Updated: May 2015
Originally Posted: June 2005
Anju T. Peters, MD
Feinberg School of Medicine
Mark D. Scarupa, MD
Associate, Institute for Asthma and Allergy
Chevy Chase and Wheaton, Maryland
Clinical Instructor, Johns Hopkins Asthma and Allergy Center
Michael A. Kaliner, MD FAAAAI
Medical Director, Institute for Asthma and Allergy
Chevy Chase and Wheaton, Maryland
Professor of Medicine, George Washington University School of Medicine
Rhinosinusitis (RS) is defined as inflammation of the sinuses and nasal cavity.1 Rhinosinusitis may be classified based on duration. The term, “rhinosinusitis” is preferred over “sinusitis” because inflammation of the sinus cavities is almost always accompanied by inflammation of the nasal cavities. RS is one of the most commonly diagnosed diseases in the world and is believed to affect more than 12% of the US population.3 Rhinosinusitis is associated with significant negative impact on quality of life and is associated with high healthcare costs due to medical visits, prescriptions and over the counter medications, sinus surgeries and missed days from work and school. Vast majority of patients with RS see primary care physicians. Other specialists including allergists and otolaryngologists also see patients with rhinosinusitis, especially those that are difficult to treat.
RS is often classified based on duration of symptoms and inflammation.
Acute rhinosinusitis (ARS) is defined as symptoms lasting less than 12 weeks. ARS is further classified based on duration and presumed etiology as
- Viral rhinosinusitis (VRS)
- Acute bacterial rhinosinusitis (ABRS)
Recurrent acute rhinosinusitis (RARS) consists of 3 or more episodes of acute bacterial rhinosinusitis (ABRS) in a year.2
Chronic rhinosinusitis (CRS) is defined as symptoms lasting longer than 12 weeks and is further classified based on clinical and inflammatory patterns as
- CRS with nasal polyps (CRSwNP)
- CRS without nasal polyps (CRSsNP)
Acute rhinosinusitis (ARS) and recurrent acute rhinosinusitis (RARS)
Most ARS are viral in origin and improve on their own. It is important to distinguish viral from bacterial RS so as to not prescribe antibiotics unnecessarily for VRS.
ABRS is diagnosed when symptoms of an upper respiratory tract infection persist longer than 10 to 14 days or for at least 10 days beyond the onset of upper respiratory symptoms. ABRS is also likely when symptoms worsen after an initial improvement. Only about 2% of VRS become ABRS.4 Most common bacteria responsible for ABRS are Streptococcus pneumoniae, Hemophilus influenzae, and Moraxella catarrhalis. Staphylococcus aureus is also isolated in adults with ABRS. ABRS is primarily a clinical diagnosis and radiographic imaging with a sinus computed tomography (CT) scan is recommended only if a complication or alternative diagnosis is suspected. RARS presents similarly with three or more episodes of acute rhinosinusitis however patients are asymptomatic in between episodes of acute infection.
Symptoms: Symptoms suggestive of ARS include nasal congestion or obstruction, facial or dental pain, purulent rhinorrhea, post nasal drainage, headache and cough. Additional signs associated with ABRS can include fever, fatigue, hyposmia, ear fullness or pressure.
Physical examination: A head, ears, eyes, nose, and throat examination should be done. Pulmonary evaluation may also be needed. Clinical examination may include tenderness on palpation overlying the sinuses, purulent nasal or oropharyngeal secretions. Fever may or may not be present. Attention should be paid to the periorbital and cheek areas of the face to look for cellulitis or extra sinus involvement. Culture from the nasal cavity is not useful.
Supportive therapy with analgesics and nasal saline irrigation may provide symptomatic relief. There is no evidence that antihistamines, oral decongestants, or guaifenesin provide significant symptomatic relief of ARS. Topical decongestants may improve symptoms but should not be used for more than 3 to 5 consecutive days.
Topical intranasal steroids improve symptoms and have shown a higher rate of clinical success and more rapid recovery when used with antibiotics.5,6
Based on guidelines, antibiotics are recommended if symptoms of rhinosinusitis last longer than 10 days, if patients don’t improve by 7 days after ABRS diagnosis or worsen after initial improvement.2,7 Antibiotics should be used earlier if there is evidence of complications such as periorbital swelling or redness. Antibiotics for ABRS that are recommended by selected guidelines are noted in Table 1. Most guidelines recommend 10-14 days of therapy with antibiotics.
