Approaching Chronic Sinusitis

Authors: Kathleen M. Sarber, MD, Gregory Robert Dion MD, MS, Erik K. Weitzel, MD, Kevin C. McMains, MD


Chronic sinusitis is a common disease that encompasses a number of syndromes that are characterized by sinonasal mucosal inflammation. Chronic sinusitis can be defined as two or more of the following symptoms lasting for more than 12 consecutive weeks: discolored rhinorrhea, postnasal drip, nasal obstruction, facial pressure or pain, or decreased sense of smell. Chronic sinusitis is further classified as chronic sinusitis with polyposis, chronic sinusitis without polyposis, or allergic fungal sinusitis using physical examination, and histologic and radiographic findings. Treatment methods for chronic sinusitis are based upon categorization of the disease and include oral and inhaled corticosteroids, nasal saline irrigations, and antibiotics in selected patients. Understanding the various forms of chronic sinusitis and managing and ruling out comorbidities are key to successful management of this common disorder.

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this article or view your purchase options.

Purchase only this article ($15)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.


1. Pleis JR, Ward BW, Lucas JW. Summary health statistics for U.S. adults: National Health Interview Survey, 2009. Vital Health Stat 10. 2010; 249: 1–207.
2. Anand VK. Epidemiology and economic impact of rhinosinusitis. Ann Otol Rhinol Laryngol Suppl. 2004; 193: 3–5.
3. Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg. 1995; 113: 104–109.
4. Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2007; 137: S1–S31.
5. Engels EA, Terrin N, Barza M, et al. Meta-analysis of diagnostic tests for acute sinusitis. J Clin Epidemiol. 2000; 53: 852–862.
6. Setzen G, Ferguson BJ, Han JK, et al. Clinical consensus statement: appropriate use of computed tomography for paranasal sinus disease. Otolaryngol Head Neck Surg. 2012; 147: 808–816.
7. Hagtvedt T, Aalokken TM, Notthellen J, et al. A new low-dose CT examination compared with standard-dose CT in the diagnosis of acute sinusitis. Eur Radiol. 2003; 13: 976–980.
8. Hojreh A, Czerny C, Kainberger F. Dose classification scheme for computed tomography of the paranasal sinuses. Eur J Radiol. 2005; 56: 31–37.
9. Tack D, Widelec J, De Maertelaer V, et al. Comparison between low-dose and standard-dose multidetector CT in patients with suspected chronic sinusitis. AJR Am J Roentgenol. 2003; 181: 939–944.
10. Brem MH, Zamani AA, Riva R, et al. Multidetector CT of the paranasal sinus: potential for radiation dose reduction. Radiology. 2007; 243: 847–852.
11. Van Crombruggen K, Zhang N, Gevaert P, et al. Pathogenesis of chronic rhinosinusitis: inflammation. J Allergy Clin Immunol. 2011; 128: 728–732.
12. Van Zele T, Claeys S, Gevaert P, et al. Differentiation of chronic sinus diseases by measurement of inflammatory mediators. Allergy. 2006; 61: 1280–1289.
13. Peakman M, Vergani D . Basic and Clinical Immunology. Edinburgh: Churchill Livingstone; 2010; .
14. Bachert C, Van Bruaene N, Toskala E, et al. Important research questions in allergy and related diseases: 3-chronic rhinosinusitis and nasal polyposis—a GALEN study. Allergy. 2009; 64: 520–533.
15. Zhang N, Van Zele T, Perez-Novo C, et al. Different types of T-effector cells orchestrate mucosal inflammation in chronic sinus disease. J Allergy Clin Immunol. 2008; 122: 961–968.
16. Cervin A. The anti-inflammatory effect of erythromycin and its derivatives, with special reference to nasal polyposis and chronic sinusitis. Acta Otolaryngol. 2001; 121: 83–92.
