Adult Chronic Sinusitis and Its Complications

By G. Douglas Campbell Jr., MD, FCCP

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Pathophysiology of Rhinosinusitis

Sinusitis refers to inflammation of the mucous membranes lining the paranasal sinuses. The sinuses, like other parts of the respiratory tract, are susceptible to a number of infectious and noninfectious insults (Table 3). The location and anatomical structure, especially the narrow ostia, affects clinical response. With chronic rhinosinusitis, there is ongoing inflammation characterized by eosinophilia that results in damage to the mucosa and ciliary components of the sinus and changes in the vasoelastic properties of mucus. The reader is referred to other sources for a more complete discussion of the role of inflammation in chronic rhinosinusitis.¹⁶

Not all cases of chronic rhinosinusitis are caused by bacterial infections. Because cultures are generally obtained by sampling via an invasive procedure and sampling is often performed only after one or more failed courses of antibiotic treatment, few studies investigating the etiology of bronchitis have been reported. A review of studies from adults with chronic rhinosinusitis shows that the most common pathogens cultured in chronic rhinosinusitis include coagulase-negative Staphylococcus spp (51% of isolates), Staphylococcus aureus (20%), anaerobes (3%), and Streptococcus pneumoniae (4%). In addition, organisms frequently encountered in acute rhinosinusitis (eg, Haemophilus influenzae and, in children, Moraxella catarrhalis) may also be recovered in chronic rhinosinusitis. The clinical significance of coagulase-negative staphylococci and anaerobes is debatable.^17,18 In one newer study, the incidence of enteric Gram-negative bacilli was reported to be 27%; these pathogens were recovered more often from patients who had prior sinus surgery or were using irrigation.¹⁹ Pseudomonas aeruginosa is seen with prolonged use of oral steroids and in patients with cystic fibrosis. It is appreciated that a number of factors affect the spectrum of pathogens recovered, including recent antimicrobial therapy, the prior presence or development of antimicrobial resistance, duration of rhinosinusitis, prior sinus surgery, and the type of culturing and processing methods used.

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