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Rhinosinusitis

Rhinosinusitis is defined as symptomatic inflammation of the paranasal sinuses and nasal cavity. The term rhinosinusitis is preferred because sinusitis is almost always accompanied by inflammation of the contiguous nasal mucosa. Rhinosinusitis may be further classified by duration as acute (less than 4 weeks), subacute (4-12 weeks), or chronic (more than 12 weeks, with or without acute exacerbations). Acute rhinosinusitis may be classified further by symptom pattern into acute bacterial rhinosinusitis (ABRS) or viral rhinosinusitis (VRS). When there are 4 or more acute episodes per year of ABRS, without persistent symptoms between episodes, the condition is termed recurrent acute rhinosinusitis. Most acute rhinosinusitis begins when a viral upper respiratory infection (URI) extends into the paranasal sinuses, which may be followed by bacterial infection.

Acute rhinosinusitis has been clinically defined as a condition that results from inflammation of the mucous membranes, fluids, or underlying bones of the nasal passage and/or paranasal sinuses. Signs and symptoms associated with rhinosinusitis can vary with each presentation and underlying cause (eg, viral, allergic). It is determined by the sudden onset of sinus pain and tenderness, nasal obstruction, and purulent rhinorrhea/ sinus discharge, with or without upper molar tooth pain.

Chronic rhinosinusitis is considered if the subject has 3 months of symptoms despite appropriate antibiotics. Patients with CRS often complain of cough, dental pain, and ear pain. The mechanisms for chronic cough and ear pain in the CRS setting remain elusive. For example, patients with CRS commonly carry clinical or subclinical evidence of reactive airways disease, and the cough may in fact be a manifestation of concurrent asthma. The relationship between uncontrolled rhinosinusitis and worsening asthma symptom scores is well-known.

Active allergic rhinitis subjects are identified by itch, swelling, sneezing, and discharge affecting eyes, nose, and/or palate during a season consistent with ambient aeroallergens and their personal allergy skin test profile. Examination shows nasal swelling, watery discharge, pallor and/or conjunctival injection.

Sinus-related pain or headache is usually described by patients as pressure-like or dull bilateral periorbital pain, usually radiating to the ears, usually worse in the morning and better as the day progresses, associated with nasal obstruction, not necessarily responsive to decongestants and antihistamine, described by patients as lasting days at a time, and not usually associated with nausea or visual disturbances. There is no correlation between the severity or site of pain and the extent or location of the mucosal disease.

signs and symptoms

Facial pain/pressure

Headache

Nasal congestion/fullness

Fever

Nasal obstruction/blockage

Halitosis

Nasal discharge/purulence

Fatigue

Hyposmia/anosmia

Dental pain

Purulence in nasal cavity on examination

Cough

Fever (acute sinusitis only)

Ear pain/pressure/fullness

Nasal endoscopy may be obtained in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis. CT of the paranasal sinuses should be obtained in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis. Mucosal abnormalities, sinus ostial obstruction, anatomical variants, and sinonasal polyposis are best displayed on CT. An important role of CT imaging is to exclude aggressive infections or neoplastic disease that might mimic CRS or recurrent acute rhinosinusitis. Osseous destruction, extrasinus extension of the disease process, and local invasion suggest malignancy. Testing for allergy and immune function may be obtained in diagnosing or evaluating a patient with CRS or recurrent acute rhinosinusitis. Laboratory studies in patients with CRS or recurrent acute rhinosinusitis may include quantitative immunoglobulin measurements (IgG, IgA, and IgM).

Pain relief is a major goal in managing ABRS and often the main reason that patients with this condition seek health care.Frequent use of analgesics is often necessary to permit patients to achieve comfort and rest, and to resume normal activities. Adjunctive treatments for rhinosinusitis that may aid in symptomatic relief include antibiotis,decongestants (alpha-adrenergic), corticosteroids, saline irrigation, and mucolytics.

Refractory headaches, presumably of sinonasal origin, might respond well to surgical intervention.The most common anatomic abnormalities cited in the literature include septal deviations (due to deflection, buckling, and spurring) and turbinate deformities (conchae bullosae, paradoxical curvature) and hypertrophy. Often these abnormalities result in contact points between the septum and turbinates.We have found that the surgical correction of obvious anatomic abnormalities in carefully selected patients can significantly improve several important clinical outcomes, including headache.

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