Category: For Allergy Fellows > Topics for Medical Professionals  

Chronic Sinusitis

This video is from the video library of Dr. Erik Weitzel, an outstanding resource.

This is not a single clinical entity but a complex disease with many phenotypes.  A single factor may initiate the process but whatever the inciting event, eventually most patients develop both inflammation and infection.  In some instances the etiology is apparent but in many cases we must treat the presenting problem then try to work our way backwards to try find the underlying cause.  If we can identify a specific subtype of chronic sinusitis then we may target therapy appropriately.   Chronic sinusitis etiologies include:

Anatomic Obstruction

Tight nasal passages that restrict drainage may narrow further with infection or allergy. The result is recurring infection and inflammation, sometimes limited to a small area. A deviated septum may impinge on a sinus ostium such as seen in the images below.

Septum

Deviated SeptumThis is an example of localized sinusitis due to anatomic obstruction, in this case it is a spur coming off of the nasal septum.

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Nasal Polyps

Nasal polyps are very common in chronic sinusitis patients and almost universally seen in patients who have mold-related sinus disease. They are often diffuse, filling muliple sinus cavities. The management is both medical and surgical. If they are localized to one area then the polyps may best be treated surgically. When nasal polyps are associated with aspirin sensitivity and asthma it is called the Aspirin Triad. Read more complete information about Nasal Polyps.

Polyps

Sinus CT showing polyps (P) within the sinus cavities. This polyp appears to be blocking the sinus outflow tract potentially causing both recurrent infection and pain.
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Immune deficiency

Immune deficiency may contribute to chronic sinusitis. The most common immune deficiency is IgA deficiency. IgA is the immune protein that helps to protect the respiratory and gastrointestinal tract from infections. 1 in 300 people have an immune defiiency but a significantly higher percentage of chronic sinusitis sufferers have IgA deficiency. Classically recurring acute sinus infections rather than chronic sinus infections are indicative of immune deficiency but the distinction between the two is sometimes blurred. If a patient has recurring sinus and ear infections as well as a history of pneumonia, then serious consideration should be given to an immune deficiency evaluation.
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Allergies

Allergies such as typical hayfever or pet allergy can certainly contribute to the disease process in chronic sinusitis. They are sometimes the principal cause but usually they are a cofactor contributing to the problem. For some chronic sinus patients there are multiple types of immune response to molds and some of them can be treated with allergy injections.
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Biofilm

Biofilms are created when bacteria or fungi attach to a surface and form a protective polysaccharide coating. An example is dental plaque. Biofilm may form on a prosthetic device or on an area that is otherwise stagnant. It may form in infected bone or on the surface of a healing surgical area. The biofilm is like a jelly surrounding the bacterial colonies. The immune system response that these bacteria evoke not only is ineffective since it cannot penetrate the surface, it may actually be harmful to surrounding healthy areas. Antibiotics may treat the infection that spreads beyond the biofilm but often cannot get at the route cause. This may be one cause of poor response to antibiotics. There is no routine way in the office to detect biofilms. This is an active area of research and it is unknown how common a problem this is in chronic sinusitis patients.

BioFilm

This image demonstrates how antibiotics and antibodies are repelled by the biofilm layer.

Oval Shape Bacteria

Oval-shaped bacteria surrounded by a light gray biofilm. The dark material around it is of unknown origin.

(Demonstration of Biofilm in Human Bacterial Chronic Rhinosinusitis. Berrylin J. Ferguson, M.D., Donna B. Stolz, Ph.D.#American Journal of Rhinology 19, 452–457, 2005)

Mold

Mold was thought to be a major cause of chronic sinusitis but treatment trials with antifungal therapy do not support this notion. Nonetheless occasionally antifungal therapy is effective, notably when eosinophilic mucinous debris is seen.  Read more about mold here.