Endoscopic surgical intervention is required when there is a risk of intracranial complication or in a patient with periorbital or intraorbital abscess
Table 1. Antibiotics for acute bacterial rhinosinusitis
|Primary antibiotic choice||Secondary antibiotic choice|
|IDSA clinical practice guidelines24|
|Amoxicillin-clavulonate||Levofloxacin (if Type I hypersensitivity to ß lactam in children or adults) Clindamycin (if non-type 1 hypersensitivity in children) Doxycycline (ß lactam allergy in adults)|
Amoxicillin/clavulonic acid or quinolones (if risk of bacterial resistance is high)
|Trimethoprim-sulfamethoxazole or a macrolide (if ß lactam allergy)|
|AAO-HNS Clinical practice guideline (Update): Adult Sinusitis7|
|Amoxicillin with or without clavulonate*||Doxycycline, levofloxacin or moxifloxacin (ß lactam allergy)|
|American Academy of Pediatrics26|
|Amoxicillin with or without clavulonate*||Cefdinir, cefuroxime, or ceftriaxone (non type-1 or type-1 penicillin allergy) Fluoroquinolones|
AAO-HNS: American Academy of Otolaryngology-Head and Neck Surgery
Chronic rhinosinusitis (CRS)
Worldwide the prevalence of CRS ranges from about 7% in Korea, 10% in Europe and 12% in the United States.3,8,9
The exact etiology of CRS is not known and infection and inflammation are believed to play a role. The diagnosis of CRS is made when patients have symptoms consistent with CRS for greater than 12 weeks in conjunction with evidence of inflammation on endoscopy and/or sinus CT scan.2 CRS is often categorized as CRS without nasal polyps (CRSsNP) and CRS with nasal polyps (CRSwNP). The exact pathogenesis of CRS is not known but inflammation with eosinophils, neutrophils and lymphocytes is associated with CRS. Th2 eosinophilic inflammation is characteristic of nasal polyps from Caucasian patients however neutrophilic and eosinophilic inflammation is seen in polyps from Asian patients. The role of bacteria is uncertain especially in CRSwNP.
A subgroup of patients with CRSwNP and asthma has worsening respiratory symptoms with aspirin and nonsteroidal anti-inflammatory drug (NSAID) ingestion and has been classified as aspirin exacerbated respiratory disease (AERD).
Symptoms: Symptoms of CRS can be varied and can include facial pressure or pain, post-nasal drainage, nasal blockage, anosmia or hyposmia, or fatigue.
Physical examination: A head, ears, eyes, nose, and throat examination should be done. Pulmonary evaluation may also be needed given the high rates of coexistence of asthma. Examination either by nasal endoscopy or anterior rhinoscopy may show purulent mucus or edema in the middle meatus or ethmoid area or polyps.
Computed tomography (CT): A sinus CT may be needed for objective confirmation of sinonasal inflammation and to distinguish CRS from other conditions that have similar symptoms (for example allergic rhinitis, atypical facial pain).
Topical intranasal corticosteroids are recommended to decrease inflammation and are beneficial in both CRSwNP and CRSsNP. They are well tolerated and have minimal adverse effects.10,11
Short-term oral corticosteroids (for CRSwNP) help shrink nasal polyps and reduce inflammation.12
Saline nasal irrigation is recommended for CRS and has shown to improve symptoms and quality of life.13
Antibiotics are used for acute exacerbations of CRS however, there is limited evidence for their efficacy.14
Aspirin desensitization, a pharmacologic induction of drug tolerance during which tolerance to aspirin is induced and maintained, is a potential therapeutic option for patients with AERD. This procedure consists of administration of incremental oral doses of aspirin over 1-2 days until a dose of 650mg of aspirin can be taken.
Biologic therapies with monoclonal antibodies such as omalizumab (anti IgE), mepolizumab (anti-IL-5), reslizumab (anti-IL-5) and dupilumab (anti-IL-4 receptor) have shown efficacy in clinical trials for CRS but are not approved for use to date.
Functional endoscopic sinus surgery may be considered in patients who fail medical therapy.
Common modifying factors associated with rhinosinusitis
Allergic rhinitis: Although no direct causality between RS and allergic rhinitis (AR) has been found, they often coexist. AR is present in 25-31% of patients with ARS and in 40-84% with CRS suggesting at least an association between the two conditions.15,16,17
Asthma: The association is supported by the high prevalence of CRS and recurrent ARS in asthmatics. 84-100% of patients with severe asthma have abnormal sinus CT scans and asthma severity is directly correlated to severity of sinus disease.18,19 Studies suggest that medical and /or surgical treatment of rhinosinusitis improves asthma control therefore, asthmatics who have difficult to control disease should be assessed for rhinosinusitis.20,21
Immunodeficiencies: Antibody deficiencies such as IgA deficiency, common variable immunodeficiency, and specific antibody deficiencies have been documented in patients with CRS and RARS.
Cystic fibrosis: CRS is reported in 40-71% of patients with cystic fibrosis (CF).22,23 CF screening should be considered in patients who experience CRS at an early age and in any child with nasal polyps.
Table 2 lists some of the other diseases associated with rhinosinustis.
Testing for allergy and immune function:
Allergy testing allows identification and treatment of allergic rhinitis that often coexists with and may modify CRS.
Immunodeficiency should be considered in patients with difficult to treat CRS or RARS especially when associated with bronchiectasis or pneumonia. Rhinosinusitis is one of the most common diseases present in patients with antibody deficiency. Evaluation of immunodeficiency most often includes quantitative immunoglobulins (IgG, IgA, and IgM), preimmunization and post immunization antibody responses to tetanus toxoid and pneumococcal polysaccharide vaccines.
