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Prim Care Clin Office Pract

35 (2008) 11–24

The Diagnosis and Management

of Acute and Chronic Sinusitis
Roxanne S. Leung, MD,
Rohit Katial, MD, FAAAAI, FACP*
National Jewish Medical and Research Center, The University of Colorado
Health Sciences Center, 1400 Jackson Street, Denver, CO 80206, USA

The objective of this article is to review the diagnosis and management of

both acute and chronic sinusitis. Areas discussed include the prevalence of
disease, our current understanding of disease pathogenesis, diagnosis, and
contemporary treatment.

Prevalence and disease burden

Sinusitis affects an estimated 16% of the adult population in the United
States, which translated into an astonishing 5.8 billion dollars of direct
health care costs in 1996 [1]. The great majority of patients present to their
primary care physician, resulting in approximately 18 million office visits
a year. From 1990 through 1992, total restricted activity days numbered
73 million [2]. Degree of impairment from sinusitis is substantial, and is
comparable to other chronic diseases, such as chronic obstructive lung
disease, angina, and back pain [3].

Anatomy
The sinuses are air-filled cavities, which are lined with classical, pseudos-
tradified and ciliated columnar epithelium. The host defense system works
to keep this pathogen free in a number of ways. In an immunocompetent
host, secretory IgA and proper mucocilliary clearance through a patent
ostium prevent local mucosal damage.

* Corresponding author.
E-mail address: katialr@njc.org (R. Katial).

0095-4543/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.pop.2007.09.002 primarycare.theclinics.com
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12 LEUNG & KATIAL

Proper function of the sinuses involves several key points [4], including:
(1) mucus that is of appropriate viscosity, composition, and volume, (2) nor-
mal mucociliary flow, and (3) open ostia to allow adequate drainage and
aeration.The cilia help to clear secretions by sweeping them toward a patent
ostial opening and into the nasal cavity. In the maxillary sinuses, proper
ciliary function is especially important because the direction of drainage is
against the pull of gravity. The ostiomeatal complex (OMC) is a narrow
drainage pathway located in the middle meatus, which allows ventilation
of the anterior ethmoid, frontal, and maxillary sinus.

Definitions
Sinusitis can be broadly defined as inflammation of one or more of the
paranasal sinuses. Classically, sinusitis is characterized as the following:
Acutedsymptoms last less than 4 weeks
Subacutedsymptoms last 4 to 8 weeks
Chronicdsymptoms last longer than 8 weeks
Recurrentdthree or more acute episodes a year
Acute sinusitis can be further defined as an infection of the paranasal
sinuses, with accompanying symptoms present for more than 10 days and
less than 4 weeks.
To fully define chronic sinusitis has been difficult. Because of the variation
in clinical expression of the disease, and the discordance between patient
symptoms and objective findings, no one set of diagnostic criteria has been
agreed on by all clinicians. Furthermore, before much of the microbiologic
or pathologic data regarding this disease had been shown, chronic sinusitis
was thought to be a chronologic extension of acute sinusitis. However, it is
now thought that chronic sinusitis is a much different disease. In contrast
to acute sinusitis, most chronic sinusitis is not an infectious disease and is
better thought of as an inflammatory disease, much akin to asthma.

Pathogenesis and contributing factors

Acute sinusitis
Several factors promote the development of acute sinusitis. In most cases,
bacterial sinusitis is preceded by a viral upper respiratory infection, which in
turn leads to sinus inflammation and obstruction of the OMC. As a result,
drainage and ventilation of the maxillary, anterior ethmoid, and frontal
sinuses are compromised. Once this occurs, both the pH and oxygen content
decrease, the cilia are less functional, mucosa are damaged, and the micro-
environment becomes more susceptible to infection. Approximately 0.5% to
2% of viral sinusitis progress into bacterial infections [5]. To distinguish