17. Suzuki H, Shimomura A, Ikeda K, et al. Il-8 secretion by cultured epithelial cells of human nasal mucosa and its suppression by macrolide antibiotics. Jpn J Antibiot. 1997; 50: 68–70.
18. Suzuki H, Shimomura A, Ikeda K, et al. Effects of long-term low-dose macrolide administration on neutrophil recruitment and IL-8 in the nasal discharge of chronic sinusitis patients. Tohoku J Exp Med. 1997; 182: 115–124.
19. Van Hamme JD, Singh A, Ward OP. Physiological aspects. Part 1 in a series of papers devoted to surfactants in microbiology and biotechnology. Biotechnol Adv. 2006; 24: 604–620.
20. Van Zele T, Gevaert P, Holtappels G, et al. Oral steroids and doxycycline: two different approaches to treat nasal polyps. J Allergy Clin Immunol. 2010; 125: 1069.e4–1076.e4.
21. Bent JP 3rd, Kuhn FA. Diagnosis of allergic fungal sinusitis. Otolaryngol Head Neck Surg. 1994; 111: 580–588.
22. Mukherji SK, Figueroa RE, Ginsberg LE, et al. Allergic fungal sinusitis: CT findings. Radiology. 1998; 207: 417–422.
23. Nussenbaum B, Marple BF, Schwade ND. Characteristics of bony erosion in allergic fungal rhinosinusitis. Otolaryngol Head Neck Surg. 2001; 124: 150–154.
24. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science. 1999; 284: 1318–1322.
25. Foreman A, Jervis-Bardy J, Wormald PJ. Do biofilms contribute to the initiation and recalcitrance of chronic rhinosinusitis? Laryngoscope. 2011; 121: 1085–1091.
26. Psaltis AJ, Weitzel EK, Ha KR, et al. The effect of bacterial biofilms on post-sinus surgical outcomes. Am J Rhinol. 2008; 22: 1–6.
27. Singhal D, Foreman A, Jervis-Bardy J, et al. Staphylococcus aureus biofilms: nemesis of endoscopic sinus surgery. Laryngoscope. 2011; 121: 1578–1583.
28. Grossman J. One airway, one disease. Chest. 1997; 111: 11S–16S.
29. Jani AL, Hamilos DL. Current thinking on the relationship between rhinosinusitis and asthma. J Asthma. 2005; 42: 1–7.
30. National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol. 2007; 120: S94–S138.
31. Marple BF. Allergic fungal rhinosinusitis: current theories and management strategies. Laryngoscope. 2001; 111: 1006–1019.
32. Pfaar O, Klimek L . Eicosanoids, aspirin-intolerance and the upper airways—current standards and recent improvements of the desensitization therapy. J Physiol Pharmacol. 2006; 57: 5–13.
33. Ferguson BJ, Otto BA, Pant H. When surgery, antibiotics, and steroids fail to resolve chronic rhinosinusitis. Immunol Allergy Clin North Am. 2009; 29: 719–732.
34. Carr TF, Koterba AP, Chandra R, et al. Characterization of specific antibody deficiency in adults with medically refractory chronic rhinosinusitis. Am J Rhinol Allergy. 2011; 25: 241–244.
35. Alqudah M, Graham SM, Ballas ZK. High prevalence of humoral immunodeficiency patients with refractory chronic rhinosinusitis. Am J Rhinol Allergy. 2010; 24: 409–412.
36. Ocampo CJ, Peters AT. Antibody deficiency in chronic rhinosinusitis: epidemiology and burden of illness. Am J Rhinol Allergy. 2013; 27: 34–38.
37. Miziara ID, Araujo Filho BC, La Cortina RC, et al. Chronic rhinosinusitis in HIV-infected patients: radiological and clinical evaluation. Braz J Otorhinolaryngol. 2005; 71: 604–608.
38. Chee L, Graham SM, Carothers DG, et al. Immune dysfunction in refractory sinusitis in a tertiary care setting. Laryngoscope. 2001; 111: 233–235.
