Chronic Sinusitis: what should I do Doc?
Dear friends, welcome back to TGIF Dr Euan's blogpost! We skipped a week last week as Dr Euan was away for lectures and conferences. Previously we touched on Acute Sinusitis, today's topic is Chronic Sinusitis.
Q: What is Chronic Sinusitis?
By definition, Sinusitis becomes chronic, after a period of 3 months of persistent symptoms eg. nasal blockage, catarrh, post nasal drip or facial pains.
Chronic sinusitis is inflammation of the paranasal sinuses lasting more than 12 weeks. Symptoms include facial pressure, rhinorrhea, postnasal drainage, congestion, and general malaise. Chronic sinusitis is divided into 2 groups, with and without polyps, which have slightly different treatment regimens.
The latest executive summary on adult sinusitis has altered the definition for CRS to read 12 weeks or longer of 2 or more of the following symptoms:
Anterior or posterior muco-purulent drainage
Decreased sense of smell
Q: What causes Chronic Sinusitis?
The aetiology of chronic sinusitis is multifactorial. The interaction between many systemic, local host, and environmental factors contribute to sinus inflammation and to the pathophysiology of the disease. Systemic factors include genetic diseases such as cystic fibrosis, conditions that cause immunodeficiency, autoimmune disease, idiopathic conditions such as Samter triad (aspirin-exacerbated respiratory disease), and acid reflux. Local host factors include sino-nasal anatomic abnormalities, iatrogenic conditions such as scarring due to prior sinus surgery, neoplasm, or the presence of a foreign body, among others. Possible environmental factors that may contribute to the condition include the presence of biofilms and bacterial infection, as well as fungal infection, allergy, environmental pollutants, and smoking. Increasing evidence shows that biofilms are critical to the pathophysiology of chronic infections including chronic sinusitis. Recent advances in methods for biofilm identification and molecular biology offer new insights into the role of biofilms in chronic sinusitis. Currently, etiologic studies of sinusitis are increasingly focusing on ostio-meatal obstruction, allergies, polyps, occult and subtle immunodeficiency states, and dental diseases. Microorganisms are more often recognised as secondary invaders. Any disease process or toxin that affects cilia has a negative effect on CRS.
Q: What are the symptoms of Chronic Sinusitis?
Patients with chronic sinusitis may present with the following symptoms:
Nasal obstruction, blockage, congestion, stuffiness
Nasal discharge (of any character from thin to thick and from clear to purulent)
Facial fullness, discomfort, pain, and headache (more with nasal polyposis)
Chronic unproductive cough (primarily in children)
Hyposmia or anosmia (more often with nasal polyposis)
Exacerbation of asthma
Dental pain (upper teeth)
Fever of unknown origin
Q: How is Chronic Sinusitis diagnosed?
There are several methods for diagnosing chronic sinusitis, such as:
Imaging tests. Images using CT or MRI can show details of your sinuses and nasal passages. These might pinpoint deep inflammation or physical blockage, such as polyps, tumours or fungi, that can be difficult to detect using an endoscope.
Looking into your sinuses. A thin, flexible camera tube with a fibre-optic light inserted through your nose allows your doctor to see the inside of your sinuses. This can help your doctor discover a deviated nasal septum, polyps or tumours.
An allergy test. If your doctor suspects that allergies might be triggering your chronic sinusitis, he or she might recommend an allergy skin prick test. A skin prick test is safe and quick and can help detect what allergen is responsible for your nasal flare-ups eg. House Dust mite / cat / dog dander.
Samples from your nose and sinus discharge (cultures). Cultures are generally unnecessary for diagnosing chronic sinusitis. However, when the condition fails to respond to treatment or gets worse, your doctor may take a swab inside your nose to collect samples that might help identify the cause, such as bacteria or fungi.
Q: How is Chronic Sinusitis treated?
There are several treatments for chronic sinusitis, such as:
Intra-nasal corticosteroids. These nasal sprays help prevent and treat inflammation. Examples include fluticasone, triamcinolone, budesonide, mometasone and beclomethasone. If the sprays are not effective enough, your doctor might recommend rinsing with a solution of saline mixed with drops of budesonide or using a nasal mist of the solution. Such irrigations help to reduce inflammation of the nasal passage and sinus linings.
