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Oncologist, otolaryngologist

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Chronic rhinosinusitis

Alexey Portnov, medical expert
Last reviewed: 07.06.2024

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Epidemiology
Causes
Risk factors
Pathogenesis
Symptoms

Complications and consequences
Diagnostics
Treatment
Who to contact?
Prevention
Forecast

A long-term inflammatory process in the perinasal sinuses (sinuses) - maxillary (maxillary), frontal (frontal), cuneiform (sphenoidal) or lattice (ethmoidal) - is defined by two synonymous terms: chronic sinusitis and chronic rhinosinusitis.

Although the inflammations localized in separate paranasal cavities are etiologically related conditions with common clinical features, they have their own names in otolaryngology. [1]

Epidemiology

According to statistics, chronic inflammation of the nasal mucosa and sinuses affects 8-12% of adults worldwide. In almost two thirds of cases, the inflammatory process is localized in the maxillary (maxillary) cavity.

Allergic fungal rhinosinusitis accounts for 5 to 10% of all cases of chronic rhinosinusitis; the aspirin triad occurs in approximately 0.3 to 0.9% of the general population, including nearly 7% of all patients with asthma. [2]

Causes of the chronic rhinosinusitis

It is meant to be distinguished by localization:

Chronic maxillary sinusitis/rhinosinusitis - chronic maxillary sinusitis;
chronic frontal sinusitis/rhinosinusitis - chronic frontitis, i.e.

Chronic inflammation of the frontal (frontal) sinus;

chronic ethmoidal sinusitis/rhinosinusitis - chronic ethmoiditis (an inflammatory process of a chronic nature involving the mucous membrane of the cells of the lattice sinus);
Chronic inflammation of the cuneiform sinus - chronic sphenoidal rhinosinusitis/sinusitis or chronic sphenoiditis. [3]

Chronic sinusitis or rhinosinusitis is usually caused by a bacterial infection with extensive colonization of the paranasal cavities by Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenza and other pathogenic bacteria and often develops secondary to a prolonged and/or untreated acute infection. [4]

If the perinasal cavities are invaded by the mold fungi ascomycetes Alternaria, Penicillium, Cladosporium, Bipolaris, Curvularia, etc., fungal rhinosinusitis develops: chronic non-invasive or invasive rhinosinusitis (resulting from slowly progressive fungal invasion). [5]

Causes may also be due to:

sinonasal polyposis - sinus polyps;
swelling of the sinus mucosa in chronic allergies;
aspirin respiratory disease - respiratory damage associated with the so-called aspirin triad (Sumter triad) - a combination of asthma, chronic rhinosinusitis with nasal polyposis and intolerance to aspirin and other NSAIDs.

Risk factors

The risk of developing a chronic form of rhinosinusitis/sinusitis is increased in the presence of:

respiratory tract infections;
deviated nasal septum or bullous nasal shell;
allergic rhinitis, bronchial asthma and other atopic reactions;
immune system disorders;
regular exposure of the respiratory system to environmental pollutants;
of dental and peri-dental infections;
hypersensitivity to NSAIDs and aspirin;
of cystic fibrosis of the mucous membranes;
ENT lesions in Wegener's granulomatosis;
cystic fibrosis;
Kartagener's syndrome (congenital ciliary dyskinesia);
disease or of Churg-Strauss syndrome.

Pathogenesis

In modern foreign otolaryngology, the pathogenesis of chronic rhinosinusitis is considered taking into account the presence or absence of nasal polyps - based on the type of inflammatory response (Th1, Th2 and Th17) and the presence or absence of immune cells in the mucosa - tissue eosinophilia. [6]

The mechanism of chronic inflammation of the mucosa of the paranasal sinuses may be due to one of three types of inflammatory response. Th1 (immune helper T cells type 1) reaction is a reaction of the adaptive (acquired) immune system, whose cells identify and destroy intracellular pathogens or prevent their growth by producing INF-γ (gamma interferon) with activation of cell-mediated immune response.

The Th2 response is a humoral response via B cells of the immune system (B-lymphocytes) with the release of IL-5 (interleukin-5), which stimulates eosinophils in killing the infection and accelerates the production of IgA class antibodies.

Pro-inflammatory T helper cells type 17 (Th17 or Treg17) play an important role in maintaining the barrier function of mucous membranes by facilitating the clearance (clearing) of pathogens from their surface.

During inflammatory reaction in the mucous membrane there is an increase in the proportion of extracellular matrix, edema and infiltration by immune cells. At the same time permeability of mucous epithelium increases with hyperplasia of bocaloid cells producing mucous secretion.

The pathogenic mechanism of respiratory reactions caused by NSAIDs in aspirin triad syndrome continues to be investigated by experts and they consider this condition to be an idiopathic hypersensitivity reaction and chronic dysregulation of various cells of innate immunity. [7]

Symptoms of the chronic rhinosinusitis

The first signs of the chronic form of rhinosinusitis are manifested by constant nasal congestion - with nasal nasality and impaired nasal breathing.

