Adult Chronic Sinusitis and Its Complications

By G. Douglas Campbell Jr., MD, FCCP

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Diagnosis of Chronic Rhinosinusitis

Clinical Criteria

The clinical signs and symptoms of rhinosinusitis are variable. The presence of nasal symptoms is common in the general population; on any given day, up to 40% of individuals without evidence of rhinosinusitis have nasal symptoms.^20,21 Among patients presenting with chronic rhinosinusitis, even when symptoms are present, they are frequently lower grade than in an acute setting except in the setting of acute exacerbations. Recently, criteria were developed to help identify the patients most likely to have rhinosinusitis (Table 1).²² The presence of chronic rhinosinusitis was suggested by the duration of symptoms of for > 12 weeks and the presence of either (1) two or more major factors (as listed in Table 1) or (2) one major and two minor factors or the presence of nasal purulence.¹⁴ Acute exacerbation of chronic rhinosinusitis was defined as a sudden worsening of chronic rhinosinusitis.

Chronic rhinosinusitis also should be considered among patients who present with difficult-to-control asthma or who have risk factors for sinusitis (mechanical obstruction, polyps, immune deficiencies).

The physician should obtain a thorough history and perform a thorough physical examination. The history should be directed not only at eliciting factors listed in Table 3, but also at identifying allergic triggers, the presence of other underlying disease (eg, immotile cilia syndrome, HIV disease), and factors that may worsen rhinosinusitis (eg, smoking). A general head and neck examination may be helpful. The presence of swelling, edema, or erythema in the orbital or cheekbone areas, cervical adenopathy, postnasal drainage, or pharyngitis may point to sinus involvement. Tenderness to palpation may be noted occasionally. Percussion of the forehead and cheeks and transillumination in a completely dark room can occasionally show abnormalities, but findings may be falsely positive as a result of anomalies in normal sinus development. Diminished visual acuity or frank loss of vision are ominous signs of extrasinus disease suggesting the need for prompt surgical intervention.

Examination via anterior rhinoscopy or nasal endoscopy is often helpful and may reveal hyperemia, edema, crusting, purulence, polyps, or nasal deviation/obstruction. Nasal endoscopy can allow culturing, with 80% of the accuracy of the more painful sinus puncture and lavage.

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