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Chronic rhinosinusitis: Clinical manifestations, pathophysiology, and diagnosis

Author
Daniel L Hamilos, MD
Section Editors
Jonathan Corren, MD
Daniel G Deschler, MD, FACS
Deputy Editor
Anna M Feldweg, MD

INTRODUCTION

Chronic rhinosinusitis (CRS) may be broadly defined as an inflammatory disorder of the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer. More precisely, it is a heterogeneous group of related disorders that share certain clinical and pathologic features. In the past, CRS lacked a clear definition and was approached differently by various specialties. However, multidisciplinary expert panels have been established to determine how these disorders should be defined, evaluated, and managed [1-5].

The definition, epidemiology, clinical manifestations, pathologic features, evaluation, and diagnosis of CRS will be discussed here. Treatment is presented separately. The complex role of microbes and antimicrobial therapy in CRS is reviewed elsewhere. (See "Chronic rhinosinusitis: Management" and "Microbiology and antibiotic management of chronic rhinosinusitis".)

DEFINITION

Chronic rhinosinusitis (CRS) is defined as an inflammatory condition involving the paranasal sinuses and linings of the nasal passages that lasts 12 weeks or longer. The diagnosis requires objective evidence of mucosal inflammation.

In some iterations of the definition, the phrase "despite attempts at medical management" is included to eliminate the possibility that CRS simply represents untreated acute rhinosinusitis. However, it is problematic to include this phrase, since there is no definitive standard of treatment [2-6].

Current definitions differ from earlier definitions of "chronic sinusitis" by adopting the term "rhinosinusitis" to emphasize the involvement of both the nasal passages and the paranasal sinuses, and by requiring objective evidence of sinus mucosal disease [1,6,7].

                                        

