Chronic Sinusitis: Symptoms, Diagnosis, and Treatment

What Is Chronic Sinusitis

Chronic rhinosinusitis is an inflammatory disease that affects the lining of the nose and the paranasal sinuses, persisting for more than 12 consecutive weeks. This condition differs from acute sinusitis not only in the duration of symptoms but also in the histopathological characteristics of the inflammatory process.

While acute sinusitis presents an exudative process predominated by neutrophils, the chronic form is characterized by a proliferative process with fibrosis of the lamina propria, where lymphocytes, plasma cells, and eosinophils are the most prevalent cells. This fundamental difference explains why treating the chronic form requires a more complex and prolonged approach.

Symptoms of Chronic Sinusitis

The symptoms of chronic rhinosinusitis are varied and can significantly impact patients’ daily activities. The main symptoms include:

Nasal Symptoms:
– Persistent nasal obstruction that makes breathing through the nose difficult
– Yellowish, greenish, or blood-tinged nasal discharge
– Postnasal drip, characterized by secretion running down the throat

Facial Symptoms:
– Facial pain or pressure that may worsen when bending the head down or lying down
– A sensation of pressure inside the head
– Ear pain that may radiate to other areas

General Symptoms:
– Reduced or lost sense of smell and taste
– Chronic cough that often worsens when lying down
– Constant bad breath
– Fatigue and excessive tiredness
– Sleep disturbances

The intensity of these symptoms can vary, but their persistence for more than 12 weeks is what characterizes the chronic form of the disease.

Causes and Predisposing Factors

Chronic rhinosinusitis can have multiple causes and is often the result of a combination of factors:

Anatomical Factors:
– Deviated nasal septum
– Obstruction of the ostiomeatal complex
– Adenoid hypertrophy

Infectious Factors:
– Recurrent bacterial infections
– Fungal infections, especially by Aspergillus
– Bacterial biofilms

Environmental and Immunological Factors:
– Exposure to cigarette smoke
– Socioeconomic factors such as low income
– Congenital or acquired immunodeficiencies
– Respiratory allergies

Associated Conditions:
– Nasal polyposis
– Bronchial asthma
– Aspirin intolerance
– Cystic fibrosis

Diagnosis

The diagnosis of chronic rhinosinusitis is based on a combination of clinical criteria, physical examination, and complementary tests when necessary.

Clinical Criteria:

Clinical diagnosis requires the presence of two or more main symptoms for more than 12 weeks, at least one of which must be nasal obstruction or nasal discharge. Symptoms are classified as major and minor:

Major symptoms: nasal obstruction, nasal/postnasal discharge, facial pain/pressure, reduced sense of smell
Minor symptoms: headache, halitosis, dental pain, ear pressure

Physical Examination:

Nasal endoscopy is essential to assess the presence of inflammation, purulent secretion, edema, or polyps in the nasal cavities. This examination makes it possible to directly visualize the nasal structures and identify changes characteristic of the disease.

Complementary Tests:

– CT scan of the paranasal sinuses: indicated when initial clinical treatment fails, allowing assessment of the extent of the disease and guiding surgical planning
– Allergy tests: may be useful to identify triggering factors
– Culture of nasal secretion: in selected cases, to identify specific pathogens

Treatment

Treatment of chronic rhinosinusitis must be individualized and often requires a multidisciplinary approach.

Conservative Treatment:

Initial management is based on measures aimed at reducing inflammation and improving drainage of the paranasal sinuses:

Nasal Rinsing:

Nasal irrigation with saline solution is one of the most important and effective measures in treatment. This technique helps to:
– Remove secretions and crusts
– Hydrate the nasal lining
– Reduce the bacterial load
– Improve mucociliary transport

Rinsing should be done with 0.9% saline solution at room temperature, using suitable devices such as needleless syringes or specific nasal irrigators. The recommended frequency is at least three times a day during symptomatic periods.

Medications:

Intranasal Corticosteroids:
These form the basis of pharmacological treatment, significantly reducing inflammation of the nasal and sinus lining. These medications should be used continuously and for a prolonged period to maintain results.

Antibiotics:

Indicated in cases of confirmed or suspected bacterial exacerbation. The choice of antibiotic should consider the most common pathogens and the local resistance pattern. Treatment can range from 5 to 14 days, depending on severity and clinical response.

Oral Corticosteroids:

These can be used in short courses during acute exacerbations, always weighing the benefits against the risks of side effects.

Other Medications:

– Antihistamines: in cases with an allergic component
– Decongestants: limited in time to avoid rhinitis medicamentosa
– Antileukotrienes: in selected cases, especially with associated asthma

Surgical Treatment:

Functional endoscopic sinus surgery (FESS) is indicated when adequate conservative treatment does not provide satisfactory improvement of symptoms.

Surgical Indications:

– Chronic rhinosinusitis refractory to optimized clinical treatment
– Recurrent acute sinusitis with multiple episodes per year
– Presence of nasal polyps or significant anatomical changes
– Complications of rhinosinusitis

Surgical Technique:

Endoscopic sinus surgery uses endoscopes for direct visualization of the structures, allowing:
– Precise removal of inflamed tissue and polyps
– Opening and widening of the drainage ostia
– Correction of anatomical changes
– Preservation of normal structures

Benefits of Surgery:

– Significant improvement of symptoms
– Reduced use of medications
– Recovery of the sense of smell
– Improved quality of life
– Lower frequency of infections

Impact on Quality of Life

Chronic rhinosinusitis has a profound impact on patients’ quality of life, comparable to or even greater than the impact of diseases such as rheumatoid arthritis and chronic obstructive pulmonary disease.

Affected Aspects:

– Sleep disturbances and fatigue
– Reduced productivity at work
– Social relationship problems
– Changes in appetite due to loss of smell
– Reduced self-esteem due to bad breath
– Impact on sexual life

Costs to the Healthcare System:

The condition is one of the leading reasons for seeking medical care, accounting for about 30% of consultations in some specialized services, in addition to the indirect costs related to lost productivity.

Final Considerations

Chronic rhinosinusitis is a complex condition that requires specialized medical care for accurate diagnosis and appropriate treatment. Management must be individualized, considering the specific characteristics of each patient, the presence of comorbidities, and the response to the treatments instituted.

Conservative treatment, based on regular nasal rinsing and the appropriate use of medications, is the first line of approach. When these measures are not enough, endoscopic surgery is an effective and safe therapeutic option, capable of providing significant improvement in symptoms and quality of life.

Educating the patient about the chronic nature of the disease and the importance of treatment adherence is essential for therapeutic success. Regular medical follow-up allows adjustments to treatment and monitoring of the disease’s progression, ensuring the best possible results for each patient.