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Chronic Rhinosinusitis

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Iqra Mazhar

Overview

Sinusitis is inflammation of the sinus or nasal canal. The term chronic sinusitis is used when the condition lasts longer than 12 weeks at a time. 
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Before understanding the disease, it is necessary to have a know-how of the anatomy and physiology of the involved structure.

There are 4 paired sinus cavities &ndash; ethmoid, sphenoid, frontal, and maxillary sinus cavities &ndash; that filter the air while it is being inhaled. These sinuses need to drain to function effectively.

However, nasal blockage due to chronic inflammation affects drainage and causes lower oxygen tension. This allows bacteria to accumulate at the site. The bacteria are usually Staphylococcus aureus, while S. aureus biofilms are frequently linked to recurrent illness (i.e., more than four episodes of sinusitis in a year). Staphylococcus aureus can pass through the paranasal sinuses&#39; columnar epithelial barrier and, consequently, aggravate the inflammatory response<a href="#accordion">[2]</a>. The situation worsens if there are any structural abnormalities or ciliary dysfunction present<a href="#accordion">[1]</a>.

Chronic rhinosinusitis (CRS) is one of the most prevalent chronic medical disorders around the world, especially because it affects all age groups. Reportedly, its incidence rate is 12.3% in the USA, 10.9% in Europe, and 13% in China<a href="#accordion">[2]</a>. 
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It is also highly prevalent in Pakistan. According to a study, it had a slight male predominance and in 73% of the patients who were suffering from allergic rhinitis, pet dander was seen to be the most common allergen<a href="#accordion">[11]</a>.

CRS decidedly lowers the quality of life. According to a study, CRS affects social function more severely than either chronic heart failure or ischemic heart disease. Furthermore, it is established that CRS puts a cost burden on society. The direct expenses of CRS are estimated to be between USD 10 and USD 13 billion annually in the USA<a href="#accordion">[2]</a>. Indirect costs of CRS are also estimated to surpass USD 20 billion annually in the USA because of lost productivity, missed workdays, and absences. 
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Chronic rhinosinusitis can be categorized into three variants: 
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<h5>1. CRS Without Nasal Polyposis (CRS Without NP):</h5>

Chronic rhinosinusitis without nasal polyps (CRSsNP) is more common as compared to chronic rhinosinusitis with nasal polyps (CRSwNP)<a href="#accordion">[8]</a>. Some diseases, including epithelial cell disorders, autoimmune diseases, and allergic and nonallergic upper and lower airway diseases, increase the risk of CRSsNP. Other factors, like smoking and innate immune defects, are also associated with this condition. It is characterized by basement membrane thickening, <a href="https://merisehat.pk/disease/cystic-fibrosis">fibrosis</a>, and goblet cell <a href="https://merisehat.pk/disease/benign-prostatic-hyperplasia">hyperplasia</a>. 
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<h5>2. CRS With Nasal Polyposis (CRS With NP):</h5>

Chronic rhinosinusitis with nasal polyps causes sinus pain, stuffy nose, and loss of smell. Nasal polyps are basically soft, painless growths on the lining of the nasal passages. Although they are not cancerous, they can cause the person to feel uncomfortable, interfere with their quality of life, and disrupt their sleep<a href="#accordion">[10]</a>. 
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<h5>3. Allergic Fungal Rhinosinusitis (AFRS):</h5>

Environmental allergens are the primary cause of allergic fungal sinusitis. Patients with this disease frequently have severe associated allergies to mold or other allergens. They may have nasal polyps or <a href="https://merisehat.pk/disease/asthma">asthma</a>, too<a href="#accordion">[9]</a>. 
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Signs and Symptoms

Both acute and chronic sinusitis present with similar signs and symptoms. Acute sinusitis is a brief (usually a week-long) sinus infection that is usually related to a cold. Even though it isn&#39;t frequently present, fever can occur with acute sinusitis. However, chronic sinusitis lasts for months (three months or longer) despite treatment and has various causes.

General signs and symptoms of chronic sinusitis include<a href="#accordion">[4]</a>:

<ul>
	<li>Nasal inflammation</li>
	<li>Runny nose</li>
	<li>Postnasal drip, i.e., drainage at the back of the throat</li>
	<li>Blocked or stuffy nose, which makes it difficult to breathe</li>
	<li>Pain, tenderness, and swelling around the eyes, cheeks, nose, or forehead</li>
	<li>Loss of sense of smell and taste 
	&nbsp;</li>
</ul>

Type-specific symptoms include: 
&nbsp;

1. CRS With Nasal Polyposis (CRS With NP)<a href="#accordion">[10]</a>:

<ul>
	<li>Stuffy or runny nose</li>
	<li>Loss of sense of smell</li>
	<li>Facial pain</li>
	<li>Postnasal drip</li>
	<li>Pain in upper teeth</li>
	<li>Snoring</li>
	<li>Headache 
	&nbsp;</li>
</ul>

