Chronic Sinusitis

Background

Chronic sinusitis is very common affecting as many as 1/1000 people. It is divided into purulent and non-purulent types. The maxillary sinus is the most frequent site. Chronic implies a symptom duration of more than 12 weeks.

Nitric oxide is produced in the upper respiratory tract. This molecule has antimicrobial activity which also probably contributes to local inflammation. Eosinophils are the predominant inflammatory cell type in sinus tissues of patients with chronic sinusitis, suggesting an immunologic and possibly allergic etiology, although many patients with chronic sinusitis are not sensitized to common aeroallergens. Patients with chronic sinusitis also have rhinitis, and many have impaired smell sensitivity, suggesting that nasal inflammation and abnormalities of the olfactory sensory epithelium contribute to sinusitis.

Although many bacterial and viruses are implicated, the role of infection in chronic sinusitis is uncertain. Non-infectious stimuli (including odorants and particulates) may induce immune and inflammatory responses. Patients with chronic sinusitis have elevated IgE levels, often an indication of an allergic response. Many patients with chronic sinusitis also have asthma, but the relationship between these two diseases is not understood.

Under the microscope, there is a mixed inflammatory cell infiltrate with eosinophils predominating. The sinus tissue has edema, glandular hyperplasia, basement membrane thickening, and squamous metaplasia.

PROGNOSIS AND TREATMENT CHARACTERIZATION

PROGNOSIS

Chronic sinusitis. Relationship of computed tomographic findings to allergy, asthma, and eosinophilia.

Newman LJ, Platts-Mills TA, Phillips CD, Hazen KC, Gross CW.

Department of Medicine, University of Virginia Health Sciences Center, Charlottesville 22908.

JAMA 1994 Feb 2;271(5):363-7 Abstract quote

OBJECTIVE--To develop a technique for evaluating the severity of chronic sinus disease and to examine the correlation with allergy, asthma, and eosinophilia.

DESIGN--A survey of 104 patients undergoing surgery for chronic sinusitis.

SETTING--A university hospital ear, nose, and throat clinic.

PATIENTS--A referral population of adult patients being scheduled for endoscopic sinus surgery was eligible; 104 completed questionnaires and agreed to participate.

MAIN OUTCOME MEASURES--Computed tomographic scans were reviewed and scored for extent of disease. Serum samples were assayed for total IgE and specific IgE antibodies to common inhalant allergens. Peripheral blood samples were analyzed for total eosinophil count. Surgical biopsy specimens were examined for eosinophilia and cultured for bacteria and fungi.

RESULTS--Extensive disease was present in 39% of subjects and correlated well with asthma, specific IgE antibodies, and eosinophilia, but not with elevated total IgE. Among patients with peripheral eosinophilia, 87% had extensive disease. All cultures grew aerobic bacteria; anaerobes and fungi were uncommon.

CONCLUSIONS--We present a system for quantitation of disease extent using computed tomographic scans of patients with chronic sinusitis. The well-accepted associations of chronic sinusitis with asthma and allergy appear to be restricted to the group with extensive disease. The presence of peripheral eosinophilia in patients with sinusitis indicates a high likelihood of extensive disease.

Does the severity of sinus computed tomography findings predict outcome in chronic sinusitis?

Stewart MG, Donovan DT, Parke RB Jr, Bautista MH. Bobby R.

Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, Texas 77030, USA.

Otolaryngol Head Neck Surg 2000 Jul;123(1 Pt 1):81-4 Abstract quote

OBJECTIVES: We studied the association between the severity of pretreatment CT scan findings and the improvement in symptoms of chronic sinusitis after treatment.

METHODS: We analyzed data from an ongoing prospective, nonrandomized clinical outcomes study of patients treated for chronic sinusitis at a tertiary-care academic medical center (n = 57, mean age 46.8 years). Disease-specific symptom severity was measured with a validated health status instrument, and CT stage was quantified with the Harvard CT staging system.

RESULTS: In a multivariate analysis, symptom severity based on CT findings emerged as a strong predictor of both improvement in symptom score outcome (beta = 0.47, P = 0.01) and absolute symptom level after treatment (beta = -0.58, P = 0.001).

CONCLUSIONS: Severity as assessed by a pretreatment CT scan is a strong predictor of outcome. Patients with higher symptom severity based on CT scans showed significantly larger improvement and lower absolute levels of symptom severity after treatment. This study links CT scan findings and subjective patient-based outcomes (symptom scores) using a validated outcomes instrument.

TREATMENT

Functional endoscopic sinus surgery in chronic sinusitis--a series of 237 consecutively operated patients.

Jakobsen J, Svendstrup F. Odense

University Hospital, Department of Otorhinolaryngology, Head and Neck Surgery, Denmark.

Acta Otolaryngol Suppl 2000;543:158-61 Abstract quote

From 1989 to 1999, 237 consecutive patients with chronic sinusitis and/or nasal polyposis entered a prospective study on the effect of functional endoscopic sinus surgery (FES).

