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Chronic sinusitis has traditionally been attributed to unresolved or improperly treated acute disease. Chronic rhinosinusitisA is now commonly subdivided into CRS with nasal polyps (NP) or CRS without nasal polyps.
Chronic rhinosinusitisA without nasal polyps may encompass early forms or controlled forms of all the disorders associated with CRS with nasal polyps. Atrophic rhinitis is a dry crusty nasal condition in which the lining of the nose is colonized and infected with bacteria.A Rhinoscleroma ozeneaA is the usual pathogen in this unusual infection which is much more commonly seen in the underdeveloped countries and in impoverished conditions.
Acute exacerbations of CRS are commonly seen in patients who have already had one or many prior sinus surgeries.
Most cases of CRS are inflammatory with only a questionable relationship to traditional bacterial infectious etiologies. Structural and anatomic factors in the early days of endoscopic sinus surgery were felt to be the major cause of CRS.
The most common finding in patients with chronic bacterial rhinosinusitis is nasal congestion, upper teeth pain on the side of the afflicted maxillary sinus, facial pain or pressure and purulent discharge. Nasal polyps may be associated with chronic bacterial sinusitis, but generally they are restricted to the side of the infection.
Infectious complications of sinusitis, are more common with acute than chronic infections (6). The gold standard for the diagnosis of an infectious agent in sinusitis is an antral tap of the maxillary sinus or the recovery of tissue from an infected sinus surgically.
The presence of organisms on aA gram stainA is an indication of moderate quantity of bacteria. While ostio- meatal obstruction is a commonly postulated mechanism for chronic and recurrent bacterial sinusitis, it appears to have little to no role in patients with diffuse sinus disease or with eosinophilic mucin plugs. Radiographs in patients with asthma with or without nasal polyps are frequently positive, even when the patient is asymptomatic with regard to sino-nasal symptoms. While nasal endoscopy may be required to visualize nasal polyps which are small or restricted to the sphenoid recess and nasopharynx, large obstructing polyps can be visualized with lighted examination of the anterior nose. As many as 60% of patients with eosinophilic mucin plugs have bacteria present by staining. Aspirin exacerbated CRS is also known as Aspirin Exacerbated Respiratory Disease (AERD), aspirin intolerant asthma or Samter’s triad. Allergic fungal sinusitis may present in children or adults and may be unilateral or bilateral.
Nonallergic fungal eosinophilic chronic rhinosinusitis is an entity popularized by Jens Ponikauand colleagues (7).A  These investigators have demonstrated that fungi can be cultured from almost anyone's nose whether afflicted with chronic rhinosinusitis or not. Steroids are the main stay of therapy, as in all eosinophilic CRS patients, both topically for control of disease and systemically for flares.
Systemic disorders such as pemphigoid, sarcoidosis, Wegener's granulomatosis and various vasculitidies can present with refractory rhinosinusitis.
Bleeding, scarring and crusting of the lining of the nose extending beyond the most anterior segment is suspicious for the diagnosis of Wegener's granulomatosis or hereditary telangectasia. In systemic disease, septal perforation particularly with disorders associated with vasculitis is common.
Patients whose nasal mucosa is chronically crusted or cobblestoned in appearance should be evaluated for Wegener's granulomatosis and sarcoidosis. From 50 to 80% of patients with sufficient symptoms to require surgery have allergies, which are usually perennial. In patients with recurrent acute sinusitis (three or more discreet episodes of < eight weeks) or medically refractory disease, the differential diagnosis includes immunodeficiency. In the vast majority of cases initial empiric therapy should include a nasal steroid spray. IntravenousA antibiotic therapy may be helpful in patients with bacterial rhinosinusitis who have failed oral therapy. In recent years, it has become apparent that a variety of causes and associations are present in the inflammatory condition of CRS. The perceived prevalence exceeds the actual prevalence, nevertheless it is common and over 500,000 endoscopic sinus surgeries are performed each year for this indication. Each of these categorizations is discussed separately under pathogenesis and clinical manifestations. In many patients with CRS without nasal polyps, the disease may be associated with structural abnormalities causing obstruction of the outflow tract of the maxillary and ethmoid sinuses. Recurrent sinus infections are considered to fall outside normative patterns, if more than 3 distinct episodes occur a year.
