Chronic Sinusitis: Current Concepts

Introduction

Chronic Sinusitis: Current Concepts

The sinuses (also called the Paranasal Sinuses) are air-filled cavities in the facial bones in & around the nasal cavities. The paranasal sinuses include the Frontal, Maxillary, Ethmoid and the Sphenoid sinuses.

The paranasal sinuses are lined by ciliated columnar epithelium which is continuous with the lining of the nasal cavity. Goblet cells in this lining secrete mucus which is emptied from the sinuses by ciliary movements. The mucus is emptied from the paranasal sinuses towards the natural openings in the lateral nasal wall.

What is Sinusitis?

Sinusitis refers to infection of one or more of the paranasal sinuses. Commonly sinusitis is the result of a blocked sinus, i.e. when the sinus openings are blocked. Blockage leads to stagnation of mucus secretions within the paranasal sinuses and decreased oxygen tension within the sinus. This provides a favourable environment for subsequent bacterial growth.

Current terminology commonly uses the word rhinosinusitis, implying infection of the nose & the paranasal sinuses. Rhinosinusitis is classified depending upon the duration of symptoms.

Acute Viral Rhinosinusitis (AVRS)

Patients with AVRS have nasal congestion, nasal / postnasal discharge, fever and facial pressure. Symptoms last less than 10 days. This happens after a common cold. It is treated with simple medications like nasal decongestants and paracetamol. Antibiotics are not prescribed at this stage. Indiscriminate use of antibiotics leads to the emergence of resistant strains. A word of caution about topical decongestants. They are not to be used for more than 5 days. Longer usage may result in Rhinitis Medicamentosa.

Acute bacterial rhinosinusitis (ABRS) - Patients with ABRS have nasal congestion accompanied by fever, discoloured nasal discharge or Postnasal discharge.

Symptoms last more than 10 days but less than 3 months. It is treated with antibiotics in addition to painkillers & decongestant medication. Common bacterial pathogens include Streptococcus Pneumoniae, H Influenza & Moraxella Catarrhalis. Antibiotic of choice would be either Amoxicillin with Potassium Clavulanate, Third Generation Cephalosporin or Quinolones. Antibiotic therapy must be for at least 10 days. Radiological investigations have little role in the diagnosis of ABRS. Radiology (preferably CT Scan) is done if complications (Like Orbital / intracranial spread) are suspected.

Chronic Rhinosinusitis (CRS) - Patients with CRS have symptoms more than 3 months. The symptoms include nasal / postnasal discharge, nasal block, disturbed smell & facial pain. Treatment of Chronic Rhinosinusitis would include Antibiotics, local steroid medications (as nasal sprays) and allergy medication if there is a coexisting nasal allergy.

Diagnostic tests would include a Nasal Endoscopy & Computerised Tomography (CT) Scan of the sinuses. Endoscopy can detect problems deviated nasal septum, blocked sinuses due to Deviated Nasal Septum, mucosal swelling or polyps.

A CT Scan is done after adequate preparation. This means treating the inflammation, so as to get an image with better clarity. CT Scan would show which of the paranasal sinuses are blocked, and would serve as a road map if surgery is contemplated.

Surgery For Chronic Sinusitis

Surgery is recommended only if medical treatment fails to control symptoms. Functional endoscopic Sinus surgery (FESS) is the current surgical technique for Chronic sinusitis. The surgery aims to remove the blockage and enhance the drainage & ventilation of the sinuses. Coexisting conditions like deviated nasal septum also need correction.

Does Treatment end With Surgery

The ideal patient would be one who needs no further treatment following surgery. This is often not the situation.

Some of the reasons for chronic symptoms are persistent inflammation in the sinuses & biofilm formation. A Biofilm refers to an organised growth of bacterial colonies in tissues which are difficult to eradicate.

FESS, however, opens up the sinus cavities allowing medications to reach better. This particularly refers to the use of Steroid nasal sprays. Other medicines used for treatment of CRS are:

  • Macrolide Antibiotics (Azithromycin, Roxithromycin & Clarithromycin). These are known to have an anti-inflammatory effect.
  • Hypertonic saline irrigations are very useful in restoring ciliary motility.
  • Mupirocin (water soluble form) can be mixed with saline and used for nasal irrigation .

Allergic Fungal Rhino Sinusitis (AFRS)

This is the equivalent of Allergic Broncho-Pulmonary Aspergillosis (ABPA) in the lungs. The patient has an allergic response to the dematiaceous fungi, especially Aspergillus. Diagnostic criteria for AFRS include Nasal polyps, Elevated Allergen-specific IgE, typical radiological findings on CT Scan, & thick tenacious mucus.

Any predisposing anatomical obstruction to the sinuses can trigger the disease. The fungus gets trapped in the sinuses, increasing the fungal load and sets up a vicious cycle which exacerbates the disease. Surgery is mandatory with the removal of all fungus material, to decrease the antigen load. Patients need frequent treatment with oral steroids and long-term treatment with topical steroids to control the disease.

Conclusion

It must be understood that Chronic Rhinosinusitis CRS is not a surgical disease but a medical condition for which surgery is done to optimise medical therapy. In other words, FESS combined with medical treatment improves the quality of life of these patients.

Article by Dr. Ranjana Kumari Gupta
Senior Consultant ENT Surgeon, Kauvery Hospital

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