Nasal stenosis associated with massive nasal polyposis was the most frequent problem found in 61% of the patients. The rest had long-lasting symptoms of chronic sinusitis. Duration of symptoms averaged 9.3 years. Most frequent symptoms preoperatively were: nasal stenosis, chronic secretion, anosmia, frontal pain, headache and maxillary pain. All patients had the operation performed under general anaesthesia. 86% of the patients have been operated bilaterally. In 72% the posterior ethmoid was opened, and in 54% the sphenoid was opened. The maxillary ostium has been enlarged in 82% of the patients and the frontal recess opened in 51% of the cases. No serious complications were registered. Annoying bleeding was experienced in 21%, hampering the intended procedure. In three patients rhinoliquore was observed. One case was treated during the procedure; the last two patients were in no need of surgical treatment.

At the 1-year follow-up study, 45% of the patients were totally satisfied with the results and without symptoms, and 44% were definitely feeling better.

Sternberg S. Diagnostic Surgical Pathology. Third Edition. Lipincott Williams and Wilkins 1999.

Commonly Used Terms

Nasopharynx

Last Updated 10/20/2001

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PROGNOSIS AND TREATMENT	CHARACTERIZATION
PROGNOSIS
Chronic sinusitis. Relationship of computed tomographic findings to allergy, asthma, and eosinophilia. Newman LJ, Platts-Mills TA, Phillips CD, Hazen KC, Gross CW. Department of Medicine, University of Virginia Health Sciences Center, Charlottesville 22908.	JAMA 1994 Feb 2;271(5):363-7 Abstract quote OBJECTIVE--To develop a technique for evaluating the severity of chronic sinus disease and to examine the correlation with allergy, asthma, and eosinophilia. DESIGN--A survey of 104 patients undergoing surgery for chronic sinusitis. SETTING--A university hospital ear, nose, and throat clinic. PATIENTS--A referral population of adult patients being scheduled for endoscopic sinus surgery was eligible; 104 completed questionnaires and agreed to participate. MAIN OUTCOME MEASURES--Computed tomographic scans were reviewed and scored for extent of disease. Serum samples were assayed for total IgE and specific IgE antibodies to common inhalant allergens. Peripheral blood samples were analyzed for total eosinophil count. Surgical biopsy specimens were examined for eosinophilia and cultured for bacteria and fungi. RESULTS--Extensive disease was present in 39% of subjects and correlated well with asthma, specific IgE antibodies, and eosinophilia, but not with elevated total IgE. Among patients with peripheral eosinophilia, 87% had extensive disease. All cultures grew aerobic bacteria; anaerobes and fungi were uncommon. CONCLUSIONS--We present a system for quantitation of disease extent using computed tomographic scans of patients with chronic sinusitis. The well-accepted associations of chronic sinusitis with asthma and allergy appear to be restricted to the group with extensive disease. The presence of peripheral eosinophilia in patients with sinusitis indicates a high likelihood of extensive disease.
Does the severity of sinus computed tomography findings predict outcome in chronic sinusitis? Stewart MG, Donovan DT, Parke RB Jr, Bautista MH. Bobby R. Alford Department of Otorhinolaryngology and Communicative Sciences, Baylor College of Medicine, Houston, Texas 77030, USA.	Otolaryngol Head Neck Surg 2000 Jul;123(1 Pt 1):81-4 Abstract quote OBJECTIVES: We studied the association between the severity of pretreatment CT scan findings and the improvement in symptoms of chronic sinusitis after treatment. METHODS: We analyzed data from an ongoing prospective, nonrandomized clinical outcomes study of patients treated for chronic sinusitis at a tertiary-care academic medical center (n = 57, mean age 46.8 years). Disease-specific symptom severity was measured with a validated health status instrument, and CT stage was quantified with the Harvard CT staging system. RESULTS: In a multivariate analysis, symptom severity based on CT findings emerged as a strong predictor of both improvement in symptom score outcome (beta = 0.47, P = 0.01) and absolute symptom level after treatment (beta = -0.58, P = 0.001). CONCLUSIONS: Severity as assessed by a pretreatment CT scan is a strong predictor of outcome. Patients with higher symptom severity based on CT scans showed significantly larger improvement and lower absolute levels of symptom severity after treatment. This study links CT scan findings and subjective patient-based outcomes (symptom scores) using a validated outcomes instrument.
TREATMENT
Functional endoscopic sinus surgery in chronic sinusitis--a series of 237 consecutively operated patients. Jakobsen J, Svendstrup F. Odense University Hospital, Department of Otorhinolaryngology, Head and Neck Surgery, Denmark.	Acta Otolaryngol Suppl 2000;543:158-61 Abstract quote From 1989 to 1999, 237 consecutive patients with chronic sinusitis and/or nasal polyposis entered a prospective study on the effect of functional endoscopic sinus surgery (FES). Nasal stenosis associated with massive nasal polyposis was the most frequent problem found in 61% of the patients. The rest had long-lasting symptoms of chronic sinusitis. Duration of symptoms averaged 9.3 years. Most frequent symptoms preoperatively were: nasal stenosis, chronic secretion, anosmia, frontal pain, headache and maxillary pain. All patients had the operation performed under general anaesthesia. 86% of the patients have been operated bilaterally. In 72% the posterior ethmoid was opened, and in 54% the sphenoid was opened. The maxillary ostium has been enlarged in 82% of the patients and the frontal recess opened in 51% of the cases. No serious complications were registered. Annoying bleeding was experienced in 21%, hampering the intended procedure. In three patients rhinoliquore was observed. One case was treated during the procedure; the last two patients were in no need of surgical treatment. At the 1-year follow-up study, 45% of the patients were totally satisfied with the results and without symptoms, and 44% were definitely feeling better.