Saline nasal irrigation, with nasal sprays or solutions, reduces drainage and rinses away irritants and allergens in the inspired air.
Oral or injected corticosteroids. These medications are used to relieve inflammation from severe sinusitis, especially if you have concomitant nasal polyps. Oral corticosteroids should only be used short term eg in short pulses as they can cause serious side effects when used long-term.
Allergy medications. If allergies are causing sinusitis, your doctor may recommend allergy medications, such as antihistamines.
Aspirin desensitisation treatment, if you have reactions to aspirin that cause sinusitis and nasal polyps. Under medical supervision, you're gradually given larger doses of aspirin to increase your tolerance. This is uncommon but can help if you have this condition.
Anti-fungal treatment. If your infection is due to fungi, you may need anti-fungal treatment, with or without sinus surgery.
Medication to treat nasal polyps and chronic sinusitis (CRSwNP). If you have nasal polyps and chronic sinusitis, your doctor may give you an injection of dupilumab or omalizumab to treat your condition. These medications may reduce the size of the nasal polyps and lessen nasal congestion.
Antibiotics are sometimes necessary for chronic sinusitis if your infection is caused by bacteria. If your doctor cannot rule out an underlying infection, he or she might empirically recommend an antibiotic, sometimes with other medications.
If allergies are contributing to your sinusitis, Immunotherapy can help reduce the body's reaction to specific allergens thereby improving the condition.
Endoscopic sinus surgery
In cases resistant to conservative treatment or medication, endoscopic sinus surgery might be an option to consider.
For this procedure, the doctor uses a thin, rigid tube with an attached light & camera (endoscope) to explore your sinus passages.
Depending on the source of the blockage, the doctor might use various instruments to remove tissue or shave away a polyp which is causing the nasal blockage. Enlarging a narrow sinus opening also may be an option to promote drainage.
Picture from Easmed on the Entellus ENT Balloon
In these cases, the surgeon uses an innovative catheter with a balloon system to enlarge the sinus openings. You see, although the sinuses themselves are quite large spaces, their openings into the nose are very narrow, even slit-like and are easily blocked. By using specific catheters and the appropriate balloon sizing.
This procedure works particularly well for certain groups eg. airline crew and pilots, undersea divers and tunnelling as it helps to equalise air pressure more efficiently as they traverse different pressure zones.
Q: How about any useful home remedies?
Lifestyle and home remedies
Rinsing out your nasal passages
These self-help remedies may help relieve your sinusitis symptoms:
Rest. This can help your body fight inflammation and speed recovery.
Moisturise your sinuses. Drape a towel over your head as you breathe in the vapour from a bowl of medium-hot water. Keep the vapour directed toward your face. Some patients like to add a scent eg Pine Co for inhalation. Or take a hot shower, breathing in the warm, moist air to help ease pain and help mucus drain.
Warm compress. A warm compress on your nose and forehead may help relieve the pressure in your sinuses.
Rinse out your nasal passages. Use a specially designed squeeze bottle, saline canister or neti pot to rinse your nasal passages. This home remedy, called nasal lavage, can help clear your sinuses.
Your ENT doctor may perform a nasoendoscopy to inspect the sinuses
If you are in doubt, do see your Family Doctor or friendly ENT Specialist for a consultation, and don't suffer in silence as CRS is usually very successfully treated.
Here are some useful references if you are keen to dig deeper!
American Academy of Pediatrics - Subcommittee on Management of Sinusitis and Committee on Quality Management. Clinical practice guideline: management of sinusitis. Pediatrics. 2001 Sep. 108(3):798-808. [QxMD MEDLINE Link].
Slavin RG, Spector SL, Bernstein IL, et al. The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol. 2005 Dec. 116(6 Suppl):S13-47. [QxMD MEDLINE Link].
Report of the Rhinosinusitis Task Force Committee Meeting. Alexandria, Virginia, August 17, 1996. Otolaryngol Head Neck Surg. 1997 Sep. 117(3 Pt 2):S1-68. [QxMD MEDLINE Link].
Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg. 2003 Sep. 129(3 Suppl):S1-32. [QxMD MEDLINE Link].
Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol. 2004 Dec. 114(6 Suppl):155-212. [QxMD MEDLINE Link].
Biel MA, Brown CA, Levinson RM, Garvis GE, Paisner HM, Sigel ME, et al. Evaluation of the microbiology of chronic maxillary sinusitis. Ann Otol Rhinol Laryngol. 1998 Nov. 107(11 Pt 1):942-5. [QxMD MEDLINE Link].
Brook I, Frazier EH, Foote PA. Microbiology of the transition from acute to chronic maxillary sinusitis. J Med Microbiol. 1996 Nov. 45(5):372-5. [QxMD MEDLINE Link].
Ramakrishnan Y, Shields RC, Elbadawey MR, Wilson JA. Biofilms in chronic rhinosinusitis: what is new and where next?. J Laryngol Otol. 2015 Aug. 129 (8):744-51. [QxMD MEDLINE Link].
Nayak N, Satpathy G, Prasad S, Thakar A, Chandra M, Nag TC. Clinical implications of microbial biofilms in chronic rhinosinusitis and orbital cellulitis. BMC Ophthalmol. 2016 Sep 21. 16 (1):165. [QxMD MEDLINE Link].
Mazza JM, Lin SY. Primary immunodeficiency and recalcitrant chronic sinusitis: a systematic review. Int Forum Allergy Rhinol. 2016 Oct. 6 (10):1029-1033. [QxMD MEDLINE Link].
Fastenberg JH, Hsueh WD, Mustafa A, Akbar NA, Abuzeid WM. Biofilms in chronic rhinosinusitis: Pathophysiology and therapeutic strategies. World J Otorhinolaryngol Head Neck Surg. 2016 Dec. 2 (4):219-229. [QxMD MEDLINE Link].
Brook I, Foote PA, Hausfeld JN. Increase in the frequency of recovery of meticillin-resistant Staphylococcus aureus in acute and chronic maxillary sinusitis. J Med Microbiol. 2008 Aug. 57:1015-7. [QxMD MEDLINE Link].
Brook I. Acute and chronic bacterial sinusitis. Infect Dis Clin North Am. 2007 Jun. 21(2):427-48, vii. [QxMD MEDLINE Link].
Brook I. Bacteriology of chronic maxillary sinusitis in adults. Ann Otol Rhinol Laryngol. 1989 Jun. 98(6):426-8. [QxMD MEDLINE Link].
Brook I. Microbiology and choice of antimicrobial therapy for acute sinusitis complicated by subperiosteal abscess in children. Int J Pediatr Otorhinolaryngol. 2016 May. 84:21-6. [QxMD MEDLINE Link].
Incorvaia C, Leo G. Treatment of rhinosinusitis: other medical options. Int J Immunopathol Pharmacol. 2010 Jan-Mar. 23(1 Suppl):70-3. [QxMD MEDLINE Link].
Brook I, Yocum P. Immune response to Fusobacterium nucleatum and Prevotella intermedia in patients with chronic maxillary sinusitis. Ann Otol Rhinol Laryngol. 1999 Mar. 108(3):293-5. [QxMD MEDLINE Link].
Brook I, Foote PA, Frazier EH. Microbiology of acute exacerbation of chronic sinusitis. Laryngoscope. 2004. 114:129-31.
Yaniv D, Stern D, Vainer I, Ben Zvi H, Yahav D, Soudry E. The bacteriology of recurrent acute exacerbations of chronic rhinosinusitis: a longitudinal analysis. Eur Arch Otorhinolaryngol. 2020. 277:3051-3057. [QxMD MEDLINE Link].
Brook I. Role of methicillin-resistant Staphylococcus aureus in head and neck infections. J Laryngol Otol. . 2009. 123::1301-7. [QxMD MEDLINE Link].
Vickery TW, Ramakrishnan VR, Suh JD. The Role of Staphylococcus aureus in Patients with Chronic Sinusitis and Nasal Polyposis. Curr Allergy Asthma Rep. 2019 Mar 11. 19 (4):21. [QxMD MEDLINE Link].
Nadel DM, Lanza DC, Kennedy DW. Endoscopically guided cultures in chronic sinusitis. Am J Rhinol. 1998 Jul-Aug. 12(4):233-41. [QxMD MEDLINE Link].