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Literature review current through: Nov 2016. | This topic last updated: Fri Oct 28 00:00:00 GMT+00:00 2016.
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References
Top
  1. Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. J Allergy Clin Immunol 2004; 114:155.
  2. Scadding GK, Durham SR, Mirakian R, et al. BSACI guidelines for the management of rhinosinusitis and nasal polyposis. Clin Exp Allergy 2008; 38:260.
  3. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg 2015; 152:S1.
  4. Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology 2012; 50:1.
  5. Slavin RG, Spector SL, Bernstein IL, et al. The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol 2005; 116:S13.
  6. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997; 117:S1.
  7. Fokkens W, Lund V, Bachert C, et al. EAACI position paper on rhinosinusitis and nasal polyps executive summary. Allergy 2005; 60:583.
  8. Shashy RG, Moore EJ, Weaver A. Prevalence of the chronic sinusitis diagnosis in Olmsted County, Minnesota. Arch Otolaryngol Head Neck Surg 2004; 130:320.
  9. Blackwell DL, Collins JG, Coles R. Summary health statistics for U.S. adults: National Health Interview Survey, 1997. Vital Health Stat 10 2002; :1.
  10. Hastan D, Fokkens WJ, Bachert C, et al. Chronic rhinosinusitis in Europe--an underestimated disease. A GA²LEN study. Allergy 2011; 66:1216.
  11. Ahsan SF, Jumans S, Nunez DA. Chronic rhinosinusitis: a comparative study of disease occurrence in North of Scotland and Southern Caribbean otolaryngology outpatient clinics over a two month period. Scott Med J 2004; 49:130.
  12. Pilan RR, Pinna FR, Bezerra TF, et al. Prevalence of chronic rhinosinusitis in Sao Paulo. Rhinology 2012; 50:129.
  13. Lusk R. Chronic rhinosinusitis: contrasts between children and adult patients. Clin Allergy Immunol 2007; 20:287.
  14. DeConde AS, Soler ZM. Chronic rhinosinusitis: Epidemiology and burden of disease. Am J Rhinol Allergy 2016; 30:134.
  15. Bhattacharyya N. The economic burden and symptom manifestations of chronic rhinosinusitis. Am J Rhinol 2003; 17:27.
  16. DelGaudio JM, Wise SK, Wise JC. Association of radiological evidence of frontal sinus disease with the presence of frontal pain. Am J Rhinol 2005; 19:167.
  17. Jones NS. Midfacial segment pain: implications for rhinitis and sinusitis. Curr Allergy Asthma Rep 2004; 4:187.
  18. Rosbe KW, Jones KR. Usefulness of patient symptoms and nasal endoscopy in the diagnosis of chronic sinusitis. Am J Rhinol 1998; 12:167.
  19. Lal D, Rounds A, Dodick DW. Comprehensive management of patients presenting to the otolaryngologist for sinus pressure, pain, or headache. Laryngoscope 2015; 125:303.
  20. Hamilos DL. Chronic rhinosinusitis patterns of illness. Clin Allergy Immunol 2007; 20:1.
  21. Harvey RJ, Lund VJ. Biofilms and chronic rhinosinusitis: systematic review of evidence, current concepts and directions for research. Rhinology 2007; 45:3.
  22. Senior BA, Glaze C, Benninger MS. Use of the Rhinosinusitis Disability Index (RSDI) in rhinologic disease. Am J Rhinol 2001; 15:15.
  23. Bhattacharyya N. Functional limitations and workdays lost associated with chronic rhinosinusitis and allergic rhinitis. Am J Rhinol Allergy 2012; 26:120.
  24. Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg 1995; 113:104.
  25. Van Crombruggen K, Zhang N, Gevaert P, et al. Pathogenesis of chronic rhinosinusitis: inflammation. J Allergy Clin Immunol 2011; 128:728.
  26. Tomassen P, Van Zele T, Zhang N, et al. Pathophysiology of chronic rhinosinusitis. Proc Am Thorac Soc 2011; 8:115.
  27. Johansson L, Akerlund A, Holmberg K, et al. Prevalence of nasal polyps in adults: the Skövde population-based study. Ann Otol Rhinol Laryngol 2003; 112:625.
  28. Klossek JM, Neukirch F, Pribil C, et al. Prevalence of nasal polyposis in France: a cross-sectional, case-control study. Allergy 2005; 60:233.
  29. Hamilos DL. Nasal polyps as immunoreactive tissue. Allergy Asthma Proc 1996; 17:293.
  30. Arslan HH, Hidir Y, Durmaz A, et al. Unexpected tumor incidence in surgically removed unilateral and bilateral nasal polyps. J Craniofac Surg 2011; 22:751.
