Chronic Rhinosinusitis

When inflammation of the nasal mucosa extends to the mucosa of the sinuses located right above the nose, the consensus term (rhino)sinusitis is used. Typical symptoms of (rhino)sinusitis are facial pain or pressure, smell dysfunction and nasal secretions dripping into the throat, in addition to the classical rhinitis symptoms of nasal blockage and nasal secretions. When these symptoms are present for more than 12 weeks, (rhino)sinusitis is addressed as chronic. Chronic (rhino)sinusitis can present with or without nasal polyps and it is currently still unclear why some chronic (rhino)sinusitis patients develop nasal polyps and others do not.

Chronic (rhino)sinusitis with nasal polyps runs in families but also chronic (rhino)sinusitis without nasal polyps has been observed in family members, strongly suggesting that a hereditary (=genetic) factor contributes to the disease. However, studies in identical twins showed that both siblings will not necessarily develop nasal polyps, which emphasises the additional and important role of non-hereditary, environmental factors. 

Sinuses are air-filled cavities covered by mucosal linings within the bones of your face and skull. The nose and sinuses are important for filtering, heating, and moistening the air you breathe through your nose. This important function protects your lungs. Sinus cavities may also contribute to voice resonance. Furthermore, a gas (nitric oxide or NO) is produced inside the sinuses which protects against sinus infections, improves the removal of secretions from the sinuses and increases the uptake of oxygen in the lungs. 

Around 10% of the population in Europe has chronic (rhino)sinusitis. This roughly equals the population of Spain. In some areas, the percentage of affected people is even higher.

Generally, this is a chronic disease that cannot easily be cured; however, patients sometimes have long periods of the well-controlled disease. The treatment aims primarily to control the patient's symptoms. Other goals are to reduce mucosal inflammation, establish sinus drainage of secretions and reduce sudden worsening of symptoms. Usually, the disease becomes less severe after 60 years of age.

Inflammation of the sinuses is often referred to as sinusitis. However, the term rhinosinusitis is preferred to sinusitis since the inflammation of the sinuses rarely occurs without simultaneous inflammation of the nasal mucosa. Both terms are commonly used interchangeably.

Lifestyle factors like smoking, work-related exposure to certain agents (or irritants) and air pollution may affect chronic (rhino)sinusitis. Inhaled pollutants like cigarette smoke cause irritation to the airways and hinder the clearance of secretions from the nose and sinuses. Moreover, cigarette smoke increases the likelihood of getting airway infections, makes it more difficult to breathe through the nose, and reduces the sense of smell. Chronic (rhino)sinusitis is also associated with acid reflux from the stomach, which some patients have without noticing. It is advised to avoid a high intake of coffee, alcohol, or acidic drinks such as sodas or juices. 

Many patients with chronic(rhino)sinusitis remember a prolonged nose infection caused by a virus or bacteria as the triggering event of their chronic illness. Infections inflame and thicken the sinus membranes and hinder the removal of secretions from the sinuses. This swelling and inflammation sometimes last long after infection. However, inflammation, which is the major cause of chronic (rhino)sinusitis, can also be caused by many other factors acting together at different stages of the disease. Sometimes chronic (rhino)sinusitis is caused by local allergic reactions to certain bacteria and fungi. The inflammation of the sinuses can also be influenced by the presence of nasal polyps or related medical conditions such as asthma, aspirin sensitivity and immune system disorders. In conclusion, bacteria and viruses can play a role both during the initiation and modulation of the disease, but additionally, other environmental and hereditary factors contribute to the disease.

The importance of allergy as a contributing factor to chronic (rhino)sinusitis is not fully understood. Allergic disease is associated with asthma and allergic patients get severe and recurrent chronic (rhino)sinusitis more often. Year-round allergies to for example moulds and dust mites seem to occur more often in patients with chronic (rhino)sinusitis than seasonal allergens such as pollen. Allergy seems to be more important in the Asiatic than the European population for chronic (rhino)sinusitis.

Chronic (rhino)sinusitis is a broad diagnosis that includes different inflammatory diseases, further classified based on the presence of nasal polyps. Although not fully understood, it is usually caused by a combination of different factors that contributes to the development of the disease. In chronic (rhino)sinusitis there is a malfunction interplay between individual patient characteristics (including genes) and several environmental factors. Hypotheses as to causes include immune system disorders, airway disease like asthma, allergies, inhaled pollutants like cigarette smoke, local allergic reaction to substances produced by certain bacteria and fungi and -seldom- anatomical variation in the nose and sinuses.

