History and exam
Key diagnostic factors
common
facial pain/pressure
Patients complain of facial pain or pressure, often specifically pointing to areas overlying involved sinuses (e.g., forehead for frontal sinusitis).
nasal obstruction
Patients are often unable to breathe through the nose.
nasal discharge/postnasal drip
There may be discolored rhinorrhea or thick postnasal drainage on the posterior pharynx.
purulence
May be seen running out of sinus opening on endoscopic examination.
headache
Can be difficult to distinguish from other sources of facial pain. Vertex headache/pain is characteristic of sphenoid sinusitis.
Other diagnostic factors
common
fatigue
A common symptom.
cough
Can be secondary to postnasal drip.
uncommon
hyposmia/anosmia
A decreased or absent sense of smell may be present. This is secondary to decreased airflow to the olfactory fibers in the superior nasal cavity.
fever
More common in acute rhinosinusitis but can be intermittent or absent in chronic rhinosinusitis.
halitosis
Sinus drainage may cause bad breath.
dental pain
Less common in chronic rhinosinusitis. More common in acute rhinosinusitis (e.g., acute maxillary rhinosinusitis).
ear pain/pressure
Generalized mucosal edema causes blockage of auditory tube.
Risk factors
strong
ciliary dysfunction
Each of the sinuses has an ostium, a bony opening that secretions drain through. The cilia beat in such a way as to direct secretions toward the natural ostium. This pattern of mucociliary clearance is essential for the proper health and function of the paranasal sinuses.[10] Patients with cystic fibrosis and primary ciliary dyskinesia have abnormal ciliary function and much higher rates of chronic rhinosinusitis.
aspirin sensitivity
Patients with the triad of Samter (nasal polyposis, aspirin sensitivity, and asthma) suffer from refractory chronic rhinosinusitis. The mechanism is increased airway reactivity and obstruction as a result of nasal polyps.
allergic rhinitis
airway hyperreactivity/asthma
previous sinus surgery
Prior sinus surgeries can result in adhesion formation or lateralization of the middle turbinate, which over time may obstruct sinus outflow tracts and interfere with mucociliary clearance. Lateralization of the middle turbinate is still a leading cause of poor outcomes following sinus surgery and may also predispose to iatrogenic frontal sinus obstruction and disease. Meticulous surgical technique sparing mucosa and minimizing trauma to the middle turbinate is, therefore, critical to ensuring positive outcomes following sinus surgery.
immunodeficiency
Both primary and acquired immune deficiencies increase risk for rhinosinusitis. Chronic rhinosinusitis is common and often more difficult to treat in patients with HIV. Studies suggest that immune deficiencies may be present in half of those with medically refractory chronic rhinosinusitis.[13][14]
severe mid-septal deviations
Abnormalities blocking the outflow tracts (especially the osteomeatal complex) prevent passage of secretions, which become stagnant and susceptible to superinfection.
concha bullosa deformity
Can contribute to outflow tract obstruction in some patients.
paradoxically bent middle turbinates
Can contribute to outflow tract obstruction in some patients.
foreign bodies
Cause outflow tract obstruction.
craniofacial anomalies
Cause outflow tract obstruction.
smoking
Impairs normal mucociliary clearance and is significantly associated with worse symptom outcomes after endoscopic sinus surgery.[15]
environmental pollution
history of asthma
An emerging concept in chronic rhinosinusitis is the "unified airway hypothesis," which highlights the similarities between disorders affecting the upper and lower airways. Poorly controlled lower airway disease (asthma) can negatively influence control of chronic rhinosinusitis and vice versa.[19] Patients with aspirin-exacerbated respiratory disease (also known as triad asthma or Samter triad) are characterized by nasal polyposis, aspirin sensitivity, and asthma. This subset of patients with chronic rhinosinusitis tend to have poorer outcomes and more aggressive polyp disease compared with those without the triad.
weak
sarcoidosis
May affect the sinonasal tract, causing chronic rhinosinusitis.
granulomatosis with polyangiitis
May affect the sinonasal tract, causing chronic rhinosinusitis.
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