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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

  • Nasal obstruction

  • Facial pain-pressure-fullness

  • 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)

  • Postnasal drip

  • Facial fullness, discomfort, pain, and headache (more with nasal polyposis)

  • Chronic unproductive cough (primarily in children)

  • Hyposmia or anosmia (more often with nasal polyposis)

  • Sore throat

  • Fetid breath

  • Malaise

  • Easy fatiguability

  • Anorexia

  • Exacerbation of asthma

  • Dental pain (upper teeth)

  • Visual disturbances

  • Sneezing

  • Stuffy ears

  • Unpleasant taste

  • 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


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.


Immunotherapy


If allergies are contributing to your sinusitis, Immunotherapy can help reduce the body's reaction to specific allergens thereby improving the condition.


Surgery


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.


Balloon Sinuplasty

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!


References:

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