An update on the classifications, diagnosis, and treatment

of rhinosinusitis
Yvonne Chana and Frederick A. Kuhnb
a
Department of Otolaryngology–Head and Neck
Surgery, University of Toronto, Toronto, Ontario,
Canada and bGeorgia Nasal and Sinus Institute,
Savannah, Georgia, USA
Correspondence to Yvonne Chan, MD, 138-1140
Burnhamthorpe Road West, Mississauga, ON L5C
4E9, Canada
Tel: +1 905 273 9220; fax: +1 905 273 6419;
e-mail: y.chan@utoronto.ca
Current Opinion in Otolaryngology & Head and
Neck Surgery 2009, 17:204–208
Purpose of review
This review is timely and relevant because rhinosinusitis is a disease process that
is heterogeneous in its clinical and pathologic manifestations. Therefore, no one
causative factor has been identified that fully accounts for all rhinosinusitis. The purpose
of this review is to provide a succinct update of rhinosinusitis classification,
pathophysiology, and management given the new movement toward evidence-based
guidelines.
Recent findings
The term rhinosinusitis reflects the concurrent inflammatory and infectious processes
that affect the nasal passages and the contiguous paranasal sinuses. The most recent
classification scheme is intended primarily to guide clinical research and divides
rhinosinusitis into four categories: acute bacterial rhinosinusitis, chronic sinusitis with
nasal polyposis, chronic rhinosinusitis with nasal polyposis, and allergic fungal
rhinosinusitis. The goals of treatment include reduction of mucosal edema,
reestablishment of sinus ventilation, and eradication of infecting pathogens. Multiple
therapies are available for the management of chronic rhinosinusitis, including
antibiotics, hypertonic and isotonic saline irrigations or sprays, topical and systemic
glucocorticords, antileukotriene agents, and endoscopic sinus surgery.
Summary
Rhinosinusitis is a common medical problem that interferes with patient quality of life
and loss of work productivity. Because of the heterogeneity that underlies its pathology,
no one treatment regimen exists for the management of rhinosinusitis.

Keywords
acute rhinosinusitis, allergic fungal sinusitis, chronic rhinosinusitis, eosinophilic chronic
rhinosinusitis

Curr Opin Otolaryngol Head Neck Surg 17:204–208

ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
1068-9508

outcome analysis of chronic rhinosinusitis (CRS) [6]. In

Introduction
Rhinosinusitis is a very common disorder that affects
more than 31 million Americans of all ages and both
sexes each year [1]. Because of the prevalence of the
disease in 14–16% of the US population, almost two of
every 100 ambulatory outpatient visits to primary care
offices, specialty practices, and emergency departments
are due to complaints of rhinosinusitis [2–4]. Direct costs
related to evaluation and treatment of rhinosinusitis as
well as indirect costs related to decreased productivity,
loss of work days, and disability total approximately
$6 billion yearly [5]. It was well recognized that there
has been a paucity of consensus definitions of sinusitis
for patient care as well as clinical research. Beginning
in 1997, the American Rhinologic Society, the American
Academy of Otolaryngologic Allergy, and the American
Academy of Otolaryngology–Head and Neck Surgery
(AAO-HNS) convened the Rhinosinusitis Task Force
to examine the definition, diagnosis, management, and
1068-9508 ß 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins
2004, five national societies, The American Academy of
Allergy, Asthma, and Immunology, the American Acad-
emy of Otolaryngic Allergy, The AAO-HNS, the Amer-
ican College of Allergy, Asthma, and Immunology, and
the American Rhinologic Society, established an expert
panel from multiple disciplines to develop definitions
and strategies for clinical trial designs [7]. Further, a set
of clinical practice guidelines for adult sinusitis was
developed in 2007 by a multidisciplinary panel selected
by the AAO-HNS Foundation [8

]. This review will
provide an update on the classifications, diagnosis, and
treatment of sinusitis.
Definitions and classifications
The term rhinosinusitis reflects the concurrent inflam-
matory and infectious processes that affect the nasal
passages and the contiguous paranasal sinuses [9

].
When the Rhinosinusitis Task Force convened, there
DOI:10.1097/MOO.0b013e32832ac393

Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

was general agreement that no one causative factor fully
explains or adequately accounts for the clinical and
pathologic manifestations or the heterogeneity of rhino-
sinusitis [6]. There are numerous causes of the condition,
including viral, bacterial, fungal, and allergic. In addition,
many patients have seemingly idiopathic disease.
Traditionally, rhinosinusitis has been classified by symp-
tom duration: acute (less than 4 weeks), subacute (4–12
weeks), or chronic (more than 12 weeks, with or without
acute exacerbations) [8