39. Hammarstrom L, Vorechovsky I, Webster D. Selective IgA deficiency (SIgAD) and common variable immunodeficiency (CVID). Clin Exp Immunol. 2000; 120: 225–231.
40. Oksenhendler E, Gerard L, Fieschi C, et al. Infections in 252 patients with common variable immunodeficiency. Clin Infect Dis. 2008; 46: 1547–1554.
41. Quinti I, Soresina A, Spadaro G, et al. Long-term follow-up and outcome of a large cohort of patients with common variable immunodeficiency. J Clin Immunol. 2007; 27: 308–316.
42. Settipane GA. Epidemiology of nasal polyps. Allergy Asthma Proc. 1996; 17: 231–236.
43. Mainz JG, Koitschev A. Management of chronic rhinosinusitis in CF. J Cyst Fibros. 2009; 8: S10–S14.
44. Feuillet-Fieux MN, Lenoir G, Sermet I, et al. Nasal polyposis and cystic fibrosis (CF): review of the literature. Rhinology. 2011; 49: 347–355.
45. Jones JW, Parsons DS, Cuyler JP. The results of functional endoscopic sinus (FES) surgery on the symptoms of patients with cystic fibrosis. Int J Pediatr Otorhinolaryngol. 1993; 28: 25–32.
46. Nishioka GJ, Barbero GJ, Konig P, et al. Symptom outcome after functional endoscopic sinus surgery in patients with cystic fibrosis: a prospective study. Otolaryngol Head Neck Surg. 1995; 113: 440–445.
47. Gysin C, Alothman GA, Papsin BC. Sinonasal disease in cystic fibrosis: clinical characteristics, diagnosis, and management. Pediatr Pulmonol. 2000; 30: 481–489.
47a. Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012; 50: 1–12.
48. Videler WJ, Badia L, Harvey RJ, et al. Lack of efficacy of long-term, low-dose azithromycin in chronic rhinosinusitis: a randomized controlled trial. Allergy. 2011; 66: 1457–1468.
49. Piccirillo JF, Merritt MG Jr, Richards ML. Psychometric and clinimetric validity of the 20-Item Sino-Nasal Outcome Test (SNOT-20). Otolaryngol Head Neck Surg. 2002; 126: 41–47.
50. Piromchai P, Thanaviratananich S, Laopaiboon M. Systemic antibiotics for chronic rhinosinusitis without nasal polyps in adults. Cochrane Database Syst Rev. 2011; CD008233
51. Cervin A, Wallwork B. Macrolide therapy of chronic rhinosinusitis. Rhinology. 2007; 45: 259–267.
52. Mosges R, Spaeth J, Berger K, et al. Topical treatment of rhinosinusitis with fusafungine nasal spray. A double-blind, placebo-controlled, parallel-group study in 20 patients. Arzneimittelforschung. 2002; 52: 877–883.
53. Scheinberg PA, Otsuji A . Nebulized antibiotics for the treatment of acute exacerbations of chronic rhinosinusitis. Ear Nose Throat J. 2002; 81: 648–652.
54. Uren B, Psaltis A, Wormald PJ. Nasal lavage with mupirocin for the treatment of surgically recalcitrant chronic rhinosinusitis. Laryngoscope. 2008; 118: 1677–1680.
55. Aukema AA, Mulder PG, Fokkens WJ. Treatment of nasal polyposis and chronic rhinosinusitis with fluticasone propionate nasal drops reduces need for sinus surgery. J Allergy Clin Immunol. 2005; 115: 1017–1023.
56. Holmberg K, Juliusson S, Balder B, et al. Fluticasone propionate aqueous nasal spray in the treatment of nasal polyposis. Ann Allergy Asthma Immunol. 1997; 78: 270–276.
57. Lund VJ, Flood J, Sykes AP, et al. Effect of fluticasone in severe polyposis. Arch Otolaryngol Head Neck Surg. 1998; 124: 513–518.