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ACUTE AND CHRONIC SINUSITIS 13

between bacterial and viral sinusitis can be difficult. Typically viral sinusitis
resolves in 7 to 10 days [6], whereas bacterial sinusitis remains persistent [7].
Rhinovirus is the most common viral pathogen and is easily transmissible.
In a study of healthy volunteers, 95% of individuals challenged with intrana-
sal rhinovirus drops became infected, and three quarters of them became
symptomatic. Within 10 hours, newly replicating virus was found in the nasal
secretions [8]. As confirmed by sinus puncture, Streptococcus pneumoniae,
Haemophilus influenza, and Moraxella catarrhalis make up the majority of
the community acquired bacterial pathogens [9]. One possible mechanism
for introduction of pathogens from the nasal passages into the sinuses may
actually be through nose blowing. This processes creates a negative intranasal
pressure with such force that nasal fluid is propelled from the middle meatus
into the sinus cavity [10].

Chronic sinusitis
The pathogenesis of chronic sinusitis is poorly understood. The mecha-
nisms that contribute to the chronicity of the disease include mucociliary
dysfunction, mucostasis, hypoxia, and release of microbial products. How-
ever, the initial stimulus and subsequent perpetuation of these processes is
unclear. Some theories have implicated anatomic, infectious, allergic, and
inflammatory disease, but none have been proven.
Unlike acute sinusitis, the role of ostiomeatal complex blockage is
uncertain. In a comparison of CT scans between patients with chronic sinus-
itis and healthy controls, there was no difference in the patency of the ostio-
meatal complex [11]. Also in contrast to acute sinusitis, the role of infection
as the driving force behind most chronic sinusitis has been brought into
question. While the most common pathogens in acute sinusitis include
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis,
pathogens found in chronic sinusitis are usually a mixture of aerobic and
anaerobic bacteria, including Staphylococcus aureus and coagulase-negative
Staphylococci. Whether these organisms are pathologic, or are merely
colonizing agents, is difficult to determine. Reports of the prevalence of
anaerobic species differ widely, and range from as high as 80% to 100%
in children [12], or to as low as 0% to 25% in adults [13,14]. Furthermore,
treatment with antibiotics tends to provide only transient benefit. Granted,
a small subset of patients with chronic sinusitis may be infectious in nature,
but it is usually in association with an underlying immunodeficiency, such as
immunoglobulin deficiency, HIV, cystic fibrosis, or Kartagener syndrome
[15].
Several other mechanisms of disease have been previously proposed. In
these cases, the inflammatory response is against the microbe as an antigen,
and not as an invasive pathogen per se. One theory proposes that immune
hyperresponsiveness to colonizing bacteria, such as Staphylococcus aureus,
may play a role in chronic sinusitis with polyps [16]. Yet another theory

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14 LEUNG & KATIAL

proposes that colonizing fungi serve as the antigen, which will be discussed
at the end of this article [17].
Regardless of the initial stimulus, the inflammatory process ensues, with
a predominance of eosinophils. Furthermore, chronic sinusitis with and
without polyps differ in their specific histopathologic presentation. In nasal
samples of patients with polyps, there were significantly more eosinophils,
plasma cells, and stromal edema compared with those without polyps.
The investigators argued that because a substantial difference was found
between these groups, they should be treated as separate entities, and not
a continuum of one [18].
Perhaps an understanding of the pathophysiology of chronic sinusitis can
be gleaned by its close association with other allergic diseases, such as aller-
gic rhinitis, asthma, and aspirin sensitivity. Based on CT studies, anywhere
from 74% to 90% of asthmatics have sinus mucosal abnormalities, albeit
asymptomatic [19]. In addition, chronic sinusitis was associated with allergic
rhinitis in 40% to 84% of adult patients [20]. Even so, a direct causal role
between these diseases has never been shown.
Lastly, gastroesophageal reflux (GERD) has been implicated as a cause
of sinusitis. Gastric acid can reflux directly into the nasopharynx and, in the-
ory, can cause inflammation of the sinus ostium, and pH probe studies have
shown a much higher incidence of GERD in patients with chronic sinusitis.
In an uncontrolled study of 19 adults with chronic sinusitis, 68% had symp-
toms of GERD, and 78% had abnormal esophageal pH probe results. After
a subset of these subjects was treated with proton pump inhibitors, 67% had
an improvement in sinus symptoms [21].

