Chronic rhinosinusitis: Treatment, symptoms, advice and help

Definition

Chronic infective inflammation of the mucous membrane of the nasal passages and the paranasal air sinuses.

Incidence/Age

Can occur at any age.

Causes

Chronic rhinosinusitis may be caused by bacterial, viral or fungal overgrowth. It may be precipitated by anything which causes swelling of the mucous membranes, eg, allergy, trauma, hormonal changes, chemical irritants, and interferes with the normal flow of mucus from the sinuses into the nasal airway (the result of the coordinated beating of microscopic hair cells or cilia) and the exchange of gases between the nasal passages and the sinuses. The normal mucus flow washes out the sinuses regularly and prevents bacterial overgrowth. If it is stopped, the resultant bacterial overgrowth causes further mucosal swelling, worsening and perpetuating the situation. Some conditions result in the formation of excessively sticky mucus, eg, cystic fibrosis, or are associated with deformed poorly beating hair cells, eg, primary ciliary dyskinesia or bacterial toxin induced damage. These make it more likely that a chronic rhinosinusitis will become established.

Physical obstruction of sinus drainage holes (ostia), eg, by nasal polyps or by tumours, may cause chronic rhinosinusitis. Generally the bodies immune defence cells will deal with an infection before a chronic picture becomes established. If these defences are deficient, eg, congenital immune deficiencies or HIV disease, or the load of infecting bacteria, virus or fungus is too great for the defences to cope with, a chronic infection may become established. Dental abscesses of the upper teeth can rupture through the floor of the sinus of the cheek (the maxillary sinus) and lead to a chronic rhinosinusitis.

Symptoms/Signs

Chronic rhinosinusitis may cause a sensation of pressure or pain in the affected sinuses, nasal obstruction and green or yellow discharge from the front or back of the nasal passages (post nasal drip or catarrh). It may also cause nasal itching, sneezing, snoring, headaches, facial pain, toothache, decreased sense of smell and taste and, occasionally, nose bleeds. A sensation of facial swelling is not uncommon, although actual facial swelling is uncommon.

Complications of Disorder

Occasionally chronic rhinosinusitis may cause erosion of bone allowing the spread of infection into the tissues surrounding the sinus. This can cause infection of the bone (osteomylitis or osteitis) or abscess formation usually in the eye socket (orbital cellulitis), cranial cavity (cerebral abscess or meninigitis) or under the skin of the forehead (Pott's puffy tumour). Chronic fungal sinusitis can be particularly dangerous in those with deficient immunity, eg, diabetics, resulting in infiltration of the bone of the base of the skull and damage to the nerves which pass out from the brain through holes in the skull base. This can cause double vision and blindness. Occasionally inflammation can spread to the arteries supplying the brain and cause a stroke. Chronic sinusitis can also cause scarring of the sinus ostia. The infection may then settle. Continued mucus production results in the formation of a boney cyst containing mucus under pressure within the sinus (a mucocoele) This may expand and cause pressure on surrounding structures, eg, the eye ball which may be pushed out of the eye socket. The mucucoele which may become reinfected (mucopyocoele) and burst.

Tests

The diagnosis of chronic rhinosinusitis is made on the basis of the symptoms and supported by the finding of swelling of the nasal mucosa and a discharge of pus from the sinus ostia on examination. In the past an opaque or clouded sinus on a plain x ray was regarded as diagnostic, but recent research has shown this to be an unreliable indicator of chronic rhinosinusitis. Perforating the maxillary sinus wall via the nose with a hollow<