2. Allergic Fungal Rhinosinusitis (AFRS)<a href="#accordion">[9]</a>:

<ul>
	<li>Nasal congestion on one side of the nose making it difficult to breathe</li>
	<li>Facial pain on one side of the face</li>
	<li>Thick yellow or brown nasal drainage</li>
	<li>Intermittent nasal discharge of green/brown &ldquo;cork-like&rdquo; fragments</li>
	<li>Frequent aggravated asthma episodes along with wheezing or chest tightness</li>
	<li>Coughing 
	&nbsp;</li>
</ul>
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Causes

The following are the most common causes of chronic sinusitis<a href="#accordion">[3]</a>:

<ul>
	<li>Allergies, in particular, hay fever or environmental allergies (such as pollen or chemicals) can cause inflammation of the nasal passages.</li>
	<li>Nasal polyps block the sinuses and make it difficult to breathe through the nose.</li>
	<li>A deviated septum is an uneven wall of tissue between the nostrils that can obstruct airflow in either one or both of the nostrils.</li>
	<li>Respiratory tract infections, i.e., viral or bacterial infections in the nose, windpipe, or lungs may cause inflammation and make it difficult for mucus to discharge. 
	&nbsp;</li>
</ul>

Other health conditions can cause chronic sinusitis too, including:

<ul>
	<li><a href="https://merisehat.pk/disease/asthma">Asthma</a>, a condition that causes chronic inflammation of the airways</li>
	<li><a href="https://merisehat.pk/disease/gerd-56">Gastroesophageal reflux disease (GERD)</a>, a disease of the digestive tract</li>
	<li><a href="https://merisehat.pk/disease/hiv-61">Human immunodeficiency virus (HIV)</a>, which weakens the immune system</li>
	<li>Cystic fibrosis, a condition in which the mucus in the body is unable to drain properly and keeps building up, usually causing bacterial infections 
	&nbsp;</li>
</ul>

Currently, there are no exclusive screening guidelines available for Chronic rhinosinusitis. However, a detailed history can be diagnostic. A study has reported that a sinonasal questionnaire (SNQ) approach can help filter the patients before they are referred for imaging studies<a href="#accordion">[12]</a>.

The patient has to tell how often they experience the following symptoms on average over the last 3 months:

1. Runny nose

2. Post-nasal drip

3. Need to blow your nose

4. Facial pain

5. Nasal obstruction

Points are given for each question and their episodes in a set duration<a href="#accordion">[12]</a>. 
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Diagnosis

A patient should present with at least two of four cardinal signs and symptoms to be diagnosed with chronic rhinosinusitis<a href="#accordion">[5]</a>:

1. Mucopurulent drainage

2. Nasal obstruction

3. Facial pain/pressure/fullness

4. Decreased sense of smell 
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When diagnosing chronic sinusitis, it&rsquo;s important to consider any serious underlying diseases, including tumors and immunodeficiencies. The cornerstone of the diagnostic process for chronic sinusitis is a radiologic examination. However, nasal endoscopy is typically advised before imaging tests because it assesses the purulent drainage and shows the status of the nasal mucosa. 
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<h5>Imaging studies</h5>

The anterior ethmoid anatomy is best understood through computed tomography (CT), which is frequently used for preoperative examination, while magnetic resonance imaging (MRI), is used to rule out orbital (the bony structure around the eye) and intracranial (skull) extension. 
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<h5>Bacterial And Fungal Cultures</h5>

The samples are taken either endoscopically from an opening or directly from the sinus cavity via maxillary sinus tap or during surgery. It should be noted that nasal swab cultures are useless for diagnosis. 
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Treatment

There are different treatment modalities to manage CRS<a href="#accordion">[3]</a>: 
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<h5>Medications</h5>

Over-the-counter (OTC) painkillers like ibuprofen and acetaminophen can help with headache and swelling-related pressure. Corticosteroid nasal sprays such as fluticasone and mometasone are another method to treat inflammation.

While significant infections that result in sinusitis are less likely to produce chronic sinusitis, they still need to be treated with antibiotics to avoid further complications. The doctor can refer to an allergist if allergies are the root of the patient&rsquo;s chronic sinusitis. 
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<h5>Home Remedies </h5>

A saline solution allows efficient mucus drainage. Additionally, this remedy can reduce edema. Moreover, a humidifier or steam can be used to reduce irritation. 
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<h5>Surgical Intervention</h5>

In the rare instances that home remedies and medication don&#39;t work, doctors suggest surgery.

Endoscopic Sinus Surgery: The doctor inserts a small tube with a light and a camera into the nose to check if polyps, mucus, or other tissue is obstructing the sinuses. The blockage is then surgically removed. In some circumstances, the doctor also widens the sinuses to improve breathing.

