Sinusitis

Acute Sinusitis

Definition and diagnostic criteria

Acute sinusitis, also known as acute rhinosinusitis, is defined as an inflammation of the sinuses and nasal passages lasting less than 12 weeks, typically following an upper respiratory tract infection (URTI). Diagnostic criteria include at least two of the following symptoms: nasal blockage or discharge, facial pain/pressure, and a reduction or loss of the sense of smell. Additionally, endoscopic signs of nasal polyps or mucopurulent discharge from the middle meatus, or CT changes within the sinuses, support the diagnosis (ENT UK).

Epidemiology

Acute sinusitis is a common condition, affecting approximately 10% of adults in the UK annually. The condition is more prevalent during the winter months, often following viral URTIs. Children and young adults are more frequently affected due to the higher incidence of viral infections in these groups.

Diagnosis

Clinical features: Key symptoms include nasal congestion, purulent nasal discharge, facial pain/pressure, particularly when bending forward, and hyposmia. Fever, fatigue, dental pain, and ear pressure may also be present. Symptoms persisting for more than ten days or worsening after an initial improvement are suggestive of bacterial sinusitis.

Investigations: Clinical diagnosis is often sufficient, but nasal endoscopy can be utilised to observe mucopurulent discharge or polyps. Imaging, typically a non-contrast CT scan, is reserved for complicated cases or those not responding to treatment. Typical abnormalities include mucosal thickening, air-fluid levels, and opacification of the sinuses.

Treatment

Management primarily focuses on symptom relief. Analgesics, saline nasal irrigation, and intranasal corticosteroids are first-line treatments. Antibiotics are generally reserved for cases with severe symptoms or those at risk of complications, with amoxicillin or doxycycline being the preferred choices. Adjunctive therapies may include decongestants and mucolytics.

Prognosis

Most cases of acute sinusitis resolve spontaneously within two to three weeks. Antibiotics may hasten recovery in bacterial cases, but the overall prognosis is favourable with rare progression to complications such as orbital cellulitis or intracranial infections.

Chronic Sinusitis

Definition and diagnostic criteria

Chronic sinusitis, or chronic rhinosinusitis (CRS), is characterised by sinonasal inflammation persisting for more than 12 weeks despite medical treatment. Diagnostic criteria require the presence of at least two of the following symptoms: nasal blockage/congestion, nasal discharge, facial pain/pressure, and reduction/loss of smell. Further evidence is obtained via endoscopic examination or CT imaging.

Epidemiology

CRS affects around 11% of the UK population. It is more common in adults aged 30-60 years and is associated with asthma, allergic rhinitis, and nasal polyps. The condition has significant impacts on quality of life, leading to considerable healthcare utilisation and economic burden.

Diagnosis

Clinical features: Persistent nasal obstruction, mucopurulent nasal discharge, facial pain/pressure, and hyposmia/anosmia are hallmark symptoms. Patients may also report fatigue, malaise, and dental pain.

Investigations: Endoscopic examination reveals mucosal swelling, polyps, or purulent discharge. CT scans are essential for diagnosis and surgical planning, typically showing sinus opacification, osteomeatal complex obstruction, and mucosal thickening.

Treatment

Initial management involves medical therapy, including saline irrigation, intranasal corticosteroids, and antibiotics for acute exacerbations. In refractory cases, functional endoscopic sinus surgery (FESS) is considered to restore normal sinus drainage and ventilation.

Prognosis

CRS is a chronic, relapsing condition with variable response to treatment. While many patients experience symptom relief with medical or surgical therapy, some may have persistent or recurrent symptoms. Regular follow-up and ongoing management are crucial to maintain quality of life and minimise exacerbations.