• Nalaka de Silva

Sinusitis and Rhinitis

Updated: Jun 16, 2019

Please note that the following is a general guideline only.




GENERAL DISCUSSION



Rhinitis definition


Characterized by; Non-purulent nasal drip/ post nasal drip/ nasal obstruction

No evidence of pus in the sinus drainage pathway, no polyps (on endoscopy)

No CT evidence of sinusitis



Important subtypes of rhinitis are

1 allergic rhinitis

2 Local allergic rhinitis -local upper and lower airway allergy, but not demonstrated systemically ie -ve skin testing, -ve RAST testing)

3 Vasomotor rhinitis

4 rhinitis medicamentosa

5 hormonal

6 chemical




Sinusitis definition


Characterized by >2/5 major sinus symptoms-

Nasal obstruction,

nasal drip (usually purulent),

post nasal drip,

anosmia,

pain


and at least one of CT evidence of sinusitis / Pus in the sinus drainage pathway (on endoscopy) or polyps




Important subtypes are


1 Acute sinusitis -If symptoms are acute ie 4-8 weeks (usually post viral)


2 Chronic Rhino Sinusitis (CRS) with nasal polyposis (>3 months)

3 CRS without polyposis


4 Other rare types

Fungal sinusitis: fungal ball, chronic invasive, acute invasive in the immunocompromised

Granulomatous; Wegners/ TB

Secondary to mucociliary dysfunction i.e. Cystic fibrosis etc

Specific cause- ie dental infection, apparent anatomic problem blocking the sinus drainage



Polyps arise mostly from Sinuses

Pus noted in the sinus drainage pathway

RHINITIS SUBTYPES-Discussion in more detail


1 Allergic Rhinitis


Classification


Intermittent: <4 days per week or <4 weeks

Persistent: >4 days per week or >4 weeks



Aetiology


allergens: seasonal and perennial groups

seasonal allergens → primarily pollens (grasses-spring, weeds-winter, trees)


perennial allergens → moulds, house dust, and animal danders




Pathophysiology


Type I hypersensitivity reaction (i.e. mast cell degranulation, TH2 driven)


Clinical


sneezing, rhinorrhea, congestion and itching

+ve Family Hx of atopy



injected conjunctiva

increased lacrimation

dark discolouration below the lower eyelids

transverse nasal crease-nasal salute

turbinate hypertrophy/ rhinorrhea (clear and profuse to stringy and mucoid)



Investigations


Should only be done if significant systemic illness ie poorly controlled asthma

Skin prick test

Blood test -RAST or ELIZA, nasal provocation test


FBC

elevated eosinophil count: nonspecific



Treatment


1 Medical therapy

Nasal symptoms - Rx with topical steroids ie Nasal irrigation followed by Nasonex (II BD) trial 3 months

Extra-nasal symptoms may respond to second-generation antihistamine ie Loratidine 10 mg od in an adult

Asthma medication as needed


2 Failed medical therapy with nasal symptoms (with or without asthma) - turbinate reduction followed by ongoing medical therapy (there is evidence that asthma control is better post surgery)


3 Ongoing asthma and very positive allergy test to a few agents; immunotherapy


No evidence for allergy avoidance

Early exposure to pathogens reduces this condition by induction of TH1 rather than TH2 (low allergy in farming communities, families with may siblings)





2 Local Allergic Rhinitis


Definition

Clinically similar to allergic rhinitis BUT no systemic evidence of allergy (i.e. -ve skin allergy, RAST, ELIZA)


Epidemiology

onset in early adulthood


Aetiology

nasal and respiratory mucosa eosinophilia with no evidence of systemic allergy

may still be a local allergy of the airways


Treatment (as per allergic rhinitis)


Topical therapy

If fails surgery-turbinoplasty

Ongoing symptoms- nasal provocation test- if positive consider immunotherapy (note -ve skin and RAST)




3 Vasomotor rhinitis


Epidemiology

onset in middle age / elderly


Pathophysiology

due to autonomic imbalance-hypoactive adrenergic system relative to parasympathetic


Clinical

present with profuse rhinorrhoea often with clear triggers eg cold, spicy foods


Treatment

medical - ipratropium (atrovent) spray and nasonex II BD longter

surgical- vidian neurectomy (stop the parasympathetic supply to the nose)




4 Drug-induced

ACE inhibitors, estrogens, B-blockers, many others



5 Rhinitis medicamentosa


loss of sympathetic tone due to down-regulation of alpha receptors caused by overuse of sympathomimetic decongestants

treat by the withdrawal of decongestant – consider 1 nostril at a time, use topical nasal steroids during withdrawal


6 Hormonal

estrogen - increases parasympathetic drive and decreases sympathetic activity

pregnancy – onset in the second month, resolves after delivery

menstruation, puberty, exogenous estrogen - OCP

hypothyroidism – myxoedema of turbinates



7 Occupational –


rhinitis induced by irritant at work. Avoidance / topical nasal steroids





SINUSITIS Types and discussion



1 Acute Bacterial


Definition

Bacterial sinusitis following a viral illness lasting up to up to 4-week duration



Diagnosis

Double worsening-(virus--- then better---- then bacterial sinusitis)

Short hx of

-purulent rhinorrhea

-face pain/pressure

-nasal obstruction.

-other; ansomia/ fever/aural fullness/cough and headache


Need to differentiate between viral (<10 days –self-limiting) and bacterial (up to 4 weeks more severe)




Aetiology

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis


Treatment

Decongestants-otrivin IV QID for 4 days, Nasal irrigation

Good response to antibiotics: -Amoxycillin, Triprim, macrolide

If no improvement culture guided antibiotics-best




2 CRS without nasal polyposis


Definition

Sy of CRS without polyps


Epidemiology

60% of CRS


Pathophysiology

mostly due to neutrophils



Diagnostics

2 Major sy + clinical/ CT evidence

No polyps on examination

pus in the sinus drainage pathway is noted



Treatment

Topical rinse followed by topic steroids spray (Nasonex II BD)

Culture guided antibiotics help

if no pus no antibiotics

Steroids 3 weeks


No improvement sinus surgery is the gold standard followed by rinsing/ topical steroids spray for 3 months.


Natural course

Earlier onset

Better prognosis

very good response to sinus surgery





3 CRS with Nasal Polyposis


Definition

Fulfils the criteria for CRS with notable polyps


Epidemiology

30 % of CRS


Pathophysiology

Eosinophillic type

Though to be the mucosal dysregulated immune response

Various associations; supra antigens, allergy to fungi, biofilms. Cause, however, is likely to be a dysregulated immune response and destruction of the mucosa.


Diagnosis

criteria for CRS and noted nasal polyps


Treatment

Combination of surgery followed by topical therapy

Pre op : can trial 4-6 weeks of Macrolide (mainly for its anti-inflammatory aspect) / oral steroids/ rinsing followed by Nasonex II BD

The response will most likely be temporary

Surgery involves full sinus clearance making a good passage for delivery of the above mentioned topical Rx

post op 2 weeks of steroids and macrolide along with long term rinsing and topical steroid spray


Adjutants

if Samster’s (Asthma, aspirin hypersensitivity, and polyps) may benefit from post-op aspirin desensitization

if intra op evidence of allergic fungal mucin; immunotherapy for fungi

if an association with asthma and positive skin allergy test; post-op desensitization (note this takes up to 3 years to accomplish)

Evidence that post-surgical improvement of nasal airway improve asthma control




4 Fungal Sinus Disease is discussed separately










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