Diagnosis
Physical examination
The nasal mucosa is best visualized after application of a topical vasocon-
strictive agent, such as oxymetazoine, and use of a nasal speculum. One ap-
proach to the exam should include notice of the color, edema, character of
nasal secretions, presence of polyps, and structure of the nasal septum [22].
Purulent discharge from the middle meatus is highly predictive of bacterial
sinusitis [23,24]. Palpation for tenderness of both the maxillary and frontal
sinuses are helpful. Because a small proportion of cases of maxillary sinusitis
may be caused by tooth infection, one should also check for maxillary teeth
tenderness by tapping with a tongue blade [25]. Transillumination of the si-
nuses is an additional diagnostic test, and is limited to the frontal and max-
illary sinuses, as other sinuses are too distal to examine. To examine the
maxillary sinus, a light source is placed over the infraorbital rim, and light
transmission is observed through the hard palate. The utility of this test is
debatable [22].

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ACUTE AND CHRONIC SINUSITIS 15

Imaging
Imaging of the sinuses is usually reserved to confirm the diagnosis, if
history and physical are equivocal, or if conventional treatment has failed.
Modalities include plain radiograph, CT, ultrasound, and MRI.
Plain X-rays come in several views. The Caldwell (anterior-posterior),
Waters (occipito-mental), and lateral films provide views of the frontal
sinus, maxillary, and sphenoid sinuses, respectively. Unlike the CT scan,
the ethmoid sinus is not well visualized. Significant opacification or mucosal
thickening and air-fluid level are all signs of disease; however, there is no
ability to predict the response to antibiotics based on the radiographic
extent of disease. MRI is best used to evaluate soft tissue structures, and
can distinguish between inflammatory and malignant disease. MRI is also
useful to determine the extent of the complications of sinusitis, such as
intracranial or orbital involvement. Ultrasound, although limited, is an
alternative technique to evaluate the maxillary and frontal sinuses without
exposure to ionizing radiation. This is an especially viable option for preg-
nant women.
CT is the modality of choice, and is better able to evaluate the ethmoid
sinuses compared with plain X-ray. CT is also much better than MRI for
evaluation of boney structures. The ability to visualize detailed anatomy
is helpful in preoperative planning. However, CT is unable to distinguish be-
tween viral or bacterial sinusitis. In one study, 31 healthy adult volunteers
with ‘‘a fresh common cold,’’ 71% of whom described nasal or head conges-
tion, underwent CT sinus imaging early on in their illness. Of the patients
with congestion, 100% had an abnormality in one or more of their sinuses,
compared with 56% of those who did not have congestion. Fourteen sub-
jects returned for repeat imaging, and without interim antibiotics, 79% of
the subjects showed either resolution or marked improvement [26]. In addi-
tion, a significant number of patients have incidental mucosal changes on
CT, in the absence of symptoms [27]. Moreover the extent of mucosal
changes on CT does not correlate with severity of symptoms [28,29].

Culture
Identification of the pathologic organism is best done through maxillary
sinus aspiration. After sterilization of the puncture site, usually through the
lateral wall of the inferior meatus, contents of the maxillary sinus are aspi-
rated. The invasive nature of this procedure often limits its use. As a less in-
vasive approach, endoscopically obtained cultures of the middle meatus,
may be a possible surrogate. However, the same organisms have been found
to colonize the middle meatus in healthy children, as those with sinusitis, so
the mere presence of the organism does not prove infection [30]. In adults,
good correlation has been shown between endoscopically obtained cultures
of the middle meatus, and those of direct antral culture [31].