]. Four or more episodes of acute
rhinosinusitis per year, with interim symptom resolution,
are termed recurrent acute rhinosinusitis [8

]. Acute
rhinosinusitis is further subdivided as acute bacterial
rhinosinusitis (ABRS) or acute viral rhinosinusitis
(AVRS).
The classification scheme proposed by Meltzer et al. [7] is
primarily intended to guide clinical research and divides
rhinosinusitis into four categories: acute presumed bac-
terial rhinosinusitis, CRS without polyps, CRS with
polyps, and classic allergic fungal rhinosinusitis. This
classification system includes information about the type
of infection (viral, bacterial, fungal), complications,
inflammatory markers, and radiologic findings to categor-
ize patients. The more complex system allows the sub-
division of patients into more detailed subgroups to
determine the precise target of the new intervention or
medication being studied.
Diagnosis and pathophysiology of acute
rhinosinusitis
ARS has been defined as persistent purulent nasal
drainage with nasal obstruction or face pain/pressure/
fullness or both up to 4-week duration [10]. It is
prudent for clinicians to differentiate between ABRS
and AVRS, as the symptoms are similar for both entities.
The distinction between the two entities is the pattern
and duration of the illness. AVRS symptoms usually last
for less than 10 days and are self-limited [10].
The analysis of the predictive value of multiple signs and
symptoms by Rosenfeld et al. [8

] has identified three
cardinal symptoms that have high sensitivity and rela-
tively high specificity for ABRS. These include purulent
rhinorrhea, face pain/pressure, and nasal obstruction.
Secondary symptoms that further support the diagnosis
are ansomia, fever, aural fullness, cough, and headache.
Moreover, worsening of symptoms after an initial
improvement (double worsening) is particularly sugges-
tive of ABRS [8

,11]. Previous consensus studies have
recommended the system using a combination of major
and minor symptoms to define acute rhinosinusitis
[6]. However, more recent studies have abandoned this
approach in favor of the three cardinal symptoms on the
basis of expert opinion and extrapolation from studies
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Update on rhinosinusitis Chan and Kuhn 205
correlating imaging results with prognostic factors
[7,9

