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FAQs Chronic Sinusitis - Diagnosis

Diagnosis of chronic (rhino)sinusitis

What is the benefit of a proper diagnosis?

Chronic (rhino)sinusitis is a difficult diagnosis. To discriminate from rhinitis and other diseases, a CT scan and nasal endoscopy (looking with a camera inside the nose) are usually required. Proper diagnosis is relevant to be able to give appropriate treatment for chronic (rhino)sinusitis and for other diseases. Part of the patients with chronic (rhino)sinusitis have nasal polyps. These can only be diagnosed by nasal endoscopy or CT scan. There are several types of chronic (rhino)sinusitis, and when proper diagnosis is made, treatment can be tailored to your specific type of chronic (rhino)sinusitis and personal preferences. Proper diagnosis enables the doctor to predict the success of treatment, and you to be more involved in the choice of treatment.

How is the diagnosis of chronic (rhino)sinusitis made?

The main diagnosis is made through the presence of symptoms which are mainly nasal blockage, runny nose, secretions dripping into the throat, facial pain and loss of smell. The symptoms need to be present for at least 12 weeks on a row. In addition, nasal examination (evaluation of excess mucus, mucosal swelling and/or polyps) by endoscopy (looking with a camera inside the nose) or CT scan are used to confirm the diagnosis.

When should a patient with sinus symptoms seek medical advice by the non-ENT doctor?

A "common cold" should resolve within one to maximum two weeks. Chronic symptoms of the nose and sinuses last longer than that and if the symptoms do not resolve completely after 1-2 weeks or if there is an transient improvement and subsequent worsening the patient is advised to see a doctor.

When should a patient with sinus symptoms seek medical advice by the ENT doctor?

Chronic (rhino)sinusitis is primarily treated by the primary care physician who usually advices nasal rinsing with saline and prescribes a nasal corticosteroid spray. If the disease is not controlled the patient can be referred to an ear-nose-throat (ENT)-doctor. Not controlled means that with the applied treatment the patient still has symptoms and impairment of quality of life. In unclear cases and thus unclear diagnosis of chronic (rhino)sinusitis by the primary care physician, the patient can also be referred to an ENT doctor.

Diagnostic procedures

Which tests are usually done to diagnose my chronic (rhino)sinusitis?

Anterior rhinoscopy or looking inside the easily accessible part of the nose is the first-line clinical examination of the upper airways (nose), which is useful to evaluate the general aspect of the nasal mucosa. Nasal endoscopy (looking with a camera inside the nose and sinuses) on the other hand, offers the advantage of a global evaluation of the nasal cavity and the outflow tracts of the  sinuses. Several technical examination methods are available to determine nasal patency. They include rhinomanometry (measuring pressure and flow during normal inspiration and expiration through the nose), acoustic rhinometry (determining the structure of the inside of the nose by transmitting sound waves through the nose) and peak nasal inspiratory flow (PNIF; measuring nasal flow during forced inspiration through the nose) measurements and can be of use to objectify reported nasal blockage and measure nasal airflow. In most patients, especially when the nasal endoscopy does not provide final diagnosis,  a CT scan of the paranasal sinuses will be performed, generally after an initial treatment. Smell tests can be required to determine a possible loss of smell and skin prick tests may be performed for diagnosing allergy to for example dust mites or pollen.

What is the role of endoscopy in the diagnosis and which additional examinations are needed?

According to the European guidelines for chronic (rhino)sinusitis (EPOS), chronic (rhino)sinusitis is diagnosed based on the presence of key symptoms, confirmed by either nasal endoscopy (looking with a camera inside the nose) and/or CT scan. Therefore nasal endoscopy is indispensable in the diagnosis of chronic (rhino)sinusitis. It offers the advantage of a global evaluation of the nasal cavity and the outflow tracts of the sinuses visualising the potential presence of nasal polyps and/or secretions at this level. In case nasal endoscopy does not provide final diagnosis, a CT scan of the sinuses will generally be performed. Other tests might be performed, such as nasal patency measurements, smell test and/or allergy tests.

How can loss of smell be tested?

Smell can tested by in a subjective way by means of different smell tests such as UPSIT (University of Pennsilvania Smell Identification Test), Sniffin' Sticks or Barcelona smell test. Additionally, there is a way to do an objective measurement by means of smell-evoked current measurements. These tests are in general supplemented by an MRI (scan) examination of the skull base in order to evaluate the olfactory bulbs (smell region in the brain).

Is there a way to measure headaches?

Headache can be measured with standard questionnaires to evaluate severity and type of pain and the influence on your daily life and functioning. Headache cannot be measured in an objective way, like in blood or on scans. 

How to diagnose nasal blockage

Nasal obstruction can be measured with standardised questionnaires but also by nasal airway tests. The ear-nose-throat (ENT)-doctor can evaluate nasal obstruction by nasal endoscopy (looking with a camera inside the nose). The most used nasal airway tests are the peak nasal inspiratory flow (PNIF; measuring nasal flow during forced inspiration through the nose), acoustic rhinometry (measuring structure of the inside of the nose by transmitting sound waves through the nose) and rhinomanometry (measuring pressure and flow during normal inspiration and expiration through the nose).

Imaging for chronic (rhino)sinusitis

When and why is an Xray of the skull advised?

We no longer advise X-ray (Röntgen radiation) of the skull or sinus in case of chronic (rhino)sinusitis.

When and why is an MRI scan advised?

MRI (magnetic resonance imaging) is an imaging modality that does not require radiation exposure. MRI instead uses a magnetic field and radio waves to create images in the area of concern within the body. MRI is often used to evaluate disease other than chronic (rhino)sinusitis or nasal polyps. The MRI scan will show more details on the type and size of a lesion and its relation with surrounding structures. This will help your ear-nose-throat (ENT)-doctor in making a diagnosis and a plan of treatment.

When and why is a CT scans advised?

A CT (computed tomography) scan is advised in case of chronic (rhino)sinusitis with or without nasal polyps or other disease in your nose/sinus that might indicate surgery or when the ear-nose-throat (ENT)-doctor is not sure about the diagnosis.  The CT scan will not only show the severity and extent of disease and its relationships with other surrounding structures, but will also work as a map for the ENT doctor showing important anatomical landmarks during surgery. In summary, this information helps in making a diagnosis and in case of surgery it helps the ENT doctor in making a plan for the extent and techniques of surgery. 

Does a sinus CT scan cause much radiation? Are the scans necessary?

Every CT scan gives radiation and for that reason it is important not to make unnecessary CT scans. Together with your ear-nose-throat (ENT)-doctor you can decide whether the CT scan is needed. Most hospitals use a low radiation dose protocol for CT scans of the sinuses. When these protocols are used, the amount of radiation you are exposed to during each scan is equivalent to few months of exposure to natural radiation from the environment or a transatlantic fligth (two-way).

Do I need repeated CT scan to assess the extent of my nasal polyps?

Repeated CT scans are not necessary to assess the extent of the nasal polyps. This is done with nasal endoscopy (looking with a camera inside the nose). Only when your ENT doctor is not sure about the extent of your nasal polyps or when surgery is indicated a CT scan may be indicated.