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16 LEUNG & KATIAL

Acute sinusitis
The diagnosis of sinusitis is usually made on clinical grounds, which
include both the history and physical examination and, if appropriate, diag-
nostic procedures. Symptoms of acute sinusitis often overlap with those of
other diagnosis, such as allergic rhinitis and the common cold. Several stud-
ies have attempted to determine the relationship between the signs and
symptoms of sinusitis, and benchmarks such as sinus puncture, CT, plain
X-ray, and ultrasound.
In a primary care clinic in Norway, 201 patients with a clinical diagnosis
of acute sinusitis underwent CT scan. Of these patients, 63% met the clinic’s
definition of acute sinusitis by having either an air fluid level or total opaci-
fication. The presence of two phases of illness, purulent rhinorrhea, erythro-
cyte sedimentation rate greater than 10 mm, and purulent secretion noted in
the nasal cavity, were all independently associated with acute sinusitis, and
a combination of three out of four of these criteria gave a specificity of 81%
and a sensitivity of 66% [32].
Williams and colleagues [33] conducted a study of adult men who
presented to a primary care clinic with either rhinorrhea, facial pain, or
a self-suspected diagnosis of sinusitis, and compared their symptoms to find-
ings of sinusitis on X-ray. The overall prevalence of sinusitis was 38%. They
found the following symptoms were most sensitive: presence of colored dis-
charge, cough, and sneezing with a sensitivity of 72%, 70%, and 70%, respec-
tively. However, not surprisingly, the specificity of these symptoms was much
less (52%, 44%, and 34% respectively). The most specific symptom (93%)
was maxillary toothache; however, this was found in only a small subset of
patients.
Van Duijn and colleagues [32] reported a study of European patients who
presented to their primary care providers. They compared an algorithm of
five symptoms, which included preceding common cold, purulent rhinor-
rhea, pain on bending, unilateral maxillary pain, and pain in teeth, to find-
ings on ultrasound, a technique primarily used in Europe. Even with this set
of criteria, the proportion of correct diagnosis was a little over one half. In
this study, the most sensitive indicator was history of preceding cold (85%),
and most specific indicator was pain in teeth (83%).
Perhaps the gold standard for the diagnosis of sinusitis is the finding of
purulent material through maxillary sinus aspiration. In marked contrast to
the studies discussed previously, Hansen and colleagues [34] found no
independent association between purulent aspirate and the following symp-
toms: preceding upper respiratory tract infection, maxillary pain, tenderness
of maxillary sinus, maxillary toothache, purulent nasal discharge, and visual-
ization of purulent material on the posterior wall of the pharynx. In summary,
there are no signs and symptoms of sinusitis that are both highly sensitive and
specific. Most will agree that if symptoms persist beyond 7 to 10 days, a diag-
nosis of bacterial sinusitis should be entertained [35].

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ACUTE AND CHRONIC SINUSITIS 17

Although rare, complications of acute sinusitis can occur through direct,

local extension. With antibiotic treatment, complications occur with an
estimated frequency of 1 per 10,000 cases [36]. Clinical presentation may
include facial edema, cellulitis, orbital, visual, and meningeal involvement.
In these cases, aggressive treatment, which may include surgical interven-
tion, is warranted.

Chronic sinusitis
Unfortunately, clinical criteria to diagnose chronic sinusitis, as well as the
predictive value of these criteria, are sorely lacking. Historically, the diagno-
sis of chronic sinusitis was based on several clinical symptoms, similar to the
presentation of acute sinusitis, although often less dramatic; however, none
of these symptoms are specific to sinusitis. In particular, headache, as the
sole presenting symptom, is not likely chronic sinusitis.
On the other hand, nasal endoscopy is useful. Evidence of nasal secre-
tions, nasal polyps, and deformation of the middle meatus have been shown
to distinguish patients with extensive sinus disease, as defined by CT image
criteria, compared with either the control group or to those with limited dis-
ease [37]. Plain X-rays are often insufficiently sensitive to diagnose chronic
sinusitis and do not provide the anatomic detail required for preoperative
evaluation. Although CT is recommended, this alone is still not evidence
enough to make the diagnosis. CT should be performed at least 2 weeks
after an upper respiratory infection, and more than 4 weeks after treatment
of acute bacterial sinusitis, to evaluate underlying chronic disease. Therefore
it is recommended that a combination of clinical signs and symptoms, nasal
endoscopy, and CT be used to make the diagnosis of chronic sinusitis.