Other common symptoms include: a feeling of pressure and pain in the forehead or eye sockets (especially in the morning); pain in the upper jaw and teeth; sensitivity and swelling of the soft tissues surrounding the nose and eyes; thick mucous discharge from the nasal passages (often with purulent exudate); partial or complete loss of smell and decreased taste sensation; bad breath, etc. [8]

When the maxillary sinus is affected, patients feel discomfort and pain in the bridge of the nose, with inflammation in the cuneiform sinuses - headaches go to the back of the head and become stronger when bending, and chronic inflammation in the frontal sinus is accompanied by pain behind the eyeballs and increased sensitivity to light.

In addition to differences in localization (rhinosinusitis maxillary, frontal, ethmoidal, and sphenoidpal), there are types such as:

Chronic polyposis rhinosinusitis - with polyps in the nose or sinuses;
chronic purulent rhinosinusitis - with formation of pus in the paranasal cavity and discharge of purulent exudate in the form of purulent rhinitis. In cases of inflammation of the cells of the lattice sinus can be diagnosed chronic purulent rhinoethmoiditis;
chronic allergic rhinosinusitis, associated with an allergic reaction and the development of allergic rhinitis, in which the swelling of the mucous membrane of the sinuses leads to their obstruction;
chronic hyperplastic rhinosinusitis - with polyp-like thickening of the nasal mucosa and paranasal cavities;
chronic hypertrophic rhinosinusitis or chronic hypertrophic polyposis rhinosinusitis - with marked hypertrophic changes in the nasal and paranasal mucosa and polyposis formations.

If there is an exacerbation of chronic rhinosinusitis, the symptomatology increases, there may also be hyperthermia and worsening of the general condition. [9]

Complications and consequences

Specialists pay attention to the possible complications and consequences of a long-term inflammatory process in the perinasal sinuses, which include:

a permanent lack of sense of smell;
the development of chronic otitis media;
cystic enlargement - mucocele of the sinuses - with occlusion of their drainage channels;
phlegmon of the tissues surrounding the eye socket and purulent inflammation of the lacrimal ducts;
visual impairment;
Inflammation of the surrounding brain membranes - meningitis, optic-chiasmal arachnoiditis, etc.;
fibrous dysplasia, and osteomyelitis of the bones of the facial skull. [10]

Diagnostics of the chronic rhinosinusitis

To make a diagnosis: take blood tests - general and biochemical, for the level of eosinophilia and antibody titers; analysis of nasal mucus (bacteriologic seeding); skin test for allergies, testing for aeroallergens;

Anterior rhinoscopy and nasal endoscopy, which can detect purulent mucus or swelling in the middle nasal passage or the lattice bone, as well as polyps in the nasal cavity. But instrumental diagnostics such as CT or MRI are needed to visualize the paranasal sinuses. [11]

CT scanning in transaxial and coronary planes reveals the degree of pathologic condition, because the staging system - determination of the stage of this disease is based on the data of CT scanning.

There are such CT signs of chronic polyposis rhinosinusitis as the presence of discrete soft tissue formation within one or more sinuses, their partial or complete darkening, thickening of the mucosa, accumulation of secretion; sclerotic bone thickening (hyperostosis) involving the wall of the sinus may be present.

A CT scan of the sinuses may be necessary to objectively confirm inflammation of the sinuses and to differentiate it from allergic rhinitis or idiopathic facial pain. [12]

Differential diagnosis is also performed with chronic inflammation of the pharyngeal tonsil (adenoiditis), cysts and epithelioma of the maxillary sinus, osteoma of the nasal cavity, fibroma of the nasopharynx.

Who to contact?

ENT doctor

Treatment of the chronic rhinosinusitis

Systemic antibiotics for sinusitis. Are needed to treat chronic rhinosinusitis/sinusitis caused by bacterial infection.

In severe chronic polyposis rhinosinusitis, glucocorticoids (corticosteroids) are used: intranasal, oral, or injectable (Fluticasone, Triamcinolone, Budesonide, Mometasone). [13]

Medications for chronic allergic rhinosinusitis are antihistamines, and for fungal sinusitis, antifungal agents.

Prevention

To reduce the risk of developing chronic rhinosinusitis, you should avoid upper respiratory tract infections (by practicing good personal hygiene and strengthening your immune system), and if you have a runny nose, treat it properly. Allergies and other atopic conditions should also be treated

During the heating season, it is recommended to humidify the air in the living space.

Forecast

Subject to treatment and the absence of complications, the prognosis of chronic inflammation of the paranasal sinuses in most cases is favorable.

Chronic rhinosinusitis and the army: compulsory military service is possible after undergoing treatment on the referral of the medical commission.