1. Rhinosinusitis
Definitions: The term sinusitis refers to a group of disorders characterized by inflammation of the
mucosa of the paranasal sinuses. Because the inflammation nearly always also involves the nose, it is
now generally accepted that rhinosinusitis is the preferred term to describe this inflammation of the
nose & paranasal sinuses.
Classification of rhinosinusitis
Classification Duration
Acute (ARS) 7days to ≤4weeks
Subacute 4-12weeks
Recurrent acute ≥4episodes of ARS per year
Chronic (CRS) ≥12weeks
Acute exacerbation of chronic Sudden worsen of CRS with return to
baseline after.
The newer definition are:
Rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose &
paranasal sinuses.
Chronic rhinosinusitis is a group of disorders characterized by inflammation of the nose & paranasal
sinuses of at least 12 consecutive weeks duration.
Rhinosinusitis symptoms/signs(require two major factors or one major &
two minor)
Major symptoms Minor symptoms
Facial pain/pressure
Facial congestion/blockage
Nasal discharge/purulent/discoloured posterior
drainage
Hyposmia /anosmia
Purulent on nasal examination
Fever (acute RS only)
Headache
Fever (nonacute)
Halitosis
Fatique
Dental pain
Cough

2. Ear pain/ pressure/fullness
Pathophysiology
An inflammatory response is an expected sequel of an infectious process.Inflammation of nose &
paranasal sinuses result in sinus ostia obstruction.
Predisposing factors to develop infection:
Genetic factors; immotile cilia syndrome, cystic fibrosis,
Anatomic abnormalities; anatomic abnormalities of concha bullosa, septal spur, paradoxical
turbinate,
Allergic or immune disorders
Trauma
Primary or secondary tobacco smoke exposure
Chronic or acute irritants
Noxious chemicals
Nasal packing
Nasogastric tube placement
Pathophysiology of ABRS
1) in conjunction of with an acute viral upper respiratory tract infection>mucosal oedema>occlusion
of sinus ostia>reduction of oxygen tension>transudation of fluid in the sinus> alteration of
mucous>mucostasis>bacterial colonization>bacterial infection>develops into acute sinus infection.
2) allergy:Antigen –antibody reactions >release of histamine& others mediators >oedema>occlusion
of sinus ostia> same as above.
Development of CRS involves eosinophils, neutrophils, mast cells, T &B cells, immunoglobulin,
interleukins, tumour necrosis factors, major basic proteins. Others factors to development of CRS
including biofilm, superantigen & osteitis.
Bacteriology of ABRS:
Streptococcus pneumoniae & Haemophilus influenzae in adult.while streptococcus pneumoniae
Haemophilus influenza & Morexella catarrhalis are predominant organisms in children.
Staphylococcus aureus is a real pathogen for ABRS to treat. Since Morexella catarrhalis is largely
self-limiting pathogen.
Bacteriology of CRS

3. Most common Staphylococcus species,(55%)Staphylococcus aureus (20%),Enterobacteriaceae,
anaerobes, gram negative organisms & fungi.
Diagnosis
The diagnosis of ABRS is best made on clinical grounds & criteria.
The diagnosis for research should include more objective information. Endoscopic-guided middle
meatus cultures in lieu of maxillary sinus taps.If one is to make diagnosis of bacterial RS, culture is
more than 1.0×104 colony forming unit (CFU)/ml in sinus aspirate.Lower colony concentrations could
represent early infection.
CRS & sub-acute RS, definitive methods for diagnosis have not yet been determined.The
recommonded time frames greater than 12 weeks for CRS & 4 to 12 weeks for SRS.(sub-acute
rhinosinusitis). Identification of length of time from onset of symptoms or first physical finding.
1) Nasal endoscopes are valuable to assess the nasal anatomy, confirm drainage & evaluate
treatment response.
2) Plain x-ray of PNS; poor specificity & sensitivity, donot add much in subacute & CRS.
3) CT scan can’t distinguish between inflammation & infections but correlate fairly well with
the extent of disease.
4) MRI; lack of bony detail needed for surgical intervention.
It has been recently recommended that either a CT scan or endoscopic evaluation of the
nose(preferably photo or video documentation) should be a part of any prospective clinical trial in
CRS.
Natural history
ABRS tende to be a self-limited disease.It is clear however, that antibiotic play an important role in
reducing symptoms & speeding the time to recovery. Because of rapid improvement, ABRS are best
treated with antibiotics. The natural history of CRS is much more variable depend on host & external
factors.
Complications of ABRS are rare. Complications of CRS are even more difficult given the
heterogeneity of the disease.
Prevalence of rhinosinusitis
It is estimated that children have between 6 to 8 URI per year & adults average 2 to3. 90% of
patients with cold have sinusitis(bacterial or viral).