  31. Chang JE, White A, Simon RA, Stevenson DD. Aspirin-exacerbated respiratory disease: burden of disease. Allergy Asthma Proc 2012; 33:117.
  32. Mafee MF. Imaging of the nasal cavities, paranasal sinuses, nasopharynx, orbits, infratemporal fossa, pterygomaxillary fissure, parapharyngeal space, and base of skull. In: Ballenger's otorhinolaryngology head and neck surgery, 16th ed, Ballenger JJ, Show JB (Eds), BC Decker, Canada 2002.
  33. Hamilos DL, Leung DY, Wood R, et al. Chronic hyperplastic sinusitis: association of tissue eosinophilia with mRNA expression of granulocyte-macrophage colony-stimulating factor and interleukin-3. J Allergy Clin Immunol 1993; 92:39.
  34. Ponikau JU, Sherris DA, Kephart GM, et al. Features of airway remodeling and eosinophilic inflammation in chronic rhinosinusitis: is the histopathology similar to asthma? J Allergy Clin Immunol 2003; 112:877.
  35. Jani AL, Hamilos DL. Current thinking on the relationship between rhinosinusitis and asthma. J Asthma 2005; 42:1.
  36. Malekzadeh S, Hamburger MD, Whelan PJ, et al. Density of middle turbinate subepithelial mucous glands in patients with chronic rhinosinusitis. Otolaryngol Head Neck Surg 2002; 127:190.
  37. Drake-Lee AB, McLaughlan P. Clinical symptoms, free histamine and IgE in patients with nasal polyposis. Int Arch Allergy Appl Immunol 1982; 69:268.
  38. Van Zele T, Gevaert P, Watelet JB, et al. Staphylococcus aureus colonization and IgE antibody formation to enterotoxins is increased in nasal polyposis. J Allergy Clin Immunol 2004; 114:981.
  39. Bernstein JM, Kansal R. Superantigen hypothesis for the early development of chronic hyperplastic sinusitis with massive nasal polyposis. Curr Opin Otolaryngol Head Neck Surg 2005; 13:39.
  40. Bernstein JM, Allen C, Rich G, et al. Further observations on the role of Staphylococcus aureus exotoxins and IgE in the pathogenesis of nasal polyposis. Laryngoscope 2011; 121:647.
  41. Asero R, Bottazzi G. Nasal polyposis: a study of its association with airborne allergen hypersensitivity. Ann Allergy Asthma Immunol 2001; 86:283.
  42. Cyriac JT, Cherian T, Hadi WA, Jose J. Optic neuropathy due to allergic fungal rhinosinusitis. J Neurosci Rural Pract 2011; 2:180.
  43. Campbell JM, Graham M, Gray HC, et al. Allergic fungal sinusitis in children. Ann Allergy Asthma Immunol 2006; 96:286.
  44. Bhattacharyya N, Lee KH. Chronic recurrent rhinosinusitis: disease severity and clinical characterization. Laryngoscope 2005; 115:306.
  45. Cryer J, Schipor I, Perloff JR, Palmer JN. Evidence of bacterial biofilms in human chronic sinusitis. ORL J Otorhinolaryngol Relat Spec 2004; 66:155.
  46. Ferguson BJ, Stolz DB. Demonstration of biofilm in human bacterial chronic rhinosinusitis. Am J Rhinol 2005; 19:452.
  47. Sanclement JA, Webster P, Thomas J, Ramadan HH. Bacterial biofilms in surgical specimens of patients with chronic rhinosinusitis. Laryngoscope 2005; 115:578.
  48. Singhal D, Psaltis AJ, Foreman A, Wormald PJ. The impact of biofilms on outcomes after endoscopic sinus surgery. Am J Rhinol Allergy 2010; 24:169.
  49. Ponikau JU, Sherris DA, Kern EB, et al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc 1999; 74:877.
  50. Shin SH, Ponikau JU, Sherris DA, et al. Chronic rhinosinusitis: an enhanced immune response to ubiquitous airborne fungi. J Allergy Clin Immunol 2004; 114:1369.
  51. Ramadan HH. Chronic rhinosinusitis and bacterial biofilms. Curr Opin Otolaryngol Head Neck Surg 2006; 14:183.
  52. Kowalski ML, Cieślak M, Pérez-Novo CA, et al. Clinical and immunological determinants of severe/refractory asthma (SRA): association with Staphylococcal superantigen-specific IgE antibodies. Allergy 2011; 66:32.
  53. Benninger MS, Ferguson BJ, Hadley JA, et al. Adult chronic rhinosinusitis: definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003; 129:S1.
  54. Lee JT, Kennedy DW, Palmer JN, et al. The incidence of concurrent osteitis in patients with chronic rhinosinusitis: a clinicopathological study. Am J Rhinol 2006; 20:278.
  55. Emanuel IA, Shah SB. Chronic rhinosinusitis: allergy and sinus computed tomography relationships. Otolaryngol Head Neck Surg 2000; 123:687.
