Adult Chronic Sinusitis and Its Complications

By G. Douglas Campbell Jr., MD, FCCP

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Objectives

1. Review the pathophysiology of chronic rhinosinusitis.
2. Learn appropriate diagnostic strategies.
3. Become familiar with current management practices.
4. Understand when surgery should be considered.

Key words

chronic rhinosinusitis; cystic fibrosis; fungal rhinosinusitis; sinusitis

Abbreviations

AFS = allergic fungal rhinosinusitis

Sinusitis represents a common health problem frequently encountered by primary health-care providers, allergists, and otolaryngologists, but its importance to physicians treating lung diseases is that sinusitis may act as a trigger for diseases in the lower respiratory tract. In 1996, the American Academy of Otolaryngology–Head and Neck Surgery proposed replacing the term sinusitis with rhinosinusitis, because the mucous membranes of the nose and sinuses are embryologically related and contiguous, disease management is similar, and isolated sinusitis infection without rhinitis is rare (Table 1).¹ They also classified rhinosinusitis based upon its temporal course and the presence of certain clinical findings (Table 2). Although clinical findings are important in identifying patients with rhinosinusitis, the diagnosis is usually confirmed by radiographic or endoscopic studies.

It is estimated that annually 35 million Americans have rhinosinusitis, resulting in 25 million office visits and 73 million days of restricted activity each year, and accounting for approximately 20% of all office visits to allergy and immunology specialists and 200,000 sinus surgeries.^2,3 Health-care expenditures for rhinosinusitis for 1996 were reported to be $5.8 billion, of which $3.5 billion was for the treatment of chronic rhinosinusitis.⁴ Twelve percent of adults < 45 years of age report symptoms of chronic rhinosinusitis.⁵ More worrisome is the fact that the reported prevalence of rhinosinusitis doubled between 1990 and 1995, and in 1995, 13 million antibiotic prescriptions were written for the treatment of rhinosinusitis.^6,7 Fortunately, rhinosinusitis is an uncommon cause of both hospitalization, accounting in 1993 for only 35,000 discharges (19,000 discharges for chronic rhinosinusitis), and death.⁸

In addition to the direct impact of rhinosinusitis on the general population, there are known associations with rhinosinusitis and other disease states, especially in older individuals.⁹ The association between asthma and rhinosinusitis is well known.^3,10 Up to 78% of asthma patients complain of rhinosinusitis, while 38% of patients with chronic rhinosinusitis have asthma, and untreated rhinosinusitis can worsen asthma and make it more resistant to therapy.¹¹ The association of rhinosinusitis and chronic bronchitis, termed sinobronchial syndrome, has been appreciated and studied for decades.¹² Today, it is commonly recognized in specific diseases such as cystic fibrosis, primary ciliary dyskinesia, allergic bronchopulmonary aspergillosis, hypogammaglobulinemia, and diffuse panbronchiolitis. Recognition of this association and aggressive treatment of chronic rhinosinusitis results in improvement in both illnesses. Chronic rhinosinusitis is also associated with nasal polyposis. Approximately 20% of patients with chronic rhinosinusitis have nasal polyps, with a subset due to aspirin-sensitivity syndrome (Samter syndrome). Rhinosinusitis is also associated with resistant otitis media infections.

The similarities in anatomy and function between the upper and lower respiratory tracts and the association of disease activity between these two areas have led to the concept of "one-airway disease."¹³

A partial list of the most common etiologies is presented in Table 3. Chronic rhinosinusitis is most likely multifactorial in origin and it is frequently impossible to identify a specific cause.¹⁴ Treatment often requires prolonged use of multiple different types of therapeutic agents.

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