Septoplasty Or Rhinoplasty: These are both nasal surgical procedures with different goals. Septoplasty deals with internal abnormalities whereas rhinoplasty deals with the outward shape and size of the nose. The doctor modifies the tissue in the nose or the wall between the nostrils to straighten or expand it to help the patient breathe easily with the nostrils. 
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Chronic sinusitis makes breathing difficult. When the body does not get adequate oxygen, it can lead to serious complications, including<a href="#accordion">[3]</a>:

<ul>
	<li>An irreversible loss of smell can occur due to an injury to the olfactory nerve</li>
	<li>Loss of vision if an infection spreads to the eyes</li>
	<li>Meningitis, which is an inflammation of the protective membranes covering the brain and spinal cord</li>
	<li>Infection spreading to the skin or bones 
	&nbsp;</li>
</ul>

These include<a href="#accordion">[4]</a>:

<ul>
	<li>A deviated nasal septum</li>
	<li>Nasal polyps</li>
	<li>Asthma</li>
	<li>Sensitivity to aspirin</li>
	<li>A dental infection</li>
	<li>A fungal infection</li>
	<li>Tumors</li>
	<li>An immune system disorder, such as HIV/AIDS or cystic fibrosis</li>
	<li>Hay fever</li>
	<li>Constant exposure to irritants such as cigarette smoke 
	&nbsp;</li>
</ul>

The following factors can help prevent chronic sinusitis<a href="#accordion">[4]</a>: 
&nbsp;

<ul>
	<li>Avoid Upper Respiratory Infections:</li>
</ul>

Avoid coming into contact with those who have a cold or are sick with other infections. Wash hands regularly with soap and water, especially before eating. 
&nbsp;

<ul>
	<li>Manage Allergies:</li>
</ul>

Consult a doctor to learn how to keep the symptoms under control. Also, make sure to avoid substances that can trigger these allergies. 
&nbsp;

<ul>
	<li>Avoid Cigarette Smoke And Pollution: </li>
</ul>

This is because tobacco smoke and airborne pollutants tend to irritate and cause inflammation in the lungs and the nasal passages. 
&nbsp;

<ul>
	<li>Use A Humidifier:</li>
</ul>

Dry air causes sinusitis. A humidifier will add moisture to the air. Just make sure to clean the humidifier thoroughly and regularly to keep it mold-free. 
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Even though allergic rhinitis is one of the most prevalent allergic presentations, each patient needs a unique course of treatment. The early identification and treatment of this widespread illness, however, may be difficult given the different allergens and other probable etiologies.

Artificial intelligence (AI) can detect risk variables to help prevent disease. This can be especially fruitful in the case of children. According to a study, exposure to poor air quality during pregnancy is a significant predictor of the development of allergic rhinitis in children.&nbsp;

Thus, with the help of public health initiatives and AI, scientists identify risk factors for allergic rhinitis and progress toward a preventive medical approach for rhinologic illnesses<a href="#accordion">[7]</a>. 
&nbsp;

Key Points

<ul>
	<li>Sinusitis is inflammation of the sinus or nasal canal. The term chronic sinusitis is used when the condition lasts longer than 12 weeks at a time.</li>
	<li>The condition is considered one of the most prevalent chronic medical disorders around the world, especially because it affects all age groups.</li>
</ul>

<ul>
	<li>Chronic Rhinosinusitis can be categorized into three variants: Chronic rhinosinusitis with nasal polyposis, chronic rhinosinusitis without nasal polyposis, and allergic fungal sinusitis.</li>
	<li>General signs and symptoms of chronic sinusitis include nasal inflammation, runny nose, postnasal drip, and loss of sense of smell and taste.</li>
	<li>Risk factors include a deviated nasal septum, nasal polyps, asthma, sensitivity to aspirin, and dental infection. 
	&nbsp;</li>
</ul>

 
&nbsp;

[1] Kwon E, O'Rourke MC. Chronic Sinusitis. [Updated 2022 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-.

[2] Albu S. Chronic Rhinosinusitis-An Update on Epidemiology, Pathogenesis and Management. J Clin Med. 2020;9(7):2285. Published 2020 Jul 18.

[3] Jewell, T. (2018) Chronic sinusitis: Treatment, symptoms, and causes, Healthline.

[4] Chronic sinusitis (2021) Mayo Clinic. Mayo Foundation for Medical Education and Research.

[5] Chronic Rhinosinusitis Management (no date) UpToDate.

[6] Itzhak Brook, M.D. (2022) Chronic sinusitis, Practice Essentials, Background, Anatomy. Medscape.

[7] The evolution and application of artificial ... - sage journals (no date).

[8] Cho SH, Kim DW, Gevaert P. Chronic Rhinosinusitis without Nasal Polyps. J Allergy Clin Immunol Pract.

[9] Allergic fungal sinusitis treatment and symptoms Houston TX (2022) Houston Advanced Sinus - Houston Advanced Sinus.

[10] Chronic rhinosinusitis with nasal polyps (2022) ACAAI Public Website.

[11] Mumtaz Ahmad Umar, M.M. (no date) Prevalence of allergic rhinitis in patients diagnosed with chronic rhinosinusitis in a tertiary care hospital, Pakistan Journal of Medical & Health Sciences.