Treatment
Acute sinusitis
The diagnosis of acute sinusitis prompts countless number of antibiotic
prescriptions per year. Although the vast majority of cases of acute sinusitis
resolve without treatment, antibiotics are prescribed for an estimated 85%
to 98% of cases presented to a primary care clinic [9]. Antibiotics, compared
with placebo, do reduce treatment failures in bacterial sinusitis by almost
one half (from 31% to 16%) [38]. If culture results are unavailable, the an-
tibiotic should target the most common bacterial pathogens. These include
S. pneumoniae, H. influenzae, and M. catarrhalis. Antibiotic resistance is on
the rise and almost half of S. pneumoniae is now resistant to penicillin, and
the majority of both H. influenzae and M. catarrhalis are B-lactamase
positive [39]. The choice of antibiotic should take into account a number
of factors, such as geographic prevalence of resistance patterns, predicted
efficacy, cost, side effects, and ease of ‘‘use.’’

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18 LEUNG & KATIAL

The American College of Physicians published practice guidelines for the

treatment of acute sinusitis [40]. This position publication was endorsed by
a number of groups, including the Centers for Disease Control and Preven-
tion, the American Academy of Family Physicians, the American College of
Physicians, American Society of Internal Medicine, and the Infectious Dis-
ease Society of America. In this publication they give the following practice
guidelines:
1. Sinus radiography is not recommended for the diagnosis of uncompli-
cated sinusitis.
2. Acute bacterial sinusitis does not require antibiotic treatment, especially
if symptoms are mild or moderate.
3. Patients with severe or persistent moderate symptoms and specific
findings of bacterial sinusitis should be treated with antibiotics. Narrow-
spectrum antibiotics (including amoxicillin, doxycycline and trimetho-
prim-sulfamethoxazole) are reasonable first-line agents.
Amoxicillin is a reasonable first line antibiotic choice for both adults and
children, unless there is a high prevalence of B-lactamase producing strains.
The higher dose (90 mg/kg/day) is recommended for children at higher risk
of amoxicillin resistance, such as those who attend day care, were recently
treated with antibiotics, or are under the age of 2 years. The addition of po-
tassium clavulanate can also counter this antibiotic resistance. The most
common side effects include abdominal cramping and diarrhea, which are
quickly reversed upon discontinuation of the drug. Trimethoprim-sulfame-
thoxazole is an alternative antibiotic in penicillin-allergic individuals; how-
ever, up to 20% of S. pneumoniae may be resistant to this alternative. In
a meta-analysis of several randomized trials, folate inhibitors were found
to be as effective as the newer, more costly antibiotics [38]; however, even
the investigators cede the limitations of their data, so this should be inter-
preted with caution. In contrast to amoxicillin, doxycycline provides
broader antibiotic coverage, including activity against B-lactamase produc-
ing strains of H. influenzae and M. catarrhalis.
First generation cephalosporins, such as cephalexin and cefadroxil, do
not provide adequate coverage against H. influenzae and should not be
used. Second generation cephalosporins, such as cefuroxime axetil and
cefprozil, as well as third generation cephalosporins, such as cefpodoxime
axetil, and cefdinir, are appropriate choices.
The first ketolide, telithromycin, was initially indicated for acute sinusitis,
but this was revoked after reports of severe hepatotoxicity. The fluoroquino-
lones, including ciprofloxacin, levofloxacin, and moxifloxacin, offer broad-
spectrum antimicrobial coverage, and are all indicated for acute sinusitis.
Because of the concern for adverse effect on the development of joints, these
should be avoided in children. These medications can also prolong the QT
interval, so should be used with caution in patients at risk for arrhythmia.
No controlled studies have examined the length of treatment. Generally,

