Vol.

8, No: 1
Jan - Jun 2012. Page 1 - 44

Amrita Journal of Medicine

review article

Chronic Rhinosinusitis An Overview

N.V Deepthi*, U.K. Menon*, K. Madhumita*
Abstract
Chronic rhinosinusitis (CRS) is a common condition with significant social implications due to the loss of working hours. The common
pathophysiologic denominator for virtually all forms of CRS is inflammation, for which extensive pharmacotherapy is available. Unfortunately, not all patients are cured or achieve control of their symptoms even with maximal medical management. In such cases, functional
endoscopic sinus surgery (FESS) is warranted. Management modalities, although varied, can be rewarding in the compliant patient. However, there is significant variability and a lack of standardization of guidelines with respect to the above modalities. This article attempts
to give the readers an overview of the methodology of investigations and treatment of this ubiquitous ENT problem.
Key words: Chronic rhinitis, sinusitis, CT scan Paranasal sinuses, surgery

Introduction
Chronic rhinosinusitis (CRS) is
one of the most frequent otorhinolaryngologic diseases encountered
in everyday practice. It is thus a
common enough medical condition,
but one in which the diagnosis and
prognosis depend on symptoms,
signs, clinical judgement and radiological evaluation. This is often
not very straightforward; numerous
investigators have attempted to
characterize this condition based on
various factors. Some of these are as
follows: Symptom scores, Computed
Tomography scores, Endoscopic findings, Surgical findings, Culture results
and Histopathology results.
CRS is a group of disorders characterized by inflammation of the
mucosa of the nose and paranasal
sinuses of at least 12 consecutive
weeks duration. In addition, osteitis
of the underlying bone can occur.
Several factors, both intrinsic and
extrinsic contribute to the development of CRS.
The management approach to
a patient presenting with CRS is in
a logical stepwise fashion with the
goal of maximizing his/her medical
management and symptom relief.
In the setting of failure of medical
management, functional endoscopic
sinus surgery (FESS) is now the widely
accepted surgical modality.
*Dept. of ENT, AIMS, Kochi.

Methods
Information used to write this
paper has been collected essentially
as part of a post-graduate dissertation accepted by the National Board
of Examination. Standard texts,
articles from indexed Journals and
various sources in the electronic data
bases using the key words chronic
rhinosinusitis, nasal polyposis and
functional endoscopic sinus surgery
were used to do the background
study. Preference was given to more
recent studies.
Incidence
Chronic rhinosinusitis (CRS) is a
common disease affecting over 30
million individuals globally each
year with more than 200,000 people
annually requiring surgical intervention1. It is reported to be more
prevalent than arthritis or hypertension, affecting between 5% and 15%
of studied populations2 according to
western literature. It is a common
problem that exacts a high cost in
terms of direct health care as well as
lost productivity.

Definition
Rhinosinusitis is a group of disorders characterized by inflammation of
the mucosa of the nose and paranasal
sinuses. Chronic rhinosinusitis is a
group of disorders characterized by

inflammation of the mucosa of the

nose and paranasal sinuses of at least
12 consecutive weeks duration3.
Aetiological factors
A] Host factors:
Systemic host factors
Allergy, Immunodeficiency, Genetic/Congenital, Mucociliary
dysfunction etc
Local host factors
Anatomic, neoplastic and acquired mucociliary dysfunction
B] Environmental:
Microorganisms, noxious
chemicals, pollutants, smoke,
medications etc
C] Other Associated Factors:
Asthma, allergy, dental disease,
polyposis, cystic fibrosis, and
immunodeficiency syndromes3.
Pathophysiology
The essential pathology in CRS
consists of inadequate or blocked
drainage of the paranasal sinuses [PNS] leading to stasis and/or
secondary infection. The site of
block is invariably the area that has
been described as the ostiomeatal
complex[OMC]. The normal anatomical-physiological system of the
air-filled PNS, draining their secretions and mucus via small ostia into
a relatively small area in the lateral
wall of the nose {Figure 1}, is liable
to assault and that too rather easily,

Amrita Journal of Medicine

nusitis, more than 4 weeks but less than 12 weeks. As
earlier stated, the RSTF further defined chronic rhinosinusitis as lasting more than 12 weeks7

Mucociliary
clearance of
frontal sinus

The major and minor symptoms and signs suggested by

RSTF are given in Table 1.

