ABSTRACT: Rhinosinusitis represents a major cause of morbidity, resulting in reduced well-being and productivity for millions of persons. The initial therapeutic approach depends on the severity of symptoms and the patient's immune status, but it typically involves the use of an antihistamine/decongestant combination. A reduced, or "pediatric," dosage is often effective in controlling nasal congestion and postnasal drip and is associated with a lower incidence of adverse effects. Intranasal corticosteroids also are a mainstay of therapy and may be particularly useful in patients with chronic congestion or allergic rhinitis. Other options include intranasal anticholinergics and leukotriene inhibitors. Antibiotics should not be given routinely, but they are a reasonable consideration after other therapies have failed. Persistent treatment failure warrants diagnostic evaluation, such as sinus imaging and allergy testing.
KEY WORDS: Rhinosinusitis, Allergic rhinitis
Acute and chronic rhinosinusitis are important clinical syndromes because of their frequency, their sometimes challenging diagnostic and therapeutic characteristics, and their significant costs--both in health care dollars and in morbidity. Rhinosinusitis is one of the 10 most common diagnoses in ambulatory practice and causes an estimated 25 to 31 million US physician office visits annually. (1-3) It is responsible for significant reductions in quality of life, workplace attendance, and productivity. Chronic rhinosinusitis is one of the most common chronic conditions. (3)
In this article, we review the clinical presentation, diagnosis, and treatment of rhinosinusitis.
Rhinosinusitis is a catch-all phrase that includes vasomotor, allergic, and nonallergic rhinitis. It includes allergic sinusitis and infectious sinusitis caused by viruses, bacteria, and fungi. All rhinosinusitis syndromes begin with mucosal inflammation. There are 3 common inflammatory stimuli--infection, allergy, and irritants. The mucosal surfaces are contiguous, and most mucosal inflammation probably involves the sinus mucosa as well as the mucosa of the main nasal passages; thus, many cases of rhinitis also involve the sinuses. (4)
The ostiomeatal complexes are relatively narrow mucosa-lined bony passageways from the sinus spaces into the turbinate areas. Any sinus secretions must pass through the ostiomeatal complexes in order to be drained. Ciliary dysfunction can impede this process. Edema of the rhinosinal mucosa can cause obstruction of the ostiomeatal complexes. (4) Superinfection of the closed space can perpetuate the disease process.
The role of postnasal drip in rhinosinusitis is complicated by the fact that it is, to a certain extent, a normal phenomenon; the entire nasal structure serves to clean inspired air of particles and irritants and to humidify it. The turbinates were named for their capacity to create turbulent flow, which enhances the deposition of particulate matter in the nasal passages. Secretions and some degree of postnasal drip are a by-product of the normal physiology of cleansing inspired air. Postnasal drip is "pathological" only when this normal defense mechanism is overstimulated or causes undue symptoms.
Rhinosinusitis has several possible presentations, which is one of the challenges of this disease. The classic presentations are well recognized. For example, obvious sinus tenderness with local pressure on palpation accompanied by a thick and possibly foul-smelling nasal discharge is almost...