These episodes may represent viral, bacterial or non infectious exacerbations of their disease. Nevertheless, CRS is one of the most common diagnoses for which outpatient antimicrobial therapy is prescribed.
If the frontal sinus is infected it may eventually cause anA osteomyelitisA of the anterior or posterior table. Recently endoscopically guided cultures have gained increased acceptance as a moderately good surrogate for invasive diagnostic procedures. Unfortunately the description of presence of white blood cells is frequently not helpful in CRS because many of these cases are rich in eosinophils regardless of infection and the microbiology lab is unable to differentiate the eosinophil from the neutrophil on the gram stain. Rather these patients suffer from a variety of as yet incompletely understood immunologic dysregulations which lead to a clinical picture characterized by eosinophilic mucin, nasal polyps and frequent association with eosinophilic inflammation of the lower airways, usually diagnosed as asthma. A positive radiograph in an asthmatic, including one demonstrating pansinusitis, is hardly ever an emergency, and usually reflects the baseline findings. The polyps are usually smooth and a light pink to slightly yellow color and may be so large on rare occasions as to completely obstruct the front of the nose. In massive nasal polyposis or in subcategories of CRS such as allergic fungal sinusitis (AFS), a remodeling of the facial skeleton may occur and hypertelorism or proptosis may be present.
Anaerobic cultures are seldom submitted in this setting unless the specimen is retrieved anaerobically from the sinuses during a surgical procedure.

These include superantigen mediated, which is believed to be a result of upregulation of inflammation by exotoxins produced byA S. This grouping associated with an adverse reaction to aspirin is usually typified as an asthma attack, is present in about 5 % of all asthmatics. The diagnosis depends on detecting hyphae in the eosinophilic mucin extracted from the nose and sinuses. Cocaine abuse can present a clinical picture very similar to vasculitis, almost always associated with a septal perforation and is a diagnosis based on exclusion of vasculitis.
The suggested laboratory evaluation for Wegener's granulomatosis includes a cANCA and sedimentation rate.
With high-speed serial sinus CT the radiation dosage is < or equivalent to a full panel sinus series and delivers much greater information. The MRI is far too sensitive to the findings of nasal congestion and also fails to adequately display the bony sinus walls. In a completed randomized placebo controlled study, patients with strict entry criteria of prior endoscopic sinus surgery in the presence of purulence were shown to have both objective and subjective improvement on daily nebulized tobramycin compared to placebo. These interventions are frequently undertaken in immunocompromised patients such as double lung transplant cystic fibrosis patients. Notably, half of patients who complain of CRS symptoms have no objective evidence of disease, either endoscopically or by radiographs (12).
While there is overlap between these two classifications, this categorization provides a simple mechanism of stratifying patients, recommending therapies and providing prognosis. In these patients, surgery directed at the limited area of obstruction restores function to the sinuses and is termed functional endoscopic sinus surgery (FESS).
A common scenario accounting for this pattern is a parent with young children who attend daycare. There are no blinded controlled studies to date demonstrating efficacy of oral or systemic antimicrobials in chronic rhinosinusitis.
The term ostiomeatal complex describes the physiologic arrangement of the structures into which the maxillary and anterior ethmoid and frontal sinuses’ mucociliary action is directed and through which they are ventilated and drain.
Having the patient blow the nasal secretions into a tissue for examination allows one to assess the material for purulence.
If the anterior table of the frontal sinus is involved then one develops pain and fluctuance over the frontal sinus and may eventually develop a sinus fistula with drainage of purulence.
TheA in vitroA sensitivities present by microbiologic testing allow direction of the antimicrobial agent to that most specific to the organism. These patients, as with most patients with nasal polyps frequently have absent or impaired sense of smell.
Close clinical integration of the patient’s time course of symptoms and any clinically localizing symptoms, with the radiographs is required. A mucocele (a dilated sinus filled with mucus because it is unable to empty into the nasal cavity) may cause double vision by eroding into the orbit.