Osteomeatal
complex

TABLE 1
Factors associated with diagnosis of rhinosinusitis3
(Requires two major factors or one major and two
minor factors)
Major factors

Mucociliary
clearance of
maxillary
sinus

Fluid
collected in
sinus

Cilia drain sinuses by propelling mucus toward

natural ostia (mucocilisty clearance)

Fig. 1: Schematic representation of ostiomeatal complex

and normal mucociliary clearance

by a host of factors. Most of these have been mentioned

in the earlier list. One or many of them can contribute
to disrupt either the anatomy or the physiology of the
PNS system.
Recent findings
Rhinologic literature has suggested the involvement
of a significant inflammatory component that has been
largely attributed to cytokines and inflammatory cells
mediated by the adaptive immune system4. Recent
papers have implicated staphylococcal super antigens,
bacterial biofilms, and fungal colonization as key elements in CRS5.
Clinical features, standardized
In August 1996, the American Academy of OtolaryngologyHead and Neck Surgery (AAOHNS) convened
a multidisciplinary Rhinosinusitis Task Force (RSTF) to
confront difficult issues related to defining, staging, and
research of rhinosinusitis5. The resulting article Adult
Rhinosinusitis Defined, emerged in 1997 and was
endorsed by the AAO-HNS, the American Academy
of Otolaryngologic Allergy (AAOA), and the American
Rhinologic Society (ARS)6.
The article Adult Rhinosinusitis Defined characterizes rhinosinusitis into 5 separate clinical categories:
acute, sub acute, chronic, recurrent acute and acute
exacerbation of CRS. Acute rhinosinusitis is a clinical
condition lasting less than 4 weeks; sub acute rhinosi-

Facial pain/pressure (this

alone does not constitute
a suggestive history for
rhinosinusitis in the absence of another major
nasal symptom or sign)

Minor factors
Headache

Nasal obstruction/
blockage

Fever (all non-acute)

Nasal discharge/
purulence/

Halitosis

Discoloured postnasal
drainage

Fatigue

Hyposmia/ anosmia

Dental pain

Purulence in nasal cavity

on examination

Cough

Fever (in acute sinusitis

alone does not constitute
a strongly suggestive history for rhinosinusitis in
the absence of another
major nasal symptom or
sign)

Ear pain/pressure/
fullness

Measures for diagnosing CRS for

adult clinical care
History:
Duration of disease is qualified by continuous symptoms for > 12 consecutive weeks or > 12 weeks of
physical findings
Clinical examination:
One of these signs of inflammation must be present
and identified in association with ongoing symptoms
consistent with CRS
a. Discoloured nasal drainage arising from the nasal passages, nasal polyps, or polypoid swelling

Amrita Journal of Medicine

as identified on physical examination, either by
anterior rhinoscopy in the decongested nose or by
nasal endoscopy. {Figure 2}

Fig. 2: Nasal endoscopic appearance of polyp in the right

middle meatus

b. Oedema or erythema of the middle meatus or

ethmoid bulla as identified by nasal endoscopy.
c. Generalized or localized erythema, edema, or
granulation tissue. If it does not involve the middle meatus or ethmoid bulla, radiologic imaging
is required to confirm a diagnosis (Other chronic
rhinologic conditions such as allergic rhinitis can
have such findings, and therefore they may not be
associated with rhinosinusitis. It is recommended
that a diagnosis of rhinosinusitis requires radiologic
confirmation under these circumstances)8.
Investigations:
Imaging modalities for confirming the diagnosis:
i) Plain sinus radiographCaldwells and Waters
views revealing:

a) Mucous membrane thickening of > 5 mm

b) Complete opacification of one or more sinuses

Fig. 3: Coronal study of Computed tomography of paranasal sinus showing opacification and diffuse mucosal
thickening of maxillary and ethmoid sinuses, right > left
6

Chronic Rhinosinusitis An Overview

c) An air-fluid level - more predictive of acute

rhinosinusitis, but may also be seen in chronic
rhinosinusitis

(A plain sinus x-ray without the equivocal signs
listed in a, b, or c is not considered diagnostic.
Aside from an air-fluid level, plain sinus radiographs have low sensitivity and specificity)
ii) Computed Tomography (CT) scandemonstrating isolated or diffuse mucosal thickening, bone
changes and air-fluid level. {Figure 3} This is the
gold standard investigation for CRS.
iii) Magnetic Resonance Imaging (MRI) is not recommended as an alternative to CT for routine diagnosis
of CRS because of its excessively high sensitivity
and lack of specificity3.
Other investigations:
A number of other tests that may be important to
individual studies and protocols include the following:

Allergy testing: There is good evidence that the
incidence of CRS is increased in the allergic
patient. Therefore allergy testing by Skin prick
test or Specific IgE or RAST may be measured
in many studies.

