Paranasal Sinus Disease: Symptoms and Objective Findings
Clinical Symptoms
Acute rhinosinusitis (symptoms <4 weeks) presents with purulent nasal drainage, nasal obstruction, localized sinus pain/pressure, and symptoms persisting without improvement for at least 10 days, or worsening within 10 days after initial improvement ("double sickening"). 1
Acute Rhinosinusitis Presentation
- Purulent rhinorrhea (colored nasal discharge) 1
- Nasal congestion/obstruction 1
- Facial pain, pressure, or fullness 1
- Postnasal drainage 1
- Fever (may be present) 1
- Headache 1
- Cough 1
- Anosmia (loss of smell) 1
Chronic Rhinosinusitis Presentation (≥12 weeks)
The European Position Paper on Rhinosinusitis (EPOS) requires at least 2 of 4 cardinal symptoms persisting ≥12 weeks: nasal blockage/obstruction, nasal discharge, facial pain/pressure, and decreased sense of smell, with nasal blockage and nasal discharge being mandatory. 2
- Nasal obstruction (mandatory symptom, present in 100% of cases) 2, 3
- Nasal discharge (mandatory symptom, present in 100% of cases) 2, 3
- Facial pressure or fullness (nonspecific, may be vague) 1, 4
- Hyposmia/anosmia (decreased or absent sense of smell) 2
- Postnasal drip (present in 62% of cases) 3
- Malaise or fatigue (particularly in children) 1
Red Flag Symptoms Requiring Further Investigation
Atypical symptoms suggest alternative diagnoses such as cerebrospinal fluid rhinorrhea, sinonasal tumors, or invasive fungal sinusitis and mandate immediate workup. 1
- Unilateral rhinorrhea or nasal blockage 1
- Epistaxis (nosebleeds) 1
- Severe headache 1
- Complete anosmia 1
- Diplopia (double vision, suggests orbital involvement) 1
- Pale mucosa progressing to ulceration/necrosis (suggests invasive fungal sinusitis in immunocompromised patients) 1
Objective Findings on Physical Examination
Nasal Endoscopy Findings
Nasal endoscopy is the preferred method for documenting inflammation and provides superior visualization compared to anterior rhinoscopy, which has insufficient sensitivity and specificity. 2, 3
- Mucopurulent discharge in middle meatus (present in 100% of chronic cases) 3
- Edematous and polypoid infundibular mucosa 3
- Nasal polyps (present in 20% of chronic cases) 3
- Septal deviation (present in 80% of cases) 3
- Inferior turbinate hypertrophy (present in 66% of cases) 3
- Middle turbinate hypertrophy or concha bullosa (present in 48% of cases) 3
- Clear rhinorrhea or colored discharge 1
- Bluish or pale swelling of nasal mucosa 1
Associated Physical Findings
- Ocular findings: watery discharge, swollen conjunctivae, scleral injection (suggests allergic component) 1
- Allergic shiners (dark circles under eyes) 1
- Nasal crease (from frequent nose rubbing) 1
- Frequent throat clearing 1
Diagnostic Confirmation Requirements
Symptoms alone are insufficient for diagnosis—objective documentation of inflammation through nasal endoscopy or CT imaging is mandatory. 2, 5
When Imaging is NOT Indicated
For acute uncomplicated rhinosinusitis (<4 weeks), the American Academy of Otolaryngology-Head and Neck Surgery recommends against obtaining radiographic imaging, as CT cannot distinguish bacterial from viral etiology. 1
When Imaging IS Indicated
CT Imaging Indications
CT maxillofacial without contrast is the gold standard for confirming chronic rhinosinusitis (≥12 weeks) and for presurgical planning, demonstrating mucosal thickening, sinus opacification, polyps, and bony changes. 1, 2, 5
- Chronic rhinosinusitis confirmation (symptoms ≥12 weeks with failed medical therapy) 2, 5
- Presurgical planning for functional endoscopic sinus surgery 1
- Recurrent acute rhinosinusitis (≥3 episodes per year) 1
- Suspected complications (orbital or intracranial involvement) 1
- Suspected invasive fungal sinusitis (immunocompromised patients with hyperattenuation in sinuses, bony erosions) 1
- Evaluation of anatomic variants that increase surgical risk 1
MRI Imaging Indications
MRI with and without contrast is indicated when invasive fungal sinusitis is suspected in immunocompromised patients, as it better demonstrates soft tissue invasion, vascular complications, and intracranial extension. 1
- Suspected invasive fungal sinusitis (high mortality 50-80%, requires urgent diagnosis) 1
- Differentiation of fluid from inflamed mucosa 1
- Exclusion of underlying obstructing mass 1
- Evaluation of vascular complications (thrombosis, pseudoaneurysm, dissection) 1
Critical Clinical Pitfalls
Diagnostic Pitfalls
- Symptoms have only 37-73% sensitivity for chronic rhinosinusitis diagnosis—up to 35% of patients with CRS have normal endoscopic findings, making imaging critical 2, 5
- Anterior rhinoscopy is insufficient due to low sensitivity/specificity, particularly in children <6 years 2
- Facial pain alone without nasal symptoms is rarely sinusitis—99 of 101 patients with facial pain, normal endoscopy, and normal CT had neurological diagnoses (migraines, tension headaches) and responded to neurological treatment, not sinus surgery 6
- CT findings do not always correlate with symptom severity, particularly in chronic rhinosinusitis without polyps 1
High-Risk Populations Requiring Heightened Suspicion
Maintain high index of suspicion for invasive fungal sinusitis in immunocompromised patients (neutropenia, hematologic malignancies, poorly controlled diabetes, organ transplant, systemic steroids/chemotherapy) presenting with acute rhinosinusitis symptoms, orbital symptoms, or headache. 1
Subclassification for Treatment Planning
The European Position Paper on Rhinosinusitis (EPOS) recommends subclassifying chronic rhinosinusitis into three categories to guide treatment: CRS with nasal polyps, CRS without nasal polyps, and allergic fungal rhinosinusitis. 2
Additional Workup Considerations
- Allergy testing is recommended in recurrent or difficult-to-treat CRS, as up to 60% have significant allergic sensitivities to perennial allergens 2
- Immunodeficiency evaluation (quantitative IgG, IgA, IgM, specific antibody responses) in patients with chronic/recurrent sinusitis plus otitis media, bronchitis, or pneumonia 1
- Evaluation for ciliary dyskinesia, cystic fibrosis, anatomic abnormalities, and aspirin-exacerbated respiratory disease when CRS is refractory 2