Ferguson BJ. Definitions of fungal rhinosinusitis. Otolaryngol Clin North Am. 2000 Apr. 33(2):227-35. [QxMD MEDLINE Link].
Brook I. Recovery of aerobic and anaerobic bacteria in sinus fungal ball. Otolaryngol Head Neck Surg . 2011. 145:851-2. [QxMD MEDLINE Link].
Marcus S, Roland LT, DelGaudio JM, Wise SK. The relationship between allergy and chronic rhinosinusitis. Laryngoscope Investig Otolaryngol. 2019 Feb. 4 (1):13-17. [QxMD MEDLINE Link].
Pleis JR, Lucas JW. Summary health statistics for U.S. adults: National Health Interview Survey, 2007. Vital Health Stat 10. 2009 May. 1-159. [QxMD MEDLINE Link].
Shah AR, Hairston JA, Tami TA. Sinusitis in HIV: microbiology and therapy. Curr Allergy Asthma Rep. 2005 Nov. 5(6):495-9. [QxMD MEDLINE Link].
Brook I. Microbiology and antimicrobial treatment of orbital and intracranial complications of sinusitis in children and their management. Int J Pediatr Otorhinolaryngol. 2009 Sep. 73(9):1183-6. [QxMD MEDLINE Link].
Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012 Mar. 50 (1):1-12. [QxMD MEDLINE Link].
Chakrabarti A, Denning DW, Ferguson BJ, et al. Fungal rhinosinusitis: a categorization and definitional schema addressing current controversies. Laryngoscope. 2009 Sep. 119(9):1809-18. [QxMD MEDLINE Link]. [Full Text].
Manes RP, Batra PS. Etiology, diagnosis and management of chronic rhinosinusitis. Expert Rev Anti Infect Ther. 2013 Jan. 11(1):25-35. [QxMD MEDLINE Link].
[Guideline] Rosenfeld RM,Piccirillo JF, Chandrasekhar SS,et al. of. Clinical practice guideline (update) on adult sinusitis. J Otolaryngol Head Neck Surg. 2015. 152(2 suppl):S1-S39. [QxMD MEDLINE Link].
Ziegler A, Patadia M, Stankiewicz J. Neurological Complications of Acute and Chronic Sinusitis. Curr Neurol Neurosci Rep. 2018 Feb 5. 18 (2):5. [QxMD MEDLINE Link].
Joshi VM, Sansi R. Imaging in Sinonasal Inflammatory Disease. Neuroimaging Clin N Am. 2015 Nov. 25 (4):549-68. [QxMD MEDLINE Link].
Paz Silva M, Pinto JM, Corey JP, Mhoon EE, Baroody FM, Naclerio RM. Diagnostic algorithm for unilateral sinus disease: a 15-year retrospective review. Int Forum Allergy Rhinol. 2015 Jul. 5 (7):590-6. [QxMD MEDLINE Link].
Benninger MS, Payne SC, Ferguson BJ, Hadley JA, Ahmad N. Endoscopically directed middle meatal cultures versus maxillary sinus taps in acute bacterial maxillary rhinosinusitis: a meta-analysis. Otolaryngol Head Neck Surg. 2006 Jan. 134(1):3-9. [QxMD MEDLINE Link].
Wise SK, Ahn CN, Lathers DM, Mulligan RM, Schlosser RJ. Antigen-specific IgE in sinus mucosa of allergic fungal rhinosinusitis patients. Am J Rhinol. 2008 Sep-Oct. 22(5):451-6. [QxMD MEDLINE Link].
Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015 Apr. 152 (2 Suppl):S1-S39. [QxMD MEDLINE Link].
United States Food and Drug Administration. Zicam cold remedy nasal products (Cold Remedy Nasal Gel, Cold Remedy Nasal Swabs, and Cold Remedy Saws, Kids Size). MedWatch Public Health Advisory. Available at http://www.fda.gov/Safety/MedWatch/SafetyInformation/SafetyAlertsforHumanMedicalProducts/ucm166996.htm. Accessed: June 16, 2009.
