of 2-3 weeks or for a longer period, as necessary.
- Several products are available for moistening: sprays, drops and nasal irrigators Saline Irrigation for Chronic Rhinosinusitis.
- Nasal sprays are most suitable for repeated daily moistening.
- Nasal irrigators are most suitable for situations where removing nasal secretions or crusts requires larger volumes of irrigation fluid.
- If in a patient with polyps topical treatment for about 2 months does not alleviate the symptoms sufficiently, a course of oral glucocorticoid treatment of about 2 weeks can be considered in addition to the topical treatment.
- Such a course can be repeated no more than 3-4 times a year. Keep in mind potential adverse effects of the treatment Pharmacological Glucocorticoid Treatment.
- A course of glucocorticoid treatment may be considered in the beginning of treatment, already, if there are numerous polyps bilaterally.
- Antimicrobial treatmentSystemic Antibiotics for Chronic Rhinosinusitis
- Targeted use based on bacterial culture and sensitivity testing, if moistening of the nasal mucosa and topical glucocorticoid treatment do not alleviate the symptoms sufficiently.
- Antihistamines should be used for patients with allergic rhinitis.
- Predisposing factors (such as smoking or allergies) should be investigated and treated as far as possible.
Indications for referral to specialized care
- Insufficient efficacy of medication
- Suspected fungal infection, tumour or foreign body
- If maxillary sinusitis of dental origin is suspected (usually foul-smelling pus on one side), the patient should be referred to a dentist.
Surgical treatment
- Surgical treatment is considered for the treatment of chronic or frequently occurring maxillary sinusitis.
- The decision to operate is based on patient history as well as diagnostic nasoscopy and CT imaging of the sinuses.
- The abbreviation (F)ESS often seen in referral feedback stands for ”functional endoscopic sinus surgery”. This means sinus procedures performed through the nostril, using a nasoscope, such as:
- infundibulotomy, or uncinectomy (opening of the natural maxillary sinus orifice in the middle nasal meatus)
- endoscopic middle meatal antrostomy (as before, but the natural orifice is widened to form a larger opening, ‘antrostomy')
- ethmoidectomy (opening of the ethmoid sinuses)
- polypectomy (excision of polyps).
- Instead of traditional endoscopic surgery, balloon dilatation of the sinuses can also be performed, particularly to widen the frontonasal duct.
Treatment of maxillary sinusitis in patients who have undergone maxillary surgery
- In endoscopic maxillary surgery (see above), an opening is formed from the middle nasal meatus into the maxillary sinus. If this has been done, maxillary lavage can, after local anaesthesia of the antrostomy in the middle meatus, be carried out using a blunt irrigation needle.
- If balloon dilatation of the sinus has been performed, irrigation through the middle meatus is not possible.
- If irrigation cannot be performed through the opening in the middle meatus, the maxillary sinus can be punctured normally through the interior meatus.
- If radical maxillary surgery (Caldwell-Luc) has been performed, there is an opening to the maxillary sinus in the inferior meatus at the normal puncture site and irrigation can be performed through that opening, using a blunt irrigation needle.
- After radical surgery, maxillary irrigation must not be performed using a sharp needle.
- After radical surgery, little information about a maxillary sinus can be obtained by paranasal sinus x-ray, which is therefore not recommended.