Different factors contribute to the development and severity of chronic (rhino)sinusitis. Although smoking or infections may be associated with the disease, many other factors contribute to chronic(rhino)sinusitis. Lifestyle with excessive intake of alcohol, coffee or soft drinks, as well as stress, can cause stomach acid reflux, and this can in some cases be related to chronic (rhino)sinusitis. Heavy stress and inadequate sleep may also weaken your immune system. In addition, structural abnormalities such as a highly deviated nasal septum may also contribute to the blockage of mucus inside the sinuses and the development of chronic (rhino)sinusitis.

A prolonged cold is caused by a sudden (delete) virus infection and is different from chronic (rhino)sinusitis. Many patients with chronic (rhino)sinusitis remember a nose infection as the first event of their chronic illness. Prolonged colds can result in swollen membranes inside the nose and sinuses with symptoms such as nasal blockage, runny nose, and a reduced sense of smell. However, in the case of chronic (rhino)sinusitis, the symptoms need to be present for at least 12 weeks in a row. In addition, confirmation of sinus disease is required by nasal endoscopy (looking with a camera inside the nose) and/or a CT scan. 

Chronic (rhino)sinusitis is characterised by the presence of two or more of the following key symptoms, one of which should be either: nasal blockage (having difficulty breathing through your nose) and/or discoloured and thick discharge from the nose or down into the throat (called post-nasal drip); with or without: facial pain/pressure or reduction of smell. Some patients also experience ear or teeth pain, bad breath, sore throat, irritability, and lack of energy.

When looking into the nose, the doctor may find mucous membranes to be swollen, red and signs of irritation. When examining further inside the nose with endoscopy, the doctor may also find polyps or secretions from sinus openings. When looking into the mouth and throat, the doctor may see discoloured and thick secretions that have come from the back of the nose down into the throat. There may also be clinical signs of complications caused by chronic (rhino)sinusitis, such as swelling and redness around one eye. 

Alcohol intolerance is seen in several patients with chronic (rhino)sinusitis. It causes congestion of the nose and sinuses but is not due to an allergic reaction.

Smoking is a major factor causing irritation in the lungs, but also in the nose and the nasal sinuses. This is true for all people who smoke, but in patients with chronic (rhino)sinusitis, this irritation can be much more severe. Stop smoking is very important and takes the irritation factor away. Otherwise, medical treatment with nasal sprays or tablets can be useless. 

If you have problems with your teeth this can result in an infection of the bone, which is directly in contact with the sinuses right above the teeth. This can result in chronic (rhino)sinusitis (mostly one-sided). It is important to treat the underlying dental problems first.

Irritation of the nose from some chemical substances, gas or an infection from dirty water with bacteria can trigger an inflammatory reaction inside the nose and sinuses. Sudden infections or irritation caused by chemicals or allergy can result in swollen membranes inside the nose and sinuses that in turn disturbs the removal of secretions. This may over time develop into chronic (rhino)sinusitis. However, chronic (rhino)sinusitis is usually caused by a combination of different factors, and other underlying factors that you were not aware of may have contributed to the development of your chronic (rhino)sinusitis. 

Poor indoor air climate and allergies to for example mould and dust mites can contribute to irritation and swelling inside the nose and sinuses, and to the formation of polyps. In some cases, this may lead to chronic (rhino)sinusitis if swelling and inadequate removal of secretions from the sinuses continue over time. It is, however, difficult to state that this alone has caused your disease. 

Inhaled pollutants like cigarette smoke are major causes of irritation to the airways, and it hinders the clearance of mucus from the nose and sinuses. Cigarette smoke, either active smoking or passive exposure, contributes to the development of chronic (rhino)sinusitis. It increases the likelihood of getting airway infections, makes it more difficult to breathe through the nose, and reduces the sense of smell. Active smoking, although at a higher risk, is not a reason not to perform sinus surgery. The impact of the number of cigarettes per day and the time the patient has smoked on the result after surgery is not fully understood.

We know that the nose, sinuses, and lungs are constantly influencing each other. Therefore, uncontrolled chronic (rhino)sinusitis can worsen complaints of asthma and vice versa. In addition, symptoms can be more severe in patients who have both chronic (rhino)sinusitis and asthma. Regarding common colds, several studies have shown that patients with chronic (rhino)sinusitis and asthma have a reduced immune defence against viral infections. This might explain why these patients have more often common colds, which also last longer.

A runny nose and nasal secretions dripping into the throat in a patient with chronic (rhino)sinusitis are both symptoms that can lead to chronic coughing. You also should be tested for asthma to confirm or exclude cough-variant asthma.