Validated outcomes instruments to measure
the quality of life and patient perception of disability.

Rhinomanometry and acoustic rhinometry to
objectively measure nasal patency and resistance

Mucociliary clearance testing including saccharine methods or radioisotopes

Olfactory evaluations with validated threshold
and suprathreshold testing

Nasal cytology

Directed laboratory evaluation to detect underlying associated systemic disease such as
measurement of serum eosinophilia, IgE levels,
and genetic testing.
Nasal Endoscopy:
Most commonly used endoscopes are 4.0mm, 30
degree rigid scope and/or 0 degree scope. In adults
with narrow nasal passages or in children, a 2.7mm,
30 degree rigid endoscope or a flexible nasopharyngoscope may be better tolerated. 30 and 45 degree scopes
provide direct line of sight and angled visualization.
An organized nasal endoscopy in 3 passes is the
usual method adopted.
The first pass is along the floor of the nose. Inferior
meatus, Eustachian tube orifices, Torus tubarius, adenoid pad and entire nasopharynx can be visualized.
Secretions originating from the OMC will typically drain
below the Eustachian tube orifice, while those originating from the posterior ethmoids or sphenoid sinuses will
pass above the torus tubarius.

Amrita Journal of Medicine

For the second pass, the endoscope is reinserted
between the middle and inferior turbinates, and advanced in a posterior direction. The inferior portion of
the middle turbinate, middle meatus, the fontanelles
and accessory ostia are examined. Sphenoethmoidal
recess, superior turbinate and natural sphenoid os may
also be visualized.
Third pass view is by lateral rotation of the endoscope beneath the posterior aspect of middle turbinate
to gain access to the deeper areas of the middle meatus,
bulla ethmoidalis, hiatus semilunaris and infundibular
entrance. As the scope is withdrawn, further excellent
view of the uncinate process is obtained.
Once diagnosed, attempts to further define the severity of CRS include methods to assess patient symptoms.
Here again, various study groups have come up with
different evaluation systems.
Rhinosinusitis Task Force Major and Minor symptom
criteria9
20 item Sinonasal Outcome Test 10 (SNOT20)
Chronic Sinusitis Survey9 (CSS)
Rhinosinusitis Symptom Inventory (RSI)10
Visual Analogue Score (VAS) Questionnaire11
An approximate algorithm in a CRS case could be as
follows:
Diagnostic Nasal Endoscopy (DNE)

Normal
Findings

Positive
Findings

Allergic

Anti-allergic
treatment

Discharge

Polyps

Culture &
sensitivity directed
antimicrobials

Protocol treatment
(Including oral
steroids)

Consider
CT PNS

Role and relevance of CT PNS study

To confirm the diagnosis of rhinosinusitis
To assess the severity of cases refractory to medical
therapy prior to surgery
To provide the anatomic precision needed to guide
endoscopic sinus surgery
To assess response to surgical intervention {Figure
4 a, b}

Lund-Mackay staging system, proposed in 1993, is

considered as the most widely accepted staging system
in CRS (Table 2).

Sinus system
Maxillary
Anterior ethmoidal
Posterior ethmoidal
Sphenoidal
Frontal
Ostiomeatal complex
Total points for each side

Right Left
0,1and 2 0,1and 2
0,1and 2 0,1and 2
0,1and 2 0,1and 2
0,1and 2 0,1and 2
0,1and 2 0,1and 2
0, and 2 0, and 2
0-12
0-12