Table 2. Diseases associated with rhinosinusitis
|Granulomatosis with polyangiitis (Wegner’s granulomatosis)|
|Eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome)|
|Immunodeficiencies: common variable immune deficiency, IgA deficiency, specific antibody deficiency, acquired immunodeficiency syndrome (AIDS)|
|Genetic abnormalities: cystic fibrosis, ciliary dyskinesia, Young’s syndrome|
|Gastroesophageal reflux disease|
- Fokkens WJ, Lund VJ Mullol J, et al. European position paper on rhinosinusitis and nasal polyps 2012. Rhinology 2012;23:1-299.
- Peters AT, Spector S, Hsu J, et al. Diagnosis and management of rhinosinusitis: a practice parameter update. Ann Allergy Asthma Immunol 2014;113:347-85.
- Shashy RG, Moore EJ, Weaver A. Prevalence of the chronic sinusitis diagnosis in Olmsted County, Minnesota. Arch Otolaryngol Head Neck Surg. 2004;130(3):320-3.
- Gwaltney MJ. Acute community acquired sinusitis. Clin Infect Dis 1996;23:1209-1223.
- Dolor RJ, Witsell DL, Hellkamp AS, et al. Comparison of cefuroxime with or without intranasal fluticasone for the treatment of rhinosinusitis. The CAFFS Trial: a randomized controlled trial. JAMA 2001;286:3097-3105.
- Zalmonovici A, Yaphe J. Intranasal steroids for acute sinusitis. Cochrane Database Syst Rev 2013;2:CD005149.
- Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline (Update): adult sinusitis. Otolaryngol Head Neck Surg 2015;152:S1-S39.
- Kim YS, Kim NH, Seong SY, et al. Prevalence and risk factors for chronic rhinosinusitis in Korea. Am J Rhinol Allergy 2011;25:117-21.
- Hastan D, Fokkens WJ, Bachert C, et al. Chronic rhinosinusitis in Europe—an underestimated disease. A GA(2)LEN study. Allergy2011;66:1216-23.
- Kalish L, Snidvongs K, Sivasubrmaniam R, et al. Topical steroids for nasal polyps. Cochrane Databse Syst Rev 2012;12:CD006549.
- Snidvongs K, Kalish L, Sacks R, et al. Topical steroid for chronic rhinosinusitis without polyps. Cochrane Database Syst Rev 2011;8:CD009274.
- Martinez-Devesa P, Patiar S. Oral steroids for nasal polyps. Cochrane Database of Systemic Reviews 2011;7:CD005232.
- Harvey R, Hannan SA, Badia L, et al. Nasal saline irrigations for the symptoms for chronic rinosinusitis. Cochrane Databse Syst Rev 2007;3:CD006394.
- Primochai P, Thanaviratananich S, Laopaiboon M. Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults. Cochrane Database Sys Rev 2011;5:CD008233.
- Emanuel IA, Shah SB. Chronic rhinosinusitis: allergy and sinus computed tomography relationships. Otolaryngol Hed Neck Surg 2000;123:687-691.
- Tan BK, Zirkle W, Chandra RK, et al. Atopic profile of patients failing medical therapy for chronic rhinosinusitis. Int Forum Allergy Rhiol 2011;1:88-94.
- Savolainen S, Schlerter WW, Man WJ, et al. Allergy in patients with acute maxillary sinusitis. Allergy 1989;44:1116-1122.
- Brinke A, Grootendorst DC, Schmidt JT, et al. Chronic sinusitis in severe asthma is related to sputum eosinophilia. Clin Immunol 2002;109:621-626.
- Lin DC, Chandra RK, Tan BK, et al. Association between severity of asthma and degree of chronic rhinosinusitis. Am J Rhinol Allergy 2011;25:205-208.
- Palmer JN, Conley DB, Dong RG, et al. Efficacy of endoscopic sinus surgery in the management of patients with asthma and chronic sinusitis. Am J Rhinol 2001;15:49-53.
- Vashishta R, Soler ZM, Nugyen SA, et al. A Systematic review and meta-analysis of asthma outcomes following endoscopic sinus surgery for chronic rhinosinusitis. Int Forum Allergy Rhinol 2013;3:788-794.
- Babinski D, Trawinska-Bartnicka M. Rhinosinusitis in cystic fibrosis: not a simple story. Int J Pediatr Otorhinol 2008;72:619-624.
- Schraven SP, Wehrmann M, Wagner W, et al. Cystic fibrosis: ultrastructural changes of nasal mucosa. Eur Arch Otorhinolaryngol 2011;10(3):181-186.
- Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Clin Infect Dis 2012;54(8):e72-e112.
- Desrosiers M, Evans GA, Keith PK, et al. Canadian clinical practice guidelines for acute and chronic rhinosinusitis. J Otolaryngol Head Neck Surg 2011;40:S99-142.
- Wald ER, Applegate KE, Bordley C, et al. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children ages 1 to 18 years. Pediatrics 2013;132:e262-e280.