].
Diagnosis and pathophysiology of chronic
rhinosinusitis
CRS is an inflammatory condition of the nasal passage
and paranasal sinuses lasting for 12 weeks or longer. The
unifying hallmark is persistent inflammation of the nasal
cavity and paranasal sinuses with no known cause. The
four cardinal symptoms of CRS are anterior/posterior
mucopurulent drainage, nasal obstruction, face pain/pres-
sure/fullness, and hyposmia. According to Benninger et al.
[3], at least two of these symptoms must be present along
with endoscopic or radiologic evidence of mucosal
inflammation for the diagnosis of CRS. They further
state that CRS represents a clinically heterogeneous
spectrum that encompasses three subtypes: CRS with
nasal polyposis (20–33%), CRS without nasal polyposis
(60–65%), and allergic fungal sinusitis (AFS) (8–12%).
The pathophysiology of each subtype remains incom-
pletely understood, and the categories may at times over-
lap with AFS being eventually found in either CRS
with nasal polyposis or CRS without nasal polyposis.
CRS without nasal polyposis is the most common form of
CRS accounting for the majority of the cases. CRS with-
out nasal polyposis lacks identifying features that are
specific to the other two subtypes (i.e. nasal polyposis
or allergic mucin). It is a heterogeneous disease entity
that may be due to a number of contributing factors that
are different across the patient population. Contributing
conditions include allergic and nonallergic rhinitis, struc-
tural abnormalities, and possibly immunodeficiency or
even early unrecognized AFS.
CRS with nasal polyposis is characterized by the presence
of polyps in the nasal cavity or paranasal sinuses. This
entity is associated with aspirin sensitivity and asthma
[12,13]. The trigger of nasal polyp formation is not
known. However, the polypoid tissue has been found
to contain eosinophils, high levels of interleukin 5 and 13,
and high levels of histamine [14].
AFS is a subtype of CRS characterized by the presence of
‘allergic mucin’, which is a thick inspissated mucus with
eosinophils and fungal hyphae. AFS was first described in
the 1980s as a distinct pathologic entity by Millar et al.
[15] and Katzenstein et al. [16]. The widely accepted
diagnostic criteria for AFS were described by Bent and
Kuhn [17] in 1994. The five criteria are type I hyper-
sensitivity by history, skin tests, or serology, nasal poly-
posis, characteristic computed tomography scan findings,
eosinophilic mucus, and positive fungal stain of mucin or
on the surface of tissue removed during surgery with no
fungal tissue invasion. Positive fungal culture does not
 206 General otolaryngology
substitute for the smear, as most people without CRS are
culture positive [18].
One of the primary factors dividing CRS into different
categories is the patient’s underlying inflammatory pro-
cess. Recent investigations into the underlying patho-
genesis of CRS have emphasized the role of eosinophils
[19]. There is a clear distinction between neutrophilic
and eosinophilic inflammation. Once this determination
is made, the lines of distinction may begin to blur,
because various other factors such as anatomic mechan-
ical obstruction or Staphylococcus aureus superantigen may
cloud the picture. If, however, we make this division of
eosinophilic chronic rhinosinusitis (ECRS) vs. non-
ECRS, we find a number of seemingly different entities
grouped under the same umbrella.
Eosinophilic CRS includes the following subgroups:
aspirin-sensitive asthma with nasal polyposis, AFS,
AFS without fungus, S. aureus-induced superantigen
sinusitis with nasal polyposis, chronic gram-negative
sinusitis with polyposis, ECRS, cause undetermined.
Non-ECRS encompasses the following: mechanical
obstruction and chronic bacterial sinusitis without mucin
or tissue eosinophilia.
One of the primary distinctions between the two groups is
that once the mechanical obstruction in non-ECRS is
relieved and all sequestered bacteria are removed, the
patients have a higher rate of disease resolution. As many
ECRS patients do not develop their disease until the
fourth to sixth decade of life, one could postulate an
external trigger that activates or upregulates a dormant
genetically coded ability to mount the eosinophilic
inflammatory response. This may explain the late onset
and the difficulty in controlling these patients’ disease
processes.
Management of acute rhinosinusitis
With the initial onset of ARS, a viral cause is presumed.
Treatment of AVRS is supportive. Its aims are to relieve
symptoms of nasal congestion and rhinorrhea even
though it does not change the duration of disease. Analge-
sics are recommended for pain relief. Nasal irrigation with
hypertonic saline solution has been shown to improve
symptoms and reduce the use of pain medication [8

,20].
Intranasal decongestants can provide quick relief as they
decrease edema of the nasal passages and allow drainage.
A study by Meltzer et al. [21] demonstrated that topical
corticosteroid is as effective in AVRS as monotherapy for
symptom relief.
For ABRS in patients with mild symptoms (mild pain,
temperature <38.38C or 1018F), the most recent clinical
practice guidelines from the AAO-HNS suggest an obser-
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
vation option [8

]. The guidelines further suggest that
antibiotics should be started if the patient’s condition
fails to improve or worsens by 7 days. A narrow-spectrum
antibiotic such as amoxicillin is first line for 10–14 days
with trimethoprimsulfamethoxazole and macrolides as
alternatives. As community-acquired infections with
drug-resistant bacteria increase, these may not be the
best choices. Endoscopic culture and sensitivity may
improve treatment results. Topical glucocorticords are
recommended as adjunctive therapy by a meta-analysis of
three studies in patients with ABRS, which found that the
use of intranasal steroids, alone or as adjuvant therapy to
antibiotics, increased symptom response compared with
placebo alone [22].
Management of chronic rhinosinusitis
No one treatment regimen exists for the management
of CRS because of its heterogeneity. However, the
principles involved in the treatment of CRS involve
identifying and treating the underlying causes. Goals
of treatment include reduction of mucosal edema,
reestablishment of sinus ventilation, and eradication of
infecting pathogens. This often requires a combination
of topical and oral therapeutics to achieve these
goals. Multiple medical therapies are available in the
armamentarium for the management of CRS, including
antibiotics, hypertonic and isotonic saline irrigations or
sprays, topical and systemic glucocorticords, antileuko-
triene agents, and antifungals. Consensus guidelines on
the management of CRS have been published, with the
most recent ones in 2008 [11,23

