Diagnosis Of Rhinosinusitis

Clinical investigations regarding the diagnosis of rhinosinusitis have been difficult until recently, due to a lack of consensus for the definition of rhinosinusitis. In 1996, the Rhinosinusitis Task Force of the American Academy of Otolaryngology–Head and Neck Surgery published general criteria for the diagnosis of rhinosinusitis.

Diagnosis is based upon the time from onset of symptoms, as well as the number and type of symptoms present. Thus, the diagnosis of rhinosinusitis is dependent upon establishing a time frame for the disease and then applying clinical criteria to assure the diagnosis.

Individuals with rhinosinusitis may present with symptoms of nasal congestion, nasal discharge, facial pressure or pain, hyposmia, or anosmia. The pain of acute rhinosinusitis is typically a stabbing pain or ache, localized over the involved sinus.

Thus, pain may provide a clue as to which sinus is involved. Maxillary sinus pain may elicit infraorbital tenderness extending to the maxillary teeth and occasionally to the ear. Ethmoid pain is typically reported between the eyes and over the nasal dorsum.

Frontal pain may present as headaches extending to the temple or occiput. Isolated sphenoid sinus pain may present with headache, particularly at the vertex of the skull. Headaches and facial pain are rarely associated with rhinosinusitis, unless a concomitant nasal symptom is present.

Children with rhinosinusitis may have a different presentation compared to their adult counterparts. Since young children are unable to verbalize their complaints, they may present with irritability as their only symptom.

Sinus pain is not a prominent feature; however, children may have nasal obstruction and purulent rhinorrhea. Cough is a feature that may be seen in children with rhinosinusitis, which is typically not seen with adults.

It may occur during the day or night; however, the cough is particularly worse at night. Rhinosinusitis is the second most common cause of chronic cough in children.

Other symptoms include foul breath, bronchial hyperresponsiveness, and periorbital edema. The periorbital edema is usually non-tender and is usually seen on the dependent side and is worse upon awakening.

The symptoms of nasal congestion/obstruction, facial pressure/pain, nasal purulence or rhinorrhea, and anosmia/hyposmia are considered major symptoms. The presence of two major symptoms is sufficient for the diagnosis of rhinosinusitis.

Cough is a minor symptom in adults, but a major symptom when seen in children. Minor symptoms include headache, irritability, fever, halitosis, fatigue, dental pain, and ear pain. The presence of one major symptom and two minor symptoms is also sufficient for the diagnosis of rhinosinusitis.

Although symptoms and time-based criteria may be appropriate in making the diagnosis in ABRS, they have been insufficient in CRS. A diagnosis of CRS is best made through a combination of symptoms and time-based criteria as in ABRS, but supported by nasal endoscopy or radiologic testing.

A thorough history of present illness is required for all patients, particularly to identify the secondary causes of rhinosinusitis. Features of the history important when evaluating an individual for rhinosinusitis include presenting symptoms, onset and duration of symptoms, and associated comorbid disorders.

A history of asthma, aspirin intolerance, nasal polyposis, and rhinosinusitis is consistent with the ASA intolerance syndrome (Sampter’s triad). This entity is difficult to treat, with persistent bronchial hyperreactivity, despite treatment of rhinosinusitis.

Immune deficiencies including HIV, common variable immune deficiency, and IgG and IgA hypogammaglobulinemia are associated with recurrent rhinosinusitis. Patients with a history of recurrent pneumonia, otitis media, sterility, and rhinosinusitis should be evaluated for primary ciliary dyskinesia.

Patients with Kartagener’s syndrome present with primary ciliary dyskinesia, rhinosinusitis, situs inversus, and bronchiectasis. Perennial or seasonal allergies may present with symptoms such as nasal congestion, cough, and behavioral changes, which are seen in both allergic rhinitis and rhinosinusitis.

It may be the underlying etiology in failed antimicrobial therapy directed at presumed rhinosinusitis. Symptoms and signs consistent with allergies include sneezing, clear nasal secretions, and itchy mucous membranes of the upper aerodigestive tract.

Allergies can play a significant role in recurrent acute and chronic rhinosinusitis. All patients should be evaluated for allergies when the history is elicited, with a focus on both food and inhalant allergies, such as dust mite, mold, dander, and pollen.

There may be a history of rhinosinusitis coinciding with the allergy season. The tendency to have allergy is genetically determined and therefore is reflected in the family history. If one parent has a history of allergy problems, any child in that family has a 20% to 40% chance of having an allergic disease.