Massoth L, Anderson C, McKinney KA. Asthma and Chronic Rhinosinusitis: Diagnosis and Medical Management. Med Sci (Basel). 2019 Mar 27. 7 (4):[QxMD MEDLINE Link].
Chong LY, Head K, Hopkins C, Philpott C, Glew S, Scadding G, et al. Saline irrigation for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016 Apr 26. 4:CD011995. [QxMD MEDLINE Link].
Vaidyanathan S, Barnes M, Williamson P, Hopkinson P, Donnan PT, Lipworth B. Treatment of chronic rhinosinusitis with nasal polyposis with oral steroids followed by topical steroids: a randomized trial. Ann Intern Med. 2011 Mar 1. 154(5):293-302. [QxMD MEDLINE Link].
Chong LY, Head K, Hopkins C, Philpott C, Schilder AG, Burton MJ. Intranasal steroids versus placebo or no intervention for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016 Apr 26. 4:CD011996. [QxMD MEDLINE Link].
Miller LE, Bhattacharyya N. Risk of COVID-19 Infection Among Chronic Rhinosinusitis Patients Receiving Oral Corticosteroids. Otolaryngol Head Neck Surg. 2022. 166(:183-185. [QxMD MEDLINE Link].
Bachert C, Mannent L, Naclerio RM, Mullol J, Ferguson BJ, Gevaert P, et al. Effect of Subcutaneous Dupilumab on Nasal Polyp Burden in Patients With Chronic Sinusitis and Nasal Polyposis: A Randomized Clinical Trial. JAMA. 2016 Feb 2. 315 (5):469-79. [QxMD MEDLINE Link].
Han JK, Bachert C, et al. Efficacy and safety of dupilumab in patients with chronic rhinosinusitis with nasal polyps: Results from the randomized phase 3 Sinus-24 study (abstract 422). J Aller Clin Immunol. 2019 Feb;143(2; suppl). Presented at the 2019 Annual Meeting of the American Academy of Allergy, Asthma & Immunology (AAAAI); San Francisco, CA; February 23, 2019. [Full Text].
Bachert C, et al. A randomized phase 3 study, SINUS-52, evaluating the efficacy and safety of dupilumab in patients with severe chronic rhinosinusitis (abstract L36). Presented at the 2019 Annual Meeting of the American Academy of Allergy, Asthma & Immunology (AAAAI); San Francisco, CA; February 25, 2019.
Ragab S, Parikh A, Darby YC, Scadding GK. An open audit of montelukast, a leukotriene receptor antagonist, in nasal polyposis associated with asthma. Clin Exp Allergy. 2001 Sep. 31(9):1385-91. [QxMD MEDLINE Link].
Alexander L Schneider 1, Robert P Schleimer , Bruce K Tan. argetable pathogenic mechanisms in nasal polyposis. Int Forum Allergy Rhinol . 2021. 11:1220-1234.
Platt MP, Brook C D. Choosing the Right Patient for Biologic Therapy in Chronic Rhinosinusitis with Nasal Polyposis: Endotypes, Patient Characteristics, and Defining Failures of Standard Therapy. Otolaryngol Clin North Am. 2021. 54:701-708.
Chong LY, Piromchai P, Sharp S, Snidvongs K, Webster KE, Philpott C, et al. Biologics for chronic rhinosinusitis. Cochrane Database Syst Rev. 2021. 12::CD013513. [QxMD MEDLINE Link].
Catalano PJ, Payne SC. Balloon dilation of the frontal recess in patients with chronic frontal sinusitis and advanced sinus disease: an initial report. Ann Otol Rhinol Laryngol. 2009 Feb. 118(2):107-12. [QxMD MEDLINE Link].
Schwartz JS, Tajudeen BA, Cohen NA. Medical management of chronic rhinosinusitis - a review of traditional and novel medical therapies. Expert Opin Investig Drugs. 2017 Oct. 26 (10):1123-1130. [QxMD MEDLINE Link].
Ferguson BJ, Narita M, Yu VL, Wagener MM, Gwaltney JM Jr. Prospective observational study of chronic rhinosinusitis: environmental triggers and antibiotic implications. Clin Infect Dis. 2012 Jan. 54(1):62-8. [QxMD MEDLINE Link].