Classically, patients also demonstrate an elevated IgE to the cultured fungus and frequently to many molds and pollens (4).
In one small pilot study they showed that there was an 8% reduction in mucosal thickening by sinus CT scan after four months of twice daily irrigation withA amphotericin B; however, there was the significant difference in symptoms in patients treated with amphotericin B and those receiving irrigation with the placebo. On top of the diseased and impaired mucosa associated with these disorders, secondary bacterial infection is common (Table 2). An angiotensin converting enzyme level may be half helpful in the diagnosis of sarcoidosis. Allergy testing may be done with blood tests for specific IgE's for a panel of antigens or with skin testing, either prick testing or intradermal testing. They magnetic resonance angiogram (MRA) is helpful in evaluation of cavernous sinus thrombosis.
Because antimicrobial therapy in CRS, if indeed it is secondary to a bacterial agent, may well require a longer course of therapy than with acute disease, an endoscopically guided culture should be performed prior to initiating antimicrobial therapy. Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomized, controlled trial. A superantigen hypothesis for the pathogenesis of chronic hypertrophic rhinosinusitis, allergic fungal sinusitis, and related disorders. Superantigens and chronic rhinosinusitis: detection of staphylococcal exotoxins in nasal polyps.
The Lighter DensityA  Represents the Allergic Mucin Plug with the Fungal Presence, the Darker Density Represents Polypoid Changes. Subsequently, in 2004, these definitions were expanded, based on consensus of experts from allergy-immunology, rhinology, infectious disease and radiology (5).A  The currently accepted definition of chronic rhinosinusitis (CRS) is inflammation of the nose and paranasal sinuses with objective evidence of disease by radiographs or nasal endoscopy and with a duration of symptoms and signs of at least 12 weeks. Within these caveats, it is true that the diagnosis is increasing in prevalence and estimated to affect approximately 31 million Americans a year.
The incidence of nasal polyps is between 0.2 to 4% of the population, and increases with age, peaking at age 50 years or greater. Surgery in these cases may also be successful because it mechanically debrides awayA biofilms. In the absence of exposure to sick children, investigations of allergy and immunodeficiency are appropriate. Patients with unilateral disease, without nasal polyps are most likely to represent chronic bacterial infectious sinusitis. Obstruction in the ostiomeatal complex can lead to disease in these dependent sinusesA (Figure 2 and 3).
The most common organism isolated from both ocular and intracranial sinogenic complications in children from one institution, wasA Streptococcus milleri. Diagnosis is facilitated with endoscopic visualization and endoscopically directed cultures and biopsies if indicated.
Anecdotally systemic and topical antifungals have been helpful; however randomized controlled trials to date have failed to show significant benefit. Other investigators in randomized controlled trials have demonstrated no difference in patients treated with topical antifungals.

Cicatricial pemphigoid is associated with scarring and narrowing of the nasal vestibule and nasal cavity even to the extent of complete obstruction. If antimicrobial therapy is initiated in the absence of a culture, one should expect clinical improvement within three to four days.
No controlled studies have documented the superiority of IV administration of antibiotic therapy in CRS.
In the lengthy document generated supporting this definition of CRS, evidence supporting a variety of etiologies, some of which are well defined and some of which are theoretical is reviewed. Patients may develop this disorder after a repeated or prolonged bacterial infection that causes irreversible mucosal thickening or osteoneogenesis, causing an obstruction of the osteomeatal complex. Anaerobes play a controversial role in CRS; however both anaerobic and aerobic cultures should be obtained if the diagnosis is suspected. In these situations, endocscopic sinus surgery limited to the area of obstruction can result in restoration of function of the sinuses.
Facial pain and pressure is less common in these patients then in patients with acute disease or non polypoid disease. To date, no studies have been performed that show that antimicrobial therapy is efficaccious in this scenario. Currently the relationship of the development of aspirin sensitivity to superantigens is under investigation.