The upper (nose and sinuses) and lower (lungs) airways are closely related to each other. A high number of patients with asthma suffer from chronic (rhino)sinusitis and the more severe the asthma is, the more common chronic (rhino)sinusitis is, with a prevalence of up to 80% in the most severe cases. Chronic (rhino)sinusitis can be first but also asthma can be first; both diseases need to be treated adequately.

Since there is a high concurrence of asthma and chronic (rhino)sinusitis with nasal polyps, asthma should always be suspected and tested. Treatment of chronic (rhino)sinusitis might be more difficult if asthma co-exists and combined therapy needs to be applied and adapted for both conditions. This is especially true for inhalers and nasal sprays with corticosteroids, but also for tablets or injections with corticosteroids for which there is the risk of overdosing and occurrence of side effects when combining these medications.

Undiagnosed and untreated chronic (rhino)sinusitis in patients with asthma can hamper therapeutic effects in the latter leading to more severe symptoms or worsening of symptoms. Well-treated chronic (rhino)sinusitis can lead to better control of asthma and the need for less (strong) medication.

The inflammation of the nasal and sinus mucosa leads to overproduction of nasal mucus causing the patient to experience a fullness of the nose and dripping of excess mucus out of the nose or into the throat.

A healthy nose produces 500 ml of fluid per day. In a healthy nose, this is released in small droplets that arrive in the throat and are swallowed. Post-nasal drip is a symptom of chronic (rhino)sinusitis where the patient feels mucus running down the throat from above. The patients feel the urge to swallow more often or spit out the mucus. Sometimes patients feel that despite their effort the mucus cannot be removed. In patients that have been operated on, mucus tends to accumulate in the sinuses and is released sometime later. Patients experience this excess accumulation of mucus as a post-nasal drip (difficult to remove mucus in the throat). When mucus production is increased due to inflammation of the nasal/sinus mucosa the problem increases. Rinsing the nose with saline can remove the mucus and therefore also reduce the symptoms of post-nasal drip.

Headache or facial pain/pressure is one of the four key symptoms that may be present in patients with chronic (rhino)sinusitis. Headache or facial pain/pressure as the only symptom is never due to chronic (rhino)sinusitis. If combined with symptoms of a runny nose and nasal blockage, the headache or facial pain/pressure is likely to be due to chronic (rhino)sinusitis. The ear-nose-throat (ENT) doctor can evaluate your symptoms, perform a nasal endoscopy (looking with a camera inside the nose) and often order a CT scan of the sinuses to determine whether the symptoms of headache or facial pain/pressure are caused by chronic (rhino)sinusitis.

Headache or facial pain/pressure as the only symptom is never caused by chronic (rhino)sinusitis. Headache or facial pain/pressure as the only symptom is in most cases due to neurological causes (or conditions related to your brain). Therefore, a consultation with a neurologist is of critical importance. Headache/facial pain that comes without any other nasal symptoms, with no clear signs of inflammation inside the nose (assessed by looking with a camera inside the nose), and does not respond to medicines, is very rarely sinus related. Nausea, vomiting, aura, photophobia (discomfort or pain due to light exposure), and phonophobia (discomfort or pain due to loud sounds) are symptoms that are also linked to the headache that is unrelated to chronic (rhino)sinusitis and require consultation with a neurologist.

Headache can be caused by chronic (rhino)sinusitis especially in the case of chronic (rhino)sinusitis without nasal polyps. The headache is usually located around the eyes and the forehead and is usually described as a dull pressing feeling. Pain located at the side of the head or in the neck is seldomly caused by chronic (rhino)sinusitis.

Chronic (rhino)sinusitis is highly linked to poor sleep quality. Because of increased airflow resistance, mouth breathing and nasal secretions, patients with chronic (rhino)sinusitis find it difficult to get to sleep and often sleep badly resulting in daytime sleepiness. 

There is a clear correlation between chronic (rhino)sinusitis and symptoms of snoring and obstructive sleep apnoea. Whether surgery will improve the symptoms of snoring and obstructive sleep apnoea depends on the amount of nasal obstruction caused by chronic (rhino)sinusitis. Your ear-nose-throat (ENT) doctor can discuss the options with you.

Chronic (rhino)sinusitis may affect many aspects of life, and work productivity is certainly one of those. The impact of chronic (rhino)sinusitis on work productivity is usually mentioned in terms of absenteeism (not being able to work) and presenteeism (being present at work but with decreased productivity). It is estimated that patients with chronic (rhino)sinusitis miss approximately 6 days of work annually due to their disease. Moreover, nasal symptoms result in poor concentration, disturbed sleep, fatigue, and daytime sleepiness, leading to reduced work productivity.