Chronic Sinusitis

Chronic sinusitis (chronic rhinosinusitis) is inflammation of the paranasal sinuses and nasal passages lasting ≥12 weeks, often following recurrent or inadequately treated acute sinusitis. It most commonly affects the maxillary and ethmoid sinuses.

Key Points

• Defined by ≥12 weeks of sinonasal symptoms and objective evidence of sinus inflammation.
• Multifactorial etiology: infection, allergy, anatomical variants, impaired mucociliary clearance.
• Management includes medical therapy (antibiotics, steroids, saline), endoscopic sinus surgery for refractory cases, and ongoing nursing care.
• Nursing assessment and education are essential to optimize outcomes and prevent recurrence.

Pathophysiology and Etiology

• Infectious: Bacterial (e.g., Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis), fungal (in immunocompromised patients).
• Allergic: IgE-mediated inflammation contributes to edema and obstruction.
• Anatomical: Deviated septum, concha bullosa, ostiomeatal complex narrowings.
• Other factors: Ciliary dysfunction (e.g., cystic fibrosis, smoking), systemic diseases, nasal polyps, foreign bodies, tumors.

Clinical Features

• Nasal congestion or obstruction.
• Purulent rhinorrhea or postnasal drip (often unilateral in odontogenic cases with foul odor).
• Facial pain or pressure worsened by bending forward or cough.
• Decreased sense of smell (hyposmia or anosmia).
• Fatigue, headache, cognitive complaints (e.g., memory loss, difficulty concentrating).
• Less common: visual changes (ethmoid/sphenoid involvement), fever, dental pain.

Assessment and Diagnosis

History and Physical Exam

• Duration of symptoms ≥12 weeks.
• Frequency of acute episodes and prior treatments.
• Allergy history, concomitant asthma or atopic disease.
• Examine nasal mucosa for edema, purulence, polyps; palpate sinuses for tenderness.

Investigation

• Nasal endoscopy: purulent discharge, mucosal edema, polyps, anatomical variations.
• Sinus CT scan: extent of mucosal thickening, opacification, osteomeatal complex block.
• Laboratory: allergy testing, culture from sinus aspirate or endoscopic swabs for refractory/invasive cases.

Differential Diagnosis

• Migraine or tension headache.
• Dental infections (odontogenic sinusitis).
• Nasal polyps or neoplasm.
• Allergic rhinitis without sinus involvement.
• Cluster headache.

Medical Management

First-line

• Saline nasal irrigation: 0.9%–3% saline rinse twice daily to improve mucociliary clearance.
• Intranasal corticosteroids: fluticasone, budesonide sprays daily for 4–8 weeks.

Adjunctive therapies

• Antibiotics: culture-guided for 7–21 days (e.g., amoxicillin-clavulanate, doxycycline, levofloxacin for penicillin-allergic patients).
• Oral corticosteroids: short taper (e.g., prednisone 30–40 mg for 5–7 days) for severe mucosal edema or polyps.
• Antihistamines or montelukast: if allergic component present.
• Mucolytics: guaifenesin or inhaled acetylcysteine to thin secretions.

Surgical Management

• Functional endoscopic sinus surgery (FESS): restore drainage and ventilation by widening ostiomeatal complexes.
• Balloon sinuplasty: dilates sinus ostia; less invasive in select patients.
• Indications: failure of maximal medical therapy, complications (mucocele, orbital involvement), anatomical obstruction.

Nursing Care and Patient Education

Assessment

• Obtain thorough history: symptom onset, severity, triggers, prior interventions.
• Evaluate psychosocial factors: stress, sleep quality, activity level.
• Monitor systemic symptoms (fever, fatigue) and local signs (nasal discharge, facial pain).

Interventions

1. Nasal irrigation training: teach correct technique and hygiene to prevent infection.
2. Medication adherence: reinforce proper use of nasal sprays and completion of antibiotic courses.
3. Symptom monitoring: maintain daily logs of congestion, pain, drainage.
4. Environmental control: advise on allergen reduction (HEPA filters, humidity control).
5. Pain management: non-opioid analgesics (acetaminophen, NSAIDs) as needed.

Discharge Planning

• Recognize red flags: worsening pain, high fever, visual changes—seek immediate care.
• Schedule follow-up appointments for endoscopy or imaging as recommended.
• Encourage smoking cessation and hydration.

Prevention and Follow-Up

• Maintain regular nasal hygiene; use saline irrigation indefinitely if prone to recurrence.
• Annual allergy evaluation for persistent sinonasal symptoms.
• Postoperative care: frequent saline rinses, avoid nose blowing for 2 weeks, attend FESS follow-up.

Referral Criteria

• Refractory disease despite optimal medical therapy.
• Complications: orbital cellulitis, intracranial extension, mucocele.
• Consider ENT or allergy/immunology specialist for complex cases.