3. Rhinosinusitis
Rhinosinusitis is the inflammation of the mucosal lining of the nasal cavity and
paranasal sinuses.
we have four paranasal sinus:
Frontal sinus
Ethmoid sinus
Sphenoid sinus
Maxillary sinus
These paranasal sinuses drain into the nasal cavity
4. Classification of acute rhinosinusitis
AVRS (Common colds) are defined as acute viral
rhinosinusitis with a duration of symptoms of <10
days (but less than 12 weeks).
APVRS (Acute post-viral rhinosinusitis) When
symptoms increase after five days, or when symptoms
are persistent for more than 10 days, with less than
12 weeks duration.
5. Cont’
ABRS (Acute bacterial rhinosinusitis) is defined by at least three symptoms/signs of
Discolored mucus, Severe local pain (often unilateral), Fever > 38°C, Raised
CRP/ESR‘double’ sickening.
RARS (recurrent acute rhinosinusitis) is defined as ≥4 episodes per year with
symptom free intervals. Each episode must meet the criteria for acute post-viral or
bacterial rhinosinusitis.
6. Pathophysiology
rhinosinusitis is triggered by three factors :
obstruction of sinus drainage pathways (sinus ostium): foreign body, nasal
polyp, rhinitis, deviated septum…
ciliary impairment: depend on mucociliary transport mechanism not gravity.
Can be caused by immobile cilia, bacterial or viral inoculation, contact
between 2 mucosal surfaces….
altered mucus quantity and quality: mucus have 2 layers, inner serous layer
(sol phase) in which cilia recover from their active beat, and outer viscous
layer (gel phase) which is transported by ciliary beats. Ex: cystic fibrosis,
overproduction.
7. The cascade of inflammation will lead to damage by the infiltrating cells, causing oedema,
engorgement, fluid extravasation, mucus production and sinus obstruction in the process.
Stasis of secretions inside the sinus proliferation of various pathogens rhinosinusitis.
8. Risk factors
The most organisms found are:
Viruses: rhinovirus, corona virus, influenza A and B, RSV, Parainfluenza
Bacteria: S. pneumonia, H. influenza, M. cattarrhalis.
Active or passive smoking
Anatomical variation, such as septal deviation
Odontogenic infection
Concomitant chronic diseases such as asthma, cystic fibrosis
Immune system disorders such as HIV/AIDS
9. Clinical presentation
Nasal blockage, congestion or stuffiness
Nasal discharge or postnasal drip, often mucopurulent
Facial pain or pressure
Reduction/loss of smell
Fever
other symptoms: headache, cough, fatigue, ear (pain, pressure
or fullness), halitosis, dental pain.
10. Investigations
Lab tests: CRP/ ESR, procalcitonin
rhinoscopy
Nasal swab
Imaging studies: when there’s no response to medication after 2weeks
o X-ray of paranasal sinuses (PNS) to demonstrate fluid level, pus or opacity
o CT scan of paranasal sinuses without contrast is standard, it may show thickening of
mucosa.
12. Red flag symptoms
Eye signs: periorbital swelling, displaced globe,
double vision, ophtalmoplegia.
Severe unilateral headache, frontal swelling, frontal
headache.
Reduced level of consciousness.
13. Complications of ABRS
Orbital complication (chandler’s classification)
Stage 1: pre-septal cellulitis
Stage 2: orbital cellulitis
Stage 3: subperiosteal abscess
Stage 4: orbital abscess
Stage 5: cavernous sinus thrombosis
Nasal septal abscess
Osteomyelitis
Pott’s puffy tumour (osteomyelitis of the frontal
sinus)
14. Take home message
acute rhinosinusitis is inflammation of the mucosal lining of the nasal passage
and paranasal sinuses.
Symptoms usually last for few days and can include nasal obstruction,
discharge, facial pain, hyposmia.
Most cases can be diagnosed clinically and managed conservatively (antibiotics
are not routinely required)
If no improvement on treatment (7-14 days) or presence of red-flag symptoms
refer to ENT specialist.
15. References
EPOS 2020 article
Current diagnosis and treatment-Otolaryngology 3rd ed-
A.Lalwani(McGraw-Hill Lange)
Uptodate
medscape