  56. Poachanukoon O, Nanthapisal S, Chaumrattanakul U. Pediatric acute and chronic rhinosinusitis: comparison of clinical characteristics and outcome of treatment. Asian Pac J Allergy Immunol 2012; 30:146.
  57. Kim YS, Kim NH, Seong SY, et al. Prevalence and risk factors of chronic rhinosinusitis in Korea. Am J Rhinol Allergy 2011; 25:117.
  58. Berrettini S, Carabelli A, Sellari-Franceschini S, et al. Perennial allergic rhinitis and chronic sinusitis: correlation with rhinologic risk factors. Allergy 1999; 54:242.
  59. Jarvis D, Newson R, Lotvall J, et al. Asthma in adults and its association with chronic rhinosinusitis: the GA2LEN survey in Europe. Allergy 2012; 67:91.
  60. Schlosser RJ, Gage SE, Kohli P, Soler ZM. Burden of illness: A systematic review of depression in chronic rhinosinusitis. Am J Rhinol Allergy 2016; 30:250.
  61. Lieu JE, Feinstein AR. Confirmations and surprises in the association of tobacco use with sinusitis. Arch Otolaryngol Head Neck Surg 2000; 126:940.
  62. Reh DD, Higgins TS, Smith TL. Impact of tobacco smoke on chronic rhinosinusitis: a review of the literature. Int Forum Allergy Rhinol 2012; 2:362.
  63. Pinto JM, Naclerio RM. Environmental and allergic factors in chronic rhinosinusitis. Clin Allergy Immunol 2007; 20:25.
  64. Bhattacharyya N. Air quality influences the prevalence of hay fever and sinusitis. Laryngoscope 2009; 119:429.
  65. Carr TF, Koterba AP, Chandra R, et al. Characterization of specific antibody deficiency in adults with medically refractory chronic rhinosinusitis. Am J Rhinol Allergy 2011; 25:241.
  66. Shapiro GG, Virant FS, Furukawa CT, et al. Immunologic defects in patients with refractory sinusitis. Pediatrics 1991; 87:311.
  67. Vanlerberghe L, Joniau S, Jorissen M. The prevalence of humoral immunodeficiency in refractory rhinosinusitis: a retrospective analysis. B-ENT 2006; 2:161.
  68. Dahl M, Tybjaerg-Hansen A, Schnohr P, Nordestgaard BG. A population-based study of morbidity and mortality in mannose-binding lectin deficiency. J Exp Med 2004; 199:1391.
  69. Psaltis AJ, Bruhn MA, Ooi EH, et al. Nasal mucosa expression of lactoferrin in patients with chronic rhinosinusitis. Laryngoscope 2007; 117:2030.
  70. Tan BK, Schleimer RP, Kern RC. Perspectives on the etiology of chronic rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg 2010; 18:21.
  71. Tewfik MA, Latterich M, DiFalco MR, Samaha M. Proteomics of nasal mucus in chronic rhinosinusitis. Am J Rhinol 2007; 21:680.
  72. Baroody FM. Mucociliary transport in chronic rhinosinusitis. Clin Allergy Immunol 2007; 20:103.
  73. Jang YJ, Kwon HJ, Park HW, Lee BJ. Detection of rhinovirus in turbinate epithelial cells of chronic sinusitis. Am J Rhinol 2006; 20:634.
  74. Lohrmann C, Uhl M, Warnatz K, et al. Sinonasal computed tomography in patients with Wegener's granulomatosis. J Comput Assist Tomogr 2006; 30:122.
  75. Alobid I, Guilemany JM, Mullol J. Nasal manifestations of systemic illnesses. Curr Allergy Asthma Rep 2004; 4:208.
  76. Reed J, deShazo RD, Houle TT, et al. Clinical features of sarcoid rhinosinusitis. Am J Med 2010; 123:856.
  77. Brook I. Sinusitis of odontogenic origin. Otolaryngol Head Neck Surg 2006; 135:349.
  78. Bomeli SR, Branstetter BF 4th, Ferguson BJ. Frequency of a dental source for acute maxillary sinusitis. Laryngoscope 2009; 119:580.
  79. Longhini AB, Branstetter BF, Ferguson BJ. Unrecognized odontogenic maxillary sinusitis: a cause of endoscopic sinus surgery failure. Am J Rhinol Allergy 2010; 24:296.
  80. Lusk RP, McAlister B, el Fouley A. Anatomic variation in pediatric chronic sinusitis: a CT study. Otolaryngol Clin North Am 1996; 29:75.
  81. Bolger WE, Butzin CA, Parsons DS. Paranasal sinus bony anatomic variations and mucosal abnormalities: CT analysis for endoscopic sinus surgery. Laryngoscope 1991; 101:56.
  82. Jones NS, Strobl A, Holland I. A study of the CT findings in 100 patients with rhinosinusitis and 100 controls. Clin Otolaryngol Allied Sci 1997; 22:47.
  83. Danese M, Duvoisin B, Agrifoglio A, et al. [Influence of naso-sinusal anatomic variants on recurrent, persistent or chronic sinusitis. X-ray computed tomographic evaluation in 112 patients]. J Radiol 1997; 78:651.