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ACUTE AND CHRONIC SINUSITIS 19

antibiotics should be prescribed for 10 to 14 days, or 7 days after the patient

is symptom free. If symptoms fail to improve in 48 to 72 hours, it is reason-
able to switch to a second line antibiotic. The most commonly prescribed
antibiotics are found in Table 1.
In general, antihistamines are not recommended in the treatment of acute
sinusitis unless the patient has underlying allergic rhinitis. However, antihis-
tamines have been shown to decrease sneezing and rhinorrhea in the com-
mon cold [41,42]. Although topical and oral decongestants are often used
in the treatment of the symptoms of sinusitis, no prospective trials have
been performed. These agents do have a modest effect in decreasing nasal
airway resistance, and in theory may widen the ostia and improve nasal
ventilation. Chronic use of topical decongestants beyond 3 to 5 days should
be discouraged, as they may result in significant rebound hyperemia and
rhinitis medicamentosa.
Nasal corticosteroids have been shown to decrease the inflammatory
process of the nasal mucosa after nasal antigen challenge, and can modify
both the early and late allergic response. As an extension, it is reasonable
to consider that nasal corticosteroids may decrease the inflammatory
response in sinusitis. Nasal corticosteroids have been studied as adjunctive
therapy to antibiotic therapy and found significant reduction in several
symptom scores; in addition, they show no increase in adverse events [43].

Table 1
Oral antibiotics for sinusitis
Antibiotic Pediatric dosage Adult dosage
First line therapy
Amoxicillin 45 mg/kg/day or 90 mg/kg/day 500 mg bid
divided
Second line therapy
Amoxicillin/potassium 22.5 mg/kg/day–45 mg/kg/day 500 mg–875 mg bid
clavulanate divided (Dose based on
amoxicillin component)
Azithromycin 10 mg/kg/day on day 1, 500 mg qd on day 1,
then 5 mg/kg/day on days 2–5 then 250 mg qd on days 2–5
Cefdinir 14 mg/kg/day 300 mg bid
Cefpodoxime 10 mg/kg qd 200 mg bid
Cefprozil 15 mg/kg bid 250 mg–500 mg bid
Cefuroxime 15 mg/kg/day bid 250 mg bid
Ciprofloxacin 500 mg bid
Clarithromycin 7.5 mg/kg bid 500 mg bid
Clindamycin 8 mg/kg/day–20 mg/kg/day 150 mg–450 mg qid
divided qid
Doxycycline 100 mg–200 mg qd
Gatifloxacin 400 mg qd
Levofloxacin 500 mg qd
Sulfamethoxazole/ 6 mg/kg/day–12 mg/kg/day 800/160 mg bid
trimethoprim divided (based on trimethoprim)

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20 LEUNG & KATIAL

However, it should be noted that nasal corticosteroids do not have

a Food and Drug Administration-approved indication for treatment of
acute sinusitis.
Surgical intervention of acute sinusitis is rare, but may be needed in the
case of complications of sinusitis, or in those patients who continue to have
severe symptoms and are unresponsive to medical therapy.