Head K, Chong LY, Piromchai P, Hopkins C, Philpott C, Schilder AG, et al. Systemic and topical antibiotics for chronic rhinosinusitis. Cochrane Database Syst Rev. 2016 Apr 26. 4:CD011994. [QxMD MEDLINE Link].
Piromchai P, Thanaviratananich S, Laopaiboon M. Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults. Cochrane Database Syst Rev. 2011 May 11. CD008233. [QxMD MEDLINE Link].
Lim M, Citardi MJ, Leong JL. Topical antimicrobials in the management of chronic rhinosinusitis: a systematic review. Am J Rhinol. 2008 Jul-Aug. 22(4):381-9. [QxMD MEDLINE Link].
Reychler G, Domachowski C, Latiers AC, Jamar F, Rombaux P. Clinical efficacy of intranasal drug delivery by nebulization in chronic rhinosinusitis: a systematic review. Rhinology. 2019 Apr 1. 57 (2):82-93. [QxMD MEDLINE Link].
Van Zele T, Gevaert P, Holtappels G, Beule A, Wormald PJ, Mayr S, et al. Oral steroids and doxycycline: two different approaches to treat nasal polyps. J Allergy Clin Immunol. 2010 May. 125(5):1069-1076.e4. [QxMD MEDLINE Link].
Sreenath SB, Taylor RJ, Miller JD, Ambrose EC, Rawal RB, Ebert CS Jr, et al. A prospective randomized cohort study evaluating 3 weeks vs 6 weeks of oral antibiotic treatment in the setting of "maximal medical therapy" for chronic rhinosinusitis. Int Forum Allergy Rhinol. 2015 May 23. [QxMD MEDLINE Link].
López-Chacón M, Mullol J, Pujols L. Clinical and biological markers of difficult-to-treat severe chronic rhinosinusitis. Curr Allergy Asthma Rep. 2015 May. 15 (5):19. [QxMD MEDLINE Link].
Qingwu Wu , Lianxiong Yuan , Huijun Qiu , Xinyue Wang , Xuekun Huang 1 Rui Zheng Qintai Yang. . Efficacy and safety of omalizumab in chronic rhinosinusitis with nasal polyps: a systematic review and meta-analysis of randomised controlled trials. BMJ Open. 2021 Sep 3. 11::e047344.
Pinto JM, Mehta N, DiTineo M, et al. A randomized, double-blind, placebo-controlled trial of anti-IgE for chronic rhinosinusitis. Rhinology. 2010;4. 8:318–24.
Gevaert P, Calus L, Van Zele T, et al. Omalizumab is effective in allergic and nonallergic patients with nasal polyps and asthma. J Allergy Clin Immunol. 2013. 131:110–6.
Rudmik L, Soler ZM. Medical Therapies for Adult Chronic Sinusitis: A Systematic Review. JAMA. 2015 Sep 1. 314 (9):926-39. [QxMD MEDLINE Link].
Bourdillon AT, Edwards HA. Mar-Apr;2):102883. doi: 10.1016/j.amjoto.2020.102883. Epub 2021 Jan 5. PMID:. Review of probiotic use in otolaryngology. Am J Otolaryngol. 2021. 42(:102883. [QxMD MEDLINE Link].
Bhattacharyya N. Radiographic stage fails to predict symptom outcomes after endoscopic sinus surgery for chronic rhinosinusitis. Laryngoscope. 2006 Jan. 116(1):18-22. [QxMD MEDLINE Link].
Welch KC, Stankiewicz JA. A contemporary review of endoscopic sinus surgery: techniques, tools, and outcomes. Laryngoscope. 2009 Nov. 119(11):2258-68. [QxMD MEDLINE Link].
Hox V, Delrue S, Scheers H, Adams E, Keirsbilck S, Jorissen M, et al. Negative impact of occupational exposure on surgical outcome in patients with rhinosinusitis. Allergy. 2012 Jan 9. [QxMD MEDLINE Link].
Purcell PL, Beck S, Davis GE. The impact of endoscopic sinus surgery on total direct healthcare costs among patients with chronic rhinosinusitis. Int Forum Allergy Rhinol. 2015 Jun. 5 (6):498-505. [QxMD MEDLINE Link].