Scoring: For all sinus systems, except the ostiomeatal

complex:
0 - no abnormalities, 1- partial opacification, 2- total
opacification
For the ostiomeatal complex:
0 - not occluded, 2 - occluded
Treatment modalities
Medical therapy12.
Absolute medications
Allergen or irritant avoidance, 3-weeks course of
culture-directed or broad spectrum antibiotics and
8-weeks course of topical nasal steroid spray
Supportive Treatment
Systemic decongestants, Antihistamines and tapering
systemic corticosteroids
Role and relevance of endoscopic sinus surgery
In those patients who have failed medical management, functional endoscopic sinus surgery (FESS) has
been demonstrated and is generally accepted to provide improved relief of symptoms and better quality
of life. Although there is some controversy as to the
best or most appropriate surgical technique for treating patients with CRS with polyposis (CRSwP) most
surgeons will recommend that these patients undergo
polypectomy, complete ethmoidectomy, and middle
meatal antrostomy, with or without frontal sinusotomy
or sphenoidotomy.
Surgical anatomy
Of all the paranasal sinuses, the ethmoid sinus is the
most complex and is aptly referred to as a labyrinth.
The ethmoids attain adult size by the twelfth year.
However, when infection spreads from the ostiomeatal
area to involve the maxillary and frontal sinuses, it is the
symptoms and the roentgenographic changes in these
latter sinuses that predominate. Thus the surgeon may
attempt to correct the secondary pathologic changes
while overlooking the underlying problem in the ostiomeatal complex.
The introduction of Functional Endoscopic Sinus
Surgery by Messerklinger and Wigand radically changed
the way Otolaryngologists treat sinusitis14. The purpose
of functional endoscopic sinus surgery is to re-establish
ventilation and mucociliary clearance of the sinuses.
This is achieved by removing disease from key areas
of the anterior ethmoid and middle meatus. Middle
7

Amrita Journal of Medicine

turbinate is preserved and sphenoethmoidectomy is
done. The technique allows for excellent visualization,
whilst causing minimal bleeding and low morbidity15.
In 1978 Messerklinger introduced the concept of
functional endoscopic sinus surgery based on endoscopic observation and documentation of anatomy and
pathology in the middle meatal area and sinus mucociliary clearance in normal and diseased mucosa16. In
1980 Stammberger published a series of papers on FESS.
The principle of the technique is limited resection
of inflammatory tissue or anatomic defects that interfere
with normal mucociliary clearance and result in localized persistent inflammation.
Routinely carried out steps in FESS for CRS w/wo
Polyps would include:
Uncinectomy: removal of the comma-shaped piece
of bone at the anterior edge of the middle meatus
Infundibulotomy: entering the narrow space just
anterior to the ethmoid air cells
Ethmoidectomy: exentration of the diseased anterior,
middle and posterior ethmoid air cells
Sphenoidotomy: opening into the sphenoid sinus to
clear disease within and widening the natural ostium
Midde meatal antrostomy: widening the natural ostium of the maxillary antrum and clearing disease within
Frontal recess and sinus clearance: careful identification and clearance of the frontal sinus ostium area to
ensure drainage of the sinus into the nose
{Figure 5 a, b}

Chronic Rhinosinusitis An Overview

techniques for biofilm detection on the sinus mucosal

specimens of CRS patients19.
For better understanding of the anatomy of paranasal
sinuses, Tolsdorff et al demonstrated a virtual reality
simulator for endonasal sinus surgery based on a volume
model. This is a fully operational simulator for sinus
surgery based on standard PC hardware20.
Balloon sinuplasty is a new surgical technique to
manage CRS, being done as an office procedure at
many Centres.

Conclusions
An improved understanding of the underlying disease process has led to an evolution in the treatment
of CRS.
Detailed recording of the clinical symptoms and
physical findings, followed by diagnostic nasal endoscopy (DNE) and CT scan of PNS play a crucial role in
the diagnosis, prognosis and follow-up of CRS patients.
Medical therapy has begun to shift from antibiotics
and decongestants to a combination of topical steroids,
systemic steroids, decongestants, antihistamines and
antibiotics. Surgical treatment of CRS, still a crucial
component of the overall treatment plan, has shifted
from radical to a more conservative, yet complete approach. Although important, surgery alone does not lead
to a long term disease free state.
A comprehensive management plan incorporating
both medical and surgical care remains the most likely
way to provide long term disease control for CRS. The exact combination continues to be debated. Nevertheless,
use of long term topical steroids and regular followup of all patients seem to be the best option till date.
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2007;117:1839-42

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