Approach
This condition can present at any age with a variety of symptoms. Initial diagnosis is clinical. Each patient's case must be investigated and treated appropriately, and there is often a delay before patients receive treatment.
The diagnostic criteria for chronic rhinosinusitis according to the American Academy of Otolaryngology is as follows:[20]
Twelve weeks or longer of two or more of the following signs and symptoms:
Mucopurulent drainage (anterior, posterior, or both)
Nasal obstruction (congestion)
Facial pain/pressure/fullness
Decreased sense of smell
Inflammation is documented by one or more of the following findings:
Purulent (not clear) mucus or edema in the middle meatus or anterior ethmoid region
Polyps in nasal cavity or the middle meatus, and/or
Radiographic imaging showing inflammation of the paranasal sinuses
Clinical evaluation
Historical features that should be elicited include duration of past and current nasal symptoms, exacerbating/relieving factors, previous nasal/paranasal sinus surgery, current medications, previous treatments, and duration. The presence of symptoms suggestive of concomitant allergic rhinitis (seasonal or perennial itching, sneezing, clear rhinorrhea, congestion, or ocular irritation) and asthma should be established. On examination, palpation of areas overlying the maxillary and frontal (forehead) sinuses can induce pain if infected. However, this is not consistent in all patients and is more meaningful in acute rhinosinusitis rather than in chronic rhinosinusitis.
Investigations
All patients should have anterior rhinoscopy: a nasal examination that may be performed using a nasal speculum and light source or even an otoscope.
Video outlining how to perform an examination of the nose and nasal cavity
Nasal endoscopy is preferable once a patient has been referred to a specialist; it provides a thorough information of sinus drainage pathways.[2][21] Both may show discolored nasal discharge/postnasal drip, nasal polyps/polypoid mucosa, edema or erythema in the middle meatus (area lateral to the middle turbinate), and generalized/localized edema, erythema, or granulation tissue in the nasal cavity.
A sinus computed tomography (CT) scan (without contrast) is not generally recommended for first presentation of symptoms. In this case, diagnosis should be achieved by history and physical exam. Patients who do not improve with medical treatment should have a maxillofacial CT scan without contrast to confirm diagnosis, stage disease extent, and evaluate anatomy for surgical intervention.[22] Confirmatory imaging findings include mucosal thickening, sinus opacification, polyps or retention cysts, and sclerotic and thickened sinus walls.[22] Coronal images in 1- to 3-mm contiguous cuts enable excellent evaluation of the four sinuses (maxillary, ethmoid, frontal, and sphenoid) and their outflow tracts. Do not order multiple maxillofacial CT scans within 90 days to evaluate uncomplicated chronic rhinosinusitis as this offers no additional information that would improve initial management and exposes the patient to ionizing radiation.[23] Magnetic resonance imaging is an adjunct to CT and is typically reserved for patients with suspected intracranial extension of inflammatory sinus disease, fungal disease, or neoplasia.[22] Referral to a specialist is warranted in the setting of recurrent or refractory rhinosinusitis, as well as to confirm diagnosis in chronic rhinosinusitis.
Allergic rhinitis is a common predisposing factor, and allergy testing (scratch, intradermal, or in vitro specific IgE determination) can be used to evaluate patients with suspected allergy. Nasal or sinus cultures are generally not necessary unless the patient fails to respond to empirical therapy.
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