Sinusitis vs Rhinitis

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Please note that the following is a general guideline only. For a full assessment, exclusion of any other underlying cause for your symptoms and an individualised treatment approach, you will need to be seen by a qualified specialist.

Sinusitis and Rhinitis

Rhinitis definition

Characterized by; Non purulent nasal drip/ post nasal drip/ nasal obstruction

• No evidence of pus in the sinus drainage pathway, no polyps (on endoscopy)
• No CT evidence of sinusitis

Important subtypes of rhinitis are

1 allergic rhinitis

2 Local allergic rhinitis -local upper and lower airway allergy, but not demonstrated systemically ie -ve skin testing, -ve RAST testing)

3 Vasomotor rhinitis

4 rhinitis medicamentosa

5 hormonal

6 chemical

Sinusitis definition

Characterized by >2/5 major sinus symptoms-

• Nasal obstruction, 
• nasal drip (usually purulent), 
• post nasal drip, 
• anosmia, 
• pain

and at least one of CT evidence of sinusitis / Pus in the sinus drainage pathway (on endoscopy) or polyps

Important sub types are 

1 Acute sinusitis -If symptoms are acute ie 4-8 weeks (usually post viral)

2 Chronic Rhino Sinusitis (CRS) with nasal polyposis (>3 months)

   

3 CRS without polyposis

4 Other rare types 

   Fungal sinusitis: fungal ball, chronic invasive, acute invasive in the immuno compromised

   Granulomatous; Wegners/ TB

   Secondary to muco ciliary disfunction ie Cystic fibrosis etc

   Specific cause- ie dental infection, clear anatomic problem blocking the sinus drainage

RHINITIS SUBTYPES-Discussion

1 Allergic Rhinitis 

Classification

Intermittent: <4 days per week or <4 weeks

Persistent: >4 days per week or >4 weeks

Aetiology

allergens: seasonal and perennial groups

seasonal allergens → primarily pollens (grasses-spring, weeds-winter, trees)

perennial allergens → moulds, house dust, and animal danders

Pathophysiology

Type I hypersensitivity reaction (ie mast cell degranulation, TH2 driven)

Clinical

sneezing, rhinorrhea, congestion and itching

+ve Family Hx of atopy

injected conjunctiva

increased lacrimation

dark discoloration below the lower eyelids

transverse nasal crease-nasal salute

turbinate hypertrophy/ rhinorrhea (clear and profuse to stringy and mucoid)

Investigations

Should only be done if significant systemic illness ie poorly controlled asthma

Skin prick test

Blood test -RAST or ELIZA, nasal provocation test

FBC

elevated eosinophil count: nonspecific 

Treatment

1 Medical therapy

Nasal symptoms - Rx with topical steroids ie Nasal irrigation followed by  Nasonex (II BD) trial 3 months

Extra nasal symptoms may respond to second generation antihistamine ie Loratidine 10 mg od in an adult

Asthma medication as needed

2 Failed medical therapy with nasal symptoms (with or without asthma) - turbinate reduction followed by ongoing medical therapy (there is evidence that asthma control is better post surgery)

3 Ongoing asthma and very positive allergy test to a few agents; immuno therapy

No evidence for allergy avoidance

Early exposure to pathogens reduces this condition by induction of TH1 rather than TH2 (low allergy in farming communities, families with may siblings)

2 Local Allergic Rhinitis

Definition

Clinically similar to allergic rhinitis BUT no systemic evidence of allergy (ie -ve skin allergy, RAST, ELIZA)

Epidemiology

onset in early adulthood

Aetiology

nasal and respiratory mucosa eosinophillia with no evidence of systemic allergy

may still be a local allergy of the airways

Treatment (as per allergic rhinitis)

Topical therapy

If fails surgery-turbinoplasty

Ongoing symptoms- nasal provocation test- if positive consider immunotherapy (note -ve skin and RAST)

3 Vasomotor rhinitis

Epidemiology

onset in middle age / elderly

Pathophysiology

due to autonomic imbalance-hypoactive adrenergic system relative to parasympathetic

Clinical

present with profuse rhinorrhoea often with clear triggers eg cold, spicy foods

Treatment

medical - ipratropium (atrovent) spray and nasonex II BD longter

surgical- vidian neurectomy (stop the parasympathetic supply to the nose)

4 Drug induced 

ACE inhibitors, estrogens, B-blockers, many others

5 Rhinitis medicamentosa 

loss of sympathetic tone due to down regulation of alpha receptors caused by overuse of sympathomimetic decongestants

treat by withdrawal of decongestant – consider 1 nostril at a time, use topical nasal steroids during withdrawal 

6 Hormonal 

estrogen - increases parasympathetic drive and decreases sympathetic activity

pregnancy – onset in second month, resolves after delivery

menstruation, puberty, exogenous estrogen - OCP

hypothyroidism – myxoedema of turbinates

7 Occupational –

rhinitis induced by irritant at work. Avoidance / topical nasal steroids

SINUSITIS Types and discussion

1 Acute Bacterial

Definition

Bacterial sinusitis following a viral illness lasting up to up to 4-week duration

Diagnosis

Double worsening-(virus--- then better---- then bacterial sinusitis)

Short hx of 

    -purulent rhinorrhea

    -face pain/pressure

    -nasal obstruction.

    -other; ansomia/ fever/aural fullness/cough and headache

Need to differentiate between viral (<10 days –self limiting) and bacterial (up to 4 weeks more severe)

Aetiology

Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis

Treatment

Decongestants-otrivin IV QID for 4 days, Nasal irrigation

Good response to antibiotics: -Amoxycillin, Triprim, macrolide

If no improvement culture guided antibiotics-best 

2 CRS without nasal polyposis

Definition

Sy of CRS without polyps

Epidemiology

60% of CRS

Pathophysiology

mostly due to neutrophills 

Diagnostics

2 Major sy + clinical/ CT evidence

No polyps on examination

pus in the sinus drainage pathway is noted

Treatment

Topical rinse followed by topic steroids spray (Nasonex II BD)

Culture guided antibiotics helps
if no pus no antibiotics

Steroids 3 weeks

No improvement sinus surgery is the gold standard followed by rinsing/ topical steroids spray for 3 months

Natural course

Earlier onset

Better prognosis

very good response to sinus surgery

3 CRS with Nasal Polyposis

Definition

Fulfills the criteria for CRS with notable polyps

Epidemiology

30 % of CRS 

Pathophysiology

Eosinophillic type

Though to be mucosal disregulated immune response 

Various associations; supra antigens, allergy to fungi, biofilms. Cause however is likely to be a disregulated immune response and destruction of the mucosa.

Diagnosis

criteria for CRS and noted nasal polyps

Treatment

Combination of surgery followed by topical therapy

Pre op : can trial 4-6 weeks of Macrolide (mainly for its ant inflammatory aspect) / oral steroids/ rinsing followed by Nasonex II BD

Response will most likely be temporary

Surgery involve full sinus clearance making a good passage for delivery of the above mentioned topical Rx

post op 2 weeks of steroids and macrolide  along with long term rinsing and topical steroid spray

Adjutants

if Samster’s  (Asthma, aspirin hypersensitivity, and polyps) may benefit from post op aspirin desensitization

if intra op evidence of allergic fungal mucin; immuno therapy for fungi

if association with asthma and positive skin allergy test; post op desensitization (note this takes up to 3 years to accomplish)

Evidence that post surgical improvement of nasal airway  improve asthma control

4 Fungal Sinus Disease is discussed separately