Allergic Disorders
7. Rhinitis and sinusitis

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Abstract

Rhinitis and sinusitis are prevalent medical conditions that are often associated with each other and may result in significant morbidity and medical costs. They can cause systemic symptoms, decrease quality of life, and result in reduced workplace productivity and missed school days. Appropriate management of rhinitis or sinusitis may be an important component in effective management of coexisting or complicating conditions, such as asthma, allergic conjunctivitis, or chronic otitis media. Rhinitis may be caused by allergic, non-allergic, infectious, hormonal, occupational, and other factors. Defining the basis for rhinitis in an individual is important in selection of therapeutic options. Rhinitis and sinusitis may be difficult to distinguish from each other on the basis of history alone. Although most acute upper respiratory infections are viral and do not require antibiotic treatment, persistence of symptoms for ≥7 days makes acute bacterial sinusitis more likely and antibiotics an appropriate consideration. Radiographic imaging is not required for diagnosis of acute, uncomplicated sinusitis, although CT scans are indicated in evaluation of suspected chronic sinusitis or treatment failures. Chronic sinusitis may have an infectious or non-infectious basis. Underlying disorders that predispose to chronic sinusitis should be identified and treated as part of the treatment of chronic sinusitis. (J Allergy Clin Immunol 2003;111:S520-9.)

Section snippets

Background

Although “rhinitis” strictly means inflammation of the nasal mucous membranes, inflammatory cell infiltrates do not always characterize some disorders termed rhinitis. Rhinitis can be more practically viewed as a heterogeneous group of nasal disorders characterized by 1 or more of the following symptoms: sneezing, nasal itching, rhinorrhea, and nasal congestion. Rhinitis may be caused by allergic, non-allergic, infectious, hormonal, occupational, and other factors.1, 3 Allergic rhinitis is the

Nasal anatomy and physiology

The nasal cavity is divided by the nasal septum, which is composed of cartilage more distally and bone more proximally. The inferior, middle, and superior turbinates in the nasal cavity promote air filtration, humidification, and temperature regulation. The nasal cavity and turbinates are lined with mucosa comprised of pseudostratified columnar ciliated epithelium that overlies a basement membrane and the submucosa (lamina propria). The submucosa consists of serous and seromucous nasal glands,

Pathophysiology

Common allergens causing allergic rhinitis include proteins and glycoproteins in airborne dust mite fecal particles, cockroach residues, animal danders, molds, and pollens. Upon inhalation, allergen particles are deposited in nasal mucus, with subsequent elution and diffusion into nasal tissues. In addition, allergic responses may be caused by small molecular weight chemicals in occupational agents or drugs that act as haptens that react with self proteins in the airway to form complete

Diagnosis

Full evaluation of a patient with rhinitis should include assessment of specific symptoms bothersome to the patient (eg, nasal congestion, pruritus, rhinorrhea, sneezing), the pattern of symptoms (eg, intermittent, seasonal, perennial), identification of precipitating factors, response to medications, coexisting conditions, and a detailed environmental history including home and occupational exposures.1 Nasal itching is more suggestive of allergic rhinitis. Because allergic rhinitis is

Avoidance measures

Avoidance of inciting factors, such as allergens (house dust mites, molds, pets, pollens, cockroaches), irritants, and medications, can effectively reduce symptoms of rhinitis. In particular, patients allergic to house dust mites should use allergen-impermeable encasings on the bed and all pillows. Pollen exposure can be reduced by keeping windows closed, using an air conditioner, and limiting the amount of time spent outdoors.

Medications

Medications should be selected in consideration of the individual

Background

Sinusitis is defined as inflammation of 1 or more of the paranasal sinuses, air-filled cavities in facial bones lined with pseudostratified ciliated columnar epithelium and mucous goblet cells. Acute bacterial sinusitis is defined to be less than 4 weeks' duration. Subacute sinusitis is frequently defined to be of 4 to 12 weeks' duration. Chronic sinusitis, defined to be symptoms lasting longer than 12 weeks (with some guidelines also requiring a failure to respond to treatment and a positive

Anatomy and physiology

Epithelial cilia in the sinuses normally beat mucus towards the ostia that communicate with the nasal cavity. The anterior ethmoid, maxillary, and frontal sinuses drain into the ostiomeatal complex, located in the middle meatus (Fig 1).

. Lateral nasal wall with the location of sinuses and their orifices in particular the anterior ethmoid. (From Montgomery WW. Surgery of the Upper Respiratory System. Philadelphia, Lea and Febiger, 1979. With permission of Lippincott Williams and Wilkins.)

The

Diagnosis

Presentation of sinusitis is highly variable, and it is sometimes difficult to distinguish from rhinitis without sinusitis. No single symptom or sign is diagnostic. Nonetheless, the overall presentation of history and physical findings is usually sufficient to make the diagnosis of acute, uncomplicated sinusitis. Diagnostic testing becomes important when initial therapy fails, or when symptoms are chronic or recurrent.

Initial treatment of sinusitis

When symptoms suggestive of rhinosinusitis persist beyond approximately 7 days, bacterial rhinosinusitis becomes more likely. Antibiotic usage is appropriate when moderate to severe symptoms are present, although most cases of milder acute bacterial rhinosinusitis will resolve without the need to prescribe antibiotics. In a study comparing antimicrobial therapy with placebo in the treatment of children with the clinical and radiographic diagnosis of acute bacterial sinusitis, those receiving

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