About Chronic Rhinosinusitis
Chronic rhinosinusitis (CRS) is a chronic inflammatory disorder affecting nasal passages and paranasal sinus cavities. It is one of the most common chronic respiratory diseases with a significant impact on quality of life and costs of health care. Paranasal sinuses are cavities in the facial and skull bones which communicate with nasal passages on the same side through small openings called sinus ostia. This communication is crucial for regular functioning of the sinus ventilation and drainage. If the communication is blocked by inflammatory process in nasal or sinus cavities or on the both sides of ostia, symptoms of rhinosinuitis occur. Classification of rhinosinusitis, according to the European Position Paper on Rhinosinusitis and Nasal Polyps (EP3OS), developed by a Task Force of the European Academy of Allergology and Clinical Immunology (EAACI), divide rhinosinusitis into acute and chronic, based on the duration of symptoms. Acute rhinosinusitis usually starts as a viral disease, lasting for 7 to 10 days, which may progress due to bacterial superinfection into bacterial rhinosinusitis. In acute rhinosinusitis symptoms last up to 12 weeks.
Chronic rhinosinusitis is defined as the presence of 2 or more symptoms of which 1 should be either nasal blockage or nasal discharge combined with facial pain and/or reduction of smell for more than 12 weeks and the diagnosis should be confirmed with nasal endoscopic signs or corresponding mucosal changes on computerized tomography (CT) scan. Besides nasal blockage, coloured discharge (yellowish, brown) that can be blown through the nose, or drips back from the nose to the throat, facial pain or pressure, headache, and smell loss or reduction, other, less frequent symptoms may occur, like cough, foul odour from the mouth, fatigue, pressure in the ears and fever. Patients with chronic rhinosinusitis have significant reduction in their quality-of-life, which is improved after adequate treatment.
The reason why chronic rhinosinusitis develops is not clear. It may result from previously poorly treated acute bacterial rhinosinusitis, but it seems rarely to be the true cause. It was shown in a number of studies that infection, the most common cause of acute rhinosinusitis, is not the main factor in the development of chronic rhinosinusitis. Even when growth of microorganisms, like bacteria or fungi, was found in nasal and sinus secretions, it was rarely shown that colonizing bacteria or fungi were the cause of the disease. There are many predisposing factors to develop chronic rhinosinusitis, like: distorted anatomy of nasal cavity or sinuses, inadequate immune response to infection, allergy or intolerance to certain drugs, impaired function of the clearance of secretion in nasal and sinus cavities, or scarring from repetitive sinus operations, etc.
Diagnosis
Although diagnosis is based on the presence of characteristic symptoms, some diagnostic procedures are performed, not only to confirm objectively referred symptoms, but also to define the severity of the disease and check for the predisposing factors. Usually, nasal endoscopy, CT-scan and allergy testing are performed. However, in cases that are not responsive to standard treatment, a lot of other procedures can be applied, including microbiology testing, cytology, measurement of secretion clearance, even biopsies of the sinus mucosa. When a main predisposing factor is recognized and treated, CRS severity is usually improved.
It is important to note that tumours, benign and malignant, have symptoms that would fit into diagnosis of CRS. If symptoms are dominantly on one side, if there are signs of bleeding on one side, and problems with vision and severe headaches occur, further diagnostic procedure, primarily detailed endoscopy and imaging with CT or magnetic resonance should be done.
Management
According to the EP3OS document, CRS should be treated in the stepwise fashion, considering severity of subjective symptoms and the impact on quality of life. In the mild disease, patients with CRS are primarily treated with saline or hypertonic saline nasal douching, followed by the application of local corticosteroids. In more severe cases, when no response to nasal douching and nasal steroid sprays is achieved, patient may try the treatment with long term low dose antibiotics, before referred to surgery. Acute exacerbations of rhinosinusitis in patients with CRS, are usually de novo infection by bacteria, and should be treated with targeted antibiotic. The treatment of CRS is a long-run treatment which most often ends up with surgical procedure. However, even after the surgery, similar kind of medical treatment, i.e. douching and intermittent topical steroids, should be continued and follow up by the surgeon is necessary.
Coping
- Avoid dwellings having rooms too warm and dry
- Avoid tobacco smoke
- Take in sufficient liquids such as water or fruit juices
- Other general measures include:
- Inhaling steam 2 – 4 times a day is extremely helpful, costs nothing, and requires no expensive equipment. The patient should sit comfortably and lean over a bowl of boiling hot water (no one should ever inhale steam from water as it boils) while covering the head and the bowl with a towel so the steam remains under the cloth. The steam should be inhaled continuously for 10 minutes. A mentholated or other aromatic preparation may be added to the water. Long, steamy showers, vaporizers, and facial saunas may be an alternative
- A nasal wash can be helpful for removing mucus from the nose. A saline solution can be purchased in a spray bottle at a drug store or made at home. Perform the nasal wash several times a day.