If both parents have allergy problems, any child has a 50% to 70% chance of having allergic manifestations at some time in his/her life. In 13% of children with a negative allergy history, skin testing is nevertheless positive.

This has prompted some to advocate formal allergy testing in all cases of CRS who failed medical treatment, and prior to proceeding with surgery. Appropriate allergy skin testing or in vitro tests (RAST, ELISA, and IgE) may be performed.

In vitro tests for allergy are useful in young children who may not tolerate skin testing. Gastroesphageal reflux disease, or GERD, has been implicated as an underlying etiology of CRS, especially in children.

Double lumen pH probanalysis of children with CRS has demonstrated esophageal reflux in 63% of patients and nasopharyngeal reflux in 32%. Seventy-nine percent of patients had improvement in CRS symptoms after medical treatment of GERD.

In a separate study, 89% of patients initially deemed as candidates for sinus surgery avoided an operation after reflux treatment. Patients with a history of maxillofacial trauma may present with recurrent rhinosinusitis or CRS due to disruption or obstruction of the osteomeatal drainage pathways.

Complete resolution of recurrent symptoms may require surgical correction of the anatomic obstruction. Occasionally mucosa may be trapped within the fracture line, resulting in the development of a mucocele or a mucopyocele and CRS.

Nasal neoplasm, both benign and malignant, may be a cause of unilateral nasal symptoms and rhinosinusitis due to obstruction of the nasal cavity and sinus drainage pathways. Unilateral nasal polyposis unresponsive to corticosteroid therapy should raise the index of suspicion for a nasal neoplasm.

Care must be taken to rule out CNS tissue prior to biopsy. Inflammatory nasal polyposis is seen in bilateral nasal cavities and responds well to systemic and topical corticosteroid therapy.

They may result from chronic nasal inflammation, often associated with nasal allergies. Inflammatory polyposis often has the classic ‘‘water bag’’ appearance. Any child with nasal polyposis should be evaluated for cystic fibrosis.

Physical Examination

Intranasal examination may provide clues for the diagnosis of rhinosinusitis. However, this is often nonspecific and thus greater emphasis is placed upon the aforementioned symptoms-driven diagnostic criteria.

Intranasal examination is facilitated through the use of a nasal speculum, handheld otoscope, or nasal endoscopes, including fiber-optic and rigid types. The examination of the mucosal linings of the symptomatic nose may demonstrate generalized rhinitis with erythema and edema.

The inferior turbinates, often engorged, may limit visualization beyond the anterior aspect of the inferior turbinate. Topical decongestion with alpha-adrenergic agonist, such as oxymetazoline, permits an improved visualization of the middle turbinate and middle meatus. Nasal purulence may be seen along the floor of the nasal cavity.

The color of the mucous is not a dependable sign to differentiate a bacterial infection from a viral URTI. Distinguishing between purulent-appearing nasal secretions from an infected sinus versus colonized stagnant secretions from the nasal cavity or chronic adenoiditis may also prove difficult.

However, purulence found within the middle meatus is highly suggestive of rhinosinusitis. Nasal polyposis may be seen, and should be characterized based upon its growth beyond the anatomic limits of the middle meatus. This may be useful to document response to therapy.

Occasionally, differentiating a nasal polyp from the middle turbinate may be a source of confusion. Palpation of the structure after application of topical 2% pontocaine may reveal a firm, tender structure more consistent with that of the middle turbinate.

Significant anatomic causes of obstructed sinonasal drainage should be noted, including septal deviation or spurring, concha bullosa, and paradoxical middle turbinate. Occasionally, adequate assessment of the lateral nasal wall may be problematic.

Percussion over the maxillary and frontal sinus may elicit tenderness, which is, however, largely nonspecific. Oral cavity examination may demonstrate an oro-antral fistula, poor dentition, or dental abscess. Purulent drainage from the nasopharynx may be seen in the posterior oropharynx.

In young children or adults with mental illness, a foreign body must be considered, especially in cases of unilateral purulent rhinorrhea. The drainage is usually foul-smelling. An otoscopic examination may demonstrate otitis media.

Due to its communication with the nasopharynx via the eustachian tube, in children the middle ear may be considered a paranasal sinus. Children with rhinosinusitis may have an associated otitis media.

If allergy is present, the patients may display allergic shiners and a supratip crease due to chronic wiping of the nose. Children may have the classic ‘‘adenoid facies’’ secondary to chronic nasal obstruction due to an enlarged adenoid.