A total IgE is not an adequate screen for allergies since it may be normal even in the presence of significant allergy. Patients with asthma, even with minimal sinus symptoms, frequently have mucosal thickening of all or most of their sinusesA (Figure 2).A  This common finding must be considered in determining the significance of the positive sinus CT scan in an asthmatic. In the absence of improvement one should suspect that the etiology is either nonbacterial or the bacteria are resistant to the antibiotic being administered.
In addition medically refractory CRS reflects immunodeficiency, allergy and exposure to environmental insults. In situations where the surgery restores function to the sinuses the term functional endoscopic sinus surgery (FESS) is frequent used. The role of anaerobic infections in chronic rhinosinusitis is controversial with the literature reporting isolation of anaerobes in 0 to 100% of cases of CRS.
A difference in density within the sinuses represents the presence of mucin plugs within the sinus surrounded by the less dense thickened mucosal lining of the sinusA (Figure 6).A  This double density is also seen in Allergic Fungal Sinusitis.
The role this plays in the disease is also unclear but may be important in superantigen mediated inflammation (discussed below). Other suggested etiologies of eosinophilic CRS include Aspirin Exacerbated Eosinophilic Chronic Rhinosinusitis, Allergic Fungal Sinusitis and nonallergic fungal eosinophilic chronic rhinosinusitis (Table 2). Ingestion of aspirin or nonsteroidal anti-inflammatory agents provokes nasal congestion and bronchoconstriction (4). Immunotherapy directed toward molds may be helpful postoperatively but not prior to surgical extraction of the disease.
The CT scan is most helpful when the findings of disease correlate with the patient’s symptomatology. There are few randomized controlled trials in the literature studying antibiotics and chronic rhinosinusitis and none with a placebo control. Biofilms have recently been demonstrated in CRS (1,A 2).A  A bacterial biofilm is relatively resistant to antimicrobial therapy and may demonstrate sensitivity to antimicrobials by culture of the planktonic form, not present in the biofilm form. Obstruction in the area the ostiomeatal complex may develop after a prolonged or repeated infection which can lead to irreversible mucosal hypertrophy or osteoneogenesis which then blocks the outflow tracts of the draining sinuses. The nasopharynx can be assessed for adenoidal hypertrophy or masses which can mimic nasal congestion. Bony erosion of the skull base or orbit is present in up to 20% of cases and does not indicate fungal invasionA (Figure 7). Serum eosinophilia is common in allergic fungal sinusitis and nasal polyps and is associated with refractory and recurrent disease. In addition a completely negative sinus CT scan is valuable in eliminating a sinus infection from the differential diagnosis. Recently Lund and colleagues demonstrated that nasal douche, nasal steroid sprays, and three months treatment with a macrolide was as effective as sinus surgery in CRS (8).
The most refractory of the CRS patients with nasal polyps, have a histopathology characterized by eosinophilia and eosinophilic mucin.
The most effective treatment of a biofilm is mechanical debridement, either with surgery of with vigorous nasal irrigations, particularly if prior sinus surgery has made the sinus cavities accessible to nasal irrigation. Because 80% of patients with a viral infection will have an abnormal sinus CT scan indistinguishable from the findings on a bacterial sinus infection, a sinus CT scan should only be obtained when the patient’s disease presentation is puzzling, or there is persistence of symptoms after maximal and directed medical therapy. In the presence of long standing disease, osteoneogenesis can be seen thickening the sinus walls radiographically.
Whether these bacteria are pathogenic or merely colonizers of irreversibly diseased mucosa may vary with the patient and the circumstance. A sinus CT should be obtained immediately in patients with orbital or potentially intracranial complications of sinusitis (6).
Whether this is secondary to bacterial infection or other inflammatory causes is unclearA (Figure 1).A  Histopathologically, patients with chronic bacterial sinusitis will often show a neutrophilic or lymphocytic infiltrate. They must be distinguished from the inferior and middle turbinates which may also have a pale and boggy appearance. The microbial flora of patients with prior surgery is complex and no definite relationship exists between therapy directed at these microbes and resolution of disease. Nevertheless it is common to have the patient use antimicrobial washes based on the sensitivities of the organisms cultured endoscopically.
Identification to the species level is difficult and is often unreliable with commercial laboratory kits.

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