Chronic sinusitis
Corticosteroids (CCSs) are potent anti-inflammatory agents, and as such,
would seem to be a logical choice to treat chronic sinusitis. Although intra-
nasal CCSs are unlikely to reach the paranasal sinuses, they do improve
nasal congestion, which is often a significant symptomatic component in
chronic sinusitis. Intranasal CCSs have also been shown to shrink nasal
polyps. These benefits, combined with their relatively safe profile, make top-
ical intranasal steroids a reasonable adjunctive therapy. Systemic corticoste-
roids are also widely used in clinical practice. Recently, a double-blind
placebo-controlled trial of prednisolone, 50 mg daily for 14 days versus
placebo, demonstrated improvement of sinonasal polyposis as measured
by symptom scores, nasal endoscopy, and MRI [44].
The use of antibiotic treatment in chronic sinusitis is quite controversial.
Patients with chronic sinusitis may also present with acute bacterial sinusitis,
and in these patients antibiotics are indicated. Immunocompromised
patients are at higher risk of a chronic infectious process, and may need to
be treated with antimicrobial therapy. However, often acute exacerbations
may be caused by reasons noninfectious in nature, such as allergic or non-
allergic rhinitis. In these cases, treating the underlying disease is more
appropriate.
Aspirin sensitivity is often present in patients with nasal polyps. In patients
with aspirin-exacerbated respiratory disease (AERD), aspirin desensitization,
followed by long term treatment (650 mg twice a day), have demonstrated
improvement of clinical outcomes and decrease in the requirement for sys-
temic corticosteroids [45].
Cysteinyl leukotrienes are proinflammatory mediators, and are especially
elevated in patients with chronic sinusitis and AERD. Several pharmaco-
logic agents target disruption of this pathway, and are collectively known
as leukotriene modifiers. In a placebo controlled study of aspirin intolerant
asthmatics, zileuton, one such leukotriene modifier, reduced polyp size and
restored the sense of smell [46].
Surgical management may be indicated in cases refractory to medical
management. In a randomized controlled study comparing medical versus
combined medical and surgical treatment of nasal polyposis, medical treat-
ment alone was often sufficient to treat most symptoms. However, if the
primary complaint is nasal obstruction, despite corticosteroid treatment,
surgical intervention is indicated [47].

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ACUTE AND CHRONIC SINUSITIS 21

The role of fungus in sinusitis

Two specific cases of fungal sinusitis are worth mention. The first, allergic
fungal sinusitis (AFS) is a well known, distinct entity of sinusitis, and is best
characterized as the upper airway equivalent to allergic bronchopulmonary
aspergillosis. AFS is a noninvasive form of sinusitis, which is characterized
by thick mucus, often described as peanut butter-like in consistency. Histo-
logic findings include fungal hyphae and degranulating eosinophils embed-
ded within mucinous material. Most patients also present with peripheral
blood eosinophilia, nasal polyposis, and evidence of allergy to fungus (by
skin testing or fungal antigen specific IgE). Treatment requires surgical
debridement and corticosteroid therapy.
An active controversy in the literature revolves around the role of fungi
as a major contributor to the pathogenesis of most chronic sinusitis. Fungi
are ubiquitous organisms, and one group has been able to collect and
culture fungi in virtually all patients with chronic sinusitis. Surprisingly, a
similarly high rate of colonization was found in healthy controls [48]. There-
fore, the mere presence of fungi is not sufficient to cause disease. The inves-
tigators argue that in a susceptible host, an immunologic response is
mounted, including the proliferation or recruitment of eosinophils, which
results in the clinical expression of chronic sinusitis. If this were true, then
eradication of the fungi should result in improvement in disease course.
This has been investigated in several trials with mixed results. In a random-
ized placebo-controlled double-blind trial, 24 subjects completed 6 months
of treatment with intranasal amphotericin B solution versus placebo. The
treatment group exhibited both improved CT scores and endoscopy, but
no change in symptoms over placebo [49]. In contrast, two European trials
have shown no clinical benefit [50,51]. Overall, there is not enough data to
routinely justify nasal antifungal therapy, and the authors do not prescribe
this in our clinical practice.

Summary
In summary, acute and chronic sinusitis are common diseases and
account for a significant number of visits to the primary care office. Both
are associated with significant morbidity and consumption of health care
dollars. Acute sinusitis is caused by an infectious process and can often be
difficult to distinguish from a viral upper respiratory infection, as signs,
symptoms, and even the results of most diagnostic tests overlap. Treatment
of choice is antibiotic therapy, and adjunctive therapy may or may not add
benefit. In contrast, chronic sinusitis is an inflammatory disease. Contrary to
common practice, long term antibiotics are likely not useful. Instead, corti-
costeroids, both in intranasal form and, if necessary, oral systemic form, are
more efficacious. In select patients with nasal polyposis and AERD, both
leukotriene modifiers and aspirin desensitization may be useful.

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22 LEUNG & KATIAL

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