How to assess and manage chronic sinusitis?

Assessment and Management of Chronic Sinusitis

Chronic sinusitis requires a combination of imaging studies, nasal-sinus evaluation, and targeted medical therapy, with surgical intervention reserved for cases that fail maximal medical management. 1

Diagnostic Approach

Clinical Evaluation

• Chronic sinusitis is defined as inflammation of the paranasal sinuses with symptoms lasting ≥8 weeks 2
• Cardinal symptoms include:
  • Facial pain/pressure
  • Hyposmia/anosmia
  • Nasal drainage
  • Nasal obstruction 3
• Diagnosis requires at least 2 of these symptoms for ≥12 consecutive weeks, plus objective evidence 3

Objective Assessment

1. Imaging studies:

   • Coronal CT scan is the gold standard for diagnosis 2
   • Should include extra cuts through the ostiomeatal complex to clarify disease extent 2
   • Perform imaging >4 weeks after acute bacterial sinusitis and after medical management 2
   • Plain radiographs have limited value due to high false-positive/negative rates 1

2. Nasal examination:

   • Anterior rhinoscopy to assess for mucosal erythema and purulent secretions 1
   • Nasal endoscopy to confirm presence/absence of polyps 1

3. Laboratory evaluation:

   • Nasal cytology to identify inflammatory cell patterns (eosinophils suggest allergic/eosinophilic NAR) 2
   • Nasal-sinus biopsy for suspected neoplasia, fungal disease, or granulomatous disease 2
   • Consider tests for immunodeficiency, cystic fibrosis, or ciliary dysfunction in recurrent cases 2, 1

Management Algorithm

First-Line Treatment

1. Saline irrigation:

   • High-volume nasal saline irrigation improves symptoms compared to no treatment 4
   • Facilitates mechanical clearance of mucus and improves mucociliary transport 1

2. Intranasal corticosteroids:

   • Improves overall symptom scores and polyp scores 4
   • Particularly helpful for patients with marked mucosal edema 1
   • Reduces polyp recurrence after surgery 4

Second-Line Treatments

1. For patients with nasal polyps:

   • Short course of systemic corticosteroids (1-3 weeks) 4
   • Short course of doxycycline (3 weeks) 4
   • Leukotriene antagonists may improve nasal symptoms 4

2. For patients without polyps:

   • Prolonged course (3 months) of macrolide antibiotics may improve quality of life 4
   • Azithromycin (500 mg once daily for 3 days) has shown comparable efficacy to amoxicillin/clavulanate for acute bacterial sinusitis, with fewer side effects 5

3. Decongestants:

   • Can reduce inflammation and congestion
   • Limit use to short periods (≤5 days) due to potential side effects 1

Surgical Intervention

• Consider when appropriate medical therapy fails to control symptoms with objective evidence of disease 1
• Functional endoscopic sinus surgery (ESS) is the contemporary surgical approach 2
• Surgery may be offered when anticipated benefits exceed nonsurgical management alone 1
• Indications include:
  • Recurrent or chronic symptoms despite aggressive medical management
  • Ostiomeatal obstruction on imaging 2
  • Extensive disease on CT scan 1

Special Considerations

Comorbidities

• Asthma may be initiated or worsened by sinusitis; consider spirometry in patients with cough 1
• Nasal polyps are more common when sinusitis complicates allergic rhinitis 1
• In children with nasal polyps, consider evaluation for cystic fibrosis 1

Post-Surgical Care

• Most patients benefit from continued individualized medical therapy after surgery 2
• Allergy management when indicated 2
• Saline irrigation is especially beneficial after ESS 1

Monitoring and Follow-up

• Evaluate response to treatment after 3-5 days 1
• Consider changing antibiotics if no response 1
• Refer to specialist for:
  • Recurrent sinusitis
  • Lack of response to treatment
  • Presence of complications 1

Potential Pitfalls

• Overuse of antibiotics if viral rhinitis is not distinguished from bacterial sinusitis 1
• Inadequate duration of therapy leading to relapse 1
• Failure to recognize complications such as orbital or intracranial involvement 1
• Relying solely on transillumination for diagnosis (low sensitivity and specificity) 2

By following this structured approach to assessment and management, chronic sinusitis can be effectively treated, improving patient quality of life and reducing the risk of complications.