Cingi C, Bayar Muluk N, Lee JT. Current indications for balloon sinuplasty. Curr Opin Otolaryngol Head Neck Surg. 2019 Feb. 27 (1):7-13. [QxMD MEDLINE Link].
Singh V. Fungal Rhinosinusitis: Unravelling the Disease Spectrum. J Maxillofac Oral Surg. 2019 Jun. 18 (2):164-179. [QxMD MEDLINE Link].
Ponikau JU, Sherris DA, Weaver A, Kita H. Treatment of chronic rhinosinusitis with intranasal amphotericin B: a randomized, placebo-controlled, double-blind pilot trial. J Allergy Clin Immunol. 2005 Jan. 115(1):125-31. [QxMD MEDLINE Link].
Sacks PL, Harvey RJ, Rimmer J, Gallagher RM, Sacks R. Topical and systemic antifungal therapy for the symptomatic treatment of chronic rhinosinusitis. Cochrane Database Syst Rev. 2011 Aug 10. CD008263. [QxMD MEDLINE Link].
Head K, Sharp S, Chong LY, Hopkins C, Philpott C. Topical and systemic antifungal therapy for chronic rhinosinusitis. Cochrane Database Syst Rev. 2018 Sep 10. 9:CD012453. [QxMD MEDLINE Link].
Gupta AK, Bansal S, Gupta A, Mathur N. Is fungal infestation of paranasal sinuses more aggressive in pediatric population?. Int J Pediatr Otorhinolaryngol. 2006 Apr. 70(4):603-8. [QxMD MEDLINE Link].
Hakim HE, Malik AC, Aronyk K, Ledi E, Bhargava R. The prevalence of intracranial complications in pediatric frontal sinusitis. Int J Pediatr Otorhinolaryngol. 2006 Aug. 70(8):1383-7. [QxMD MEDLINE Link].
Sharma GD, Doershuk CF, Stern RC. Erosion of the wall of the frontal sinus caused by mucopyocele in cystic fibrosis. J Pediatr. 1994 May. 124(5 Pt 1):745-7. [QxMD MEDLINE Link].
Benninger MS, Sindwani R, Holy CE, Hopkins C. Impact of medically recalcitrant chronic rhinosinusitis on incidence of asthma. Int Forum Allergy Rhinol. 2016 Feb. 6 (2):124-9. [QxMD MEDLINE Link].
Thamboo A, Kilty S, Witterick I, et al. Canadian Rhinology Working Group consensus statement: biologic therapies for chronic rhinosinusitis. J Otolaryngol Head Neck Surg. 2021. 50::15. [QxMD MEDLINE Link]. [Full Text].
Brook I. Treatment modalities for bacterial rhinosinusitis. Expert Opin Pharmacother. 2010 Apr. 11(5):755-69. [QxMD MEDLINE Link].
Huang A, Govindaraj S. Topical therapy in the management of chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg. 2013 Feb. 21(1):31-8. [QxMD MEDLINE Link]. [Full Text].
Joanna Krajewska 1, Krzysztof Zub 1, Adam Słowikowski 2, Tomasz Zatoński 3. Chronic rhinosinusitis in cystic fibrosis: a review of therapeutic options. Eur Arch Otorhinolaryngol. Jan;2022:. 279:1-24. [QxMD MEDLINE Link]. [Full Text].
McCann MR, Kessler AT, Bhatt AA. Emergency radiologic approach to sinus disease. Emerg Radiol. 2021 Oct;. 28(5):1003-1010. [QxMD MEDLINE Link].
Gregurić T, Prokopakis E, Vlastos I, Doulaptsi M, Cingi C, Košec A, et al. Imaging in chronic rhinosinusitis.:A systematic review of MRI and CT diagnostic accuracy and reliability in severity staging. J Neuroradiol. J. 2021. 48:277-281. [QxMD MEDLINE Link].
Macias-Valle L, Psaltis AJ. A Scholarly Review of the Safety and Efficacy of Intranasal Corticosteroids Preparations in the Treatment of Chronic Rhinosinusitis. Ear Nose Throat J. 2021. 100(:295-301. [QxMD MEDLINE Link].