Sinus EOSEosinophil granule major basic protein (MBP) is directly toxic to microorganisms as well as to human tissue, including the upper and lower respiratory tract. Special stains for MBP show it in both the tissue but especially in the mucous of chronic sinusitis.

Sinus FungusSpecial stains show fungus surrounded by allergic cells in the mucous of chronic sinusitis.

It is difficult to predict which chronic sinusitis/polyp patients will improved but the response to antifungal therapy may be impressive.
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Symptoms

Symptoms of chronic sinusitis may be severe or subtle. Some patients simply have chronic fatigue and a post nasal drip. For others, nasal congestion and poor sense of smell may be the problem. Symptoms seen in chronic sinusitis include:

  • Pressure-like pain in frontal, maxillary, temporal regions.
  • Nasal Congestion
  • Thick, yellow or greenish discharge
  • Reduced sense of smell
  • Aching in upper jaw and teeth
  • Headache
  • Bad breath
  • Ear pain
  • Fatigue
  • Cough

***Two of the symptoms in bold suggest a chronic sinus problem.***

Diagnosis

Allergy skin testing:

Testing and treatment for immediate sensitivity to environmental allergens is important for all chronic sinus patients.  It is not always easy to distinguish allergic from nonallergic patients on clinical grounds alone.

Nasal Endoscopy:

Usually a direct look in the nose identifies many things such as anatomic causes of sinusitis, sinus drainage or nasal polyps. However, in some cases the inflammation is restricted to the sinus cavities themselves which cannot be viewed directly unless someone has already had nasal surgery to open the passages.

Sinus CAT Scan:

This test is the gold standard for the diagnosis of sinusitis. If the CAT scan does not show swelling within the sinus passages then chronic sinusitis is not the diagnosis. However, this does not rule out a nasal source of sinus pain.

CBC:
The amount of eosinophils in Nasal Polyps is related to eosinophilia of the peripheral blood, but not to elevated serum IgE.

Treatment

Surgery

Most chronic sinusitis patients will require surgery.   It’s not curative but it usually results in improved sinus quality of life.  Sinus surgery is done endoscopically and complex cases are often done under image guidance (CT guided surgery).  Many patients require more than one surgery and risk factors for earlier re-operative procedures include aspirin sensitivity and elevated peripheral eosinphil count (>520).

Antibiotics

Antibiotics are almost always given at some point in chronic sinusitis care, usually when bacteria overgrow in an area. This is often considered a superinfection (bacterial infection superimposed on a chronic sinus problem). Sometimes bacteria are the main cause of the problem. In patients who have had sinus surgery, sometimes a bacterial infection can be managed with an antibiotic nasal spray. In some causes of chronic sinusitis (biofilm) long term antibiotics may be appropriate.

Antifungal

Since mold is sometimes the root cause of chronic sinusitis, treating with an antifungal spray or irrigation sometimes results in dramatic responses.  Itraconazole or Amphotericin B may be obtained from a compounding pharmacy only.

Steroids

Steroids effectively control the inflammatory response in allergy and chronic sinusitis but often steroid nasal sprays are not enough.  Oral steroids are often required to control nasal mucosal edema and polyps. Sometimes a very low dose of alternate day oral steroids is enough to control the inflammation.

Leukotriene Modifiers

These drugs block leukotrienes which are potent agents produced by allergic cells. Occasionally patients with (eosinophilic) nasal polyps have a dramatic response.

Allergy Immunotherapy

Allergy shots as an adjunct therapy in chronic sinusitis are helpful in a select chronic sinusitis patients.  Patients with allergic fungal sinusitis or those with profound seasonal allergen sensitivities may benefit.

REFERENCES:
1.  Matsuwaki Y, Ookushi T, Asaka D, et al.  Chronic rhinosinusitis: risk factors for the recurrence of chronic rhinosinusitis based on 5-year follow-up after endoscopic sinus surgery. Int Arch Allergy Immunol. 2008;146 Suppl 1:77-81.  2008.

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