58. Penttila M, Poulsen P, Hollingworth K, et al. Dose-related efficacy and tolerability of fluticasone propionate nasal drops 400 microg once daily and twice daily in the treatment of bilateral nasal polyposis: a placebo-controlled randomized study in adult patients. Clin Exp Allergy. 2000; 30: 94–102.
59. Small CB, Hernandez J, Reyes A, et al. Efficacy and safety of mometasone furoate nasal spray in nasal polyposis. J Allergy Clin Immunol. 2005; 116: 1275–1281.
60. Stjarne P, Blomgren K, Caye-Thomasen P, et al. The efficacy and safety of once-daily mometasone furoate nasal spray in nasal polyposis: a randomized, double-blind, placebo-controlled study. Acta Otolaryngol. 2006; 126: 606–612.
61. Stjarne P, Mosges R, Jorissen M, et al. A randomized controlled trial of mometasone furoate nasal spray for the treatment of nasal polyposis. Arch Otolaryngol Head Neck Surg. 2006; 132: 179–185.
62. Salib RJ, Howarth PH. Safety and tolerability profiles of intranasal antihistamines and intranasal corticosteroids in the treatment of allergic rhinitis. Drug Saf. 2003; 26: 863–893.
63. Welch KC, Thaler ER, Doghramji LL, et al. The effects of serum and urinary cortisol levels of topical intranasal irrigations with budesonide added to saline in patients with recurrent polyposis after endoscopic sinus surgery. Am J Rhinol Allergy. 2010; 24: 26–28.
64. Passalacqua G, Albano M, Canonica GW, et al. Inhaled and nasal corticosteroids: safety aspects. Allergy. 2000; 55: 16–33.
65. Lal D, Hwang PH. Oral corticosteroid therapy in chronic rhinosinusitis without polyposis: a systematic review. Int Forum Allergy Rhinol. 2011; 1: 136–143.
66. Fokkens W, Lund V, Mullol J, et al. European position paper on rhinosinusitis and nasal polyps 2007. Rhinol Suppl. 2007; 20: 1–136.
67. Glass D, Amedee RG. Allergic fungal rhinosinusitis: a review. Ochsner J. 2011; 11: 271–275.
68. Friedman M, Vidyasagar R, Joseph N. A randomized, prospective, double-blind study on the efficacy of dead sea salt nasal irrigations. Laryngoscope. 2006; 116: 878–882.
69. Burton MJ, Eisenberg LD, Rosenfeld RM. Extracts from the Cochrane Library: nasal saline irrigations for the symptoms of chronic rhinosinusitis. Otolaryngol Head Neck Surg. 2007; 137: 532–534.
70. Papsin B, McTavish A. Saline nasal irrigation: its role as an adjunct treatment. Can Fam Physician. 2003; 49: 168–173.
71. Tomooka LT, Murphy C, Davidson TM. Clinical study and literature review of nasal irrigation. Laryngoscope. 2000; 110: 1189–1193.
72. Levine H, Rabago D. Balloon sinuplasty: a minimally invasive option for patients with chronic rhinosinusitis. Postgrad Med. 2011; 123: 112–118.
73. Brenner PS, Abadie WM, Weitzel EK, et al. Unexpected consequences of transnasal balloon dilation of the maxillary ostium. Int Forum Allergy Rhinol. 2011; 1: 466–470.
74. Abadie WM, McMains KC, Weitzel EK . Irrigation penetration of nasal delivery systems: a cadaver study. Int Forum Allergy Rhinol. 2011; 1: 46–49.
75. Singhal D, Weitzel EK, Lin E, et al. Effect of head position and surgical dissection on sinus irrigant penetration in cadavers. Laryngoscope. 2010; 120: 2528–2531.
76. Chiu AG, Palmer JN, Woodworth BA, et al. Baby shampoo nasal irrigations for the symptomatic post-functional endoscopic sinus surgery patient. Am J Rhinol. 2008; 22: 34–37.