  84. Holbrook EH, Brown CL, Lyden ER, Leopold DA. Lack of significant correlation between rhinosinusitis symptoms and specific regions of sinus computer tomography scans. Am J Rhinol 2005; 19:382.
  85. Committee on Damp Indoor Spaces and Health. Damp indoor spaces and health. The National Academies Press; Board of Health Promotion and Disease Prevention, Institute of Medicine of the National Academies, Washington, DC, 2004.
  86. Bhattacharyya N, Lee LN. Evaluating the diagnosis of chronic rhinosinusitis based on clinical guidelines and endoscopy. Otolaryngol Head Neck Surg 2010; 143:147.
  87. Tichenor WS, Adinoff A, Smart B, Hamilos DL. Nasal and sinus endoscopy for medical management of resistant rhinosinusitis, including postsurgical patients. J Allergy Clin Immunol 2008; 121:917.
  88. Peters AT, Spector S, Hsu J, et al. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol 2014; 113:347.
  89. Mafee MF, Tran BH, Chapa AR. Imaging of rhinosinusitis and its complications: plain film, CT, and MRI. Clin Rev Allergy Immunol 2006; 30:165.
  90. Bhattacharyya N, Fried MP. The accuracy of computed tomography in the diagnosis of chronic rhinosinusitis. Laryngoscope 2003; 113:125.
  91. Berrington de González A, Mahesh M, Kim KP, et al. Projected cancer risks from computed tomographic scans performed in the United States in 2007. Arch Intern Med 2009; 169:2071.
  92. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med 2007; 357:2277.
  93. Rose AS, Thorp BD, Zanation AM, Ebert CS Jr. Chronic rhinosinusitis in children. Pediatr Clin North Am 2013; 60:979.
  94. Setzen G, Ferguson BJ, Han JK, et al. Clinical consensus statement: appropriate use of computed tomography for paranasal sinus disease. Otolaryngol Head Neck Surg 2012; 147:808.
  95. Stammberger H. Functional Endoscopic Sinus Surgery, BC Decker, Philadelphia 1991.
  96. Socher JA, Cassano M, Filheiro CA, et al. Diagnosis and treatment of isolated sphenoid sinus disease: a review of 109 cases. Acta Otolaryngol 2008; 128:1004.
  97. Nour YA, Al-Madani A, El-Daly A, Gaafar A. Isolated sphenoid sinus pathology: spectrum of diagnostic and treatment modalities. Auris Nasus Larynx 2008; 35:500.
  98. Güvenç MG, Kaytaz A, Ozbilen Acar G, Ada M. Current management of isolated sphenoiditis. Eur Arch Otorhinolaryngol 2009; 266:987.
  99. Grillone GA, Kasznica P. Isolated sphenoid sinus disease. Otolaryngol Clin North Am 2004; 37:435.
  100. Lin HW, Bhattacharyya N. Diagnostic and staging accuracy of magnetic resonance imaging for the assessment of sinonasal disease. Am J Rhinol Allergy 2009; 23:36.
  101. Zinreich SJ, Kennedy DW, Malat J, et al. Fungal sinusitis: diagnosis with CT and MR imaging. Radiology 1988; 169:439.
  102. Mukherji SK, Figueroa RE, Ginsberg LE, et al. Allergic fungal sinusitis: CT findings. Radiology 1998; 207:417.
  103. Asero R, Bottazzi G. Hypersensitivity to molds in patients with nasal polyposis: A clinical study. J Allergy Clin Immunol 2000; 105:186.
  104. Bhattacharyya T, Piccirillo J, Wippold FJ 2nd. Relationship between patient-based descriptions of sinusitis and paranasal sinus computed tomographic findings. Arch Otolaryngol Head Neck Surg 1997; 123:1189.
  105. Hopkins C, Browne JP, Slack R, et al. The Lund-Mackay staging system for chronic rhinosinusitis: how is it used and what does it predict? Otolaryngol Head Neck Surg 2007; 137:555.
  106. Jones NS. The prevalence of facial pain and purulent sinusitis. Curr Opin Otolaryngol Head Neck Surg 2009; 17:38.
  107. Ozturk O, Oz F, Karakullukcu B, et al. Hoarseness and laryngopharyngeal reflux: a cause and effect relationship or coincidence? Eur Arch Otorhinolaryngol 2006; 263:935.
  108. von Kalle T, Fabig-Moritz C, Heumann H, Winkler P. Incidental findings in paranasal sinuses and mastoid cells: a cross-sectional magnetic resonance imaging (MRI) study in a pediatric radiology department. Rofo 2012; 184:629.
  109. Kroll KE, Camacho MA, Gautam S, et al. Findings of chronic sinusitis on brain computed tomography are not associated with acute headaches. J Emerg Med 2014; 46:753.