].
Antimicrobials
The microbiology of rhinosinusitis evolves from the early
phase of acute rhinosinusitis in which it is usually caused
by a viral infection to a secondary acute bacterial infec-
tion. The most prevalent bacteria cultured from these
infections include Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis [24]. If the ARS does
not resolve and the infection continues, colonizing
anaerobic oropharyngeal flora and aerobes (i.e. S. aureus,
Pseudomonas aeruginosa) become predominant [25]. Anti-
microbials play a role in the management of CRS to clear
infection at the onset of the condition and periodically
thereafter to treat any exacerbations of CRS. There is
limited evidence that antimicrobials as a sole modality of
therapy are effective in the management of CRS [26];
however, experts consider it an essential component in
the comprehensive approach to the disease. Wallwork
et al. [27] assessed the efficacy of roxithromycin as a
monotherapy in 64 CRS patients in a placebo-controlled
trial, which found a small but statistically significant
benefit over placebo in patients’ subjective improvement.
Several randomized trials evaluating different antibiotics

in the treatment of CRS demonstrated comparable treat-
ment results between the different agents [28–30].
The choice of antibiotic should be guided by cultures of
purulent mucus obtained from the middle meatus or sinus
ostium. A minimum of 3–4 weeks of, preferably culture-
directed, antibiotics is usually adequate. In addition to
prolonged oral antibiotics, adjunctive therapy may include
intranasal corticosteroids, hypertonic and isotonic saline
irrigations, short courses (2–3 weeks) of oral steroids, oral
or intranasal decongestants, topical vasoconstrictors, and
mucolytics.
Nasal hypertonic and isotonic saline
irrigations or sprays
Nasal irrigations or sprays with hypertonic and isotonic
saline have been advocated as one component in the
management of CRS. The positive effects of washing the
nasal cavities with hypertonic or isotonic saline include
the elimination of allergens, thinning and removal of
secretions, and the reduction in postnasal drainage. A
systematic review of eight studies demonstrated nasal
hypertonic and isotonic saline (irrigation or spray) is a
beneficial adjunct in the treatment of CRS [31]. There is
evidence in the literature that hypertonic and isotonic
saline irrigation is a more effective method of delivery
than the spray format [32,33].
Intranasal glucocorticords
A number of studies have demonstrated the efficacy of
intranasal glucocorticords in the management of CRS
[23

,34,35]. Nasal drops of glucocorticord solution as well
as intranasal sprays have been demonstrated as effective
methods of delivery, with the head-down instillation
method as a superior means of reaching the middle meatus.
Topical glucocorticord solutions available commercially
include betamethasone and fluticasone propionate (UK,
Europe) and budesonide and mometasone (USA).
Systemic glucocorticords
Oral prednisone decreases mucosal inflammation, restores
the sense of smell, and reduces the size of nasal polyps in
CRS with and without nasal polyposis. Hissaria et al. [36],
in a randomized trial, demonstrated that prednisone
improved sinonasal symptoms and reduced polyp size in
2 weeks. British guidelines have suggested prednisolone
(0.5 mg/kg for 5–10 days) with the instillation of beta-
methasone nasal drops (not available in the USA) [23

].
Antileukotriene agents
Antileukotriene agents are designed to suppress the
inflammatory response caused by leukotrienes in the
inflammatory cascade. These responses include increased
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Update on rhinosinusitis Chan and Kuhn 207
vascular permeability, mucus production, and mucosal
edema of the upper and lower airways. The available
agents include leukotriene D4 receptor blockers such as
montelukast or zafirlukast. A new agent, zileuton, is a
5-lipoxygenase inhibitor. These agents may be used as
an adjunct in the management of CRS as this is an off-label
use at the present time.
Surgery
Surgery is reserved for patients who are refractory to
medical treatment and for patients with anatomic
obstruction as causes of CRS. Patients with AFRS usually
require surgery to remove the inspissated mucus in order
to reestablish sinus ventilation and drainage. Over the
past two decades, the surgical management of CRS has
evolved because of advancing technology as well as
understanding of sinus disease and anatomy. Endoscopic
sinus surgery involves minimally invasive techniques
in which sinus air cells are opened under direct visual-
ization. The goal of this procedure is to restore sinus
ventilation and normal function of the mucociliary clear-
ance system [37]. As surgery strives to restore functional
integrity of inflamed mucosal lining, a conservative
mucosa-sparing approach is advocated. Although endo-
scopic sinus surgery is a well tolerated procedure, the
Cochrane review by Khalil and Nunez [38] demonstrated
that there is a lack of good evidence in the literature for its
superiority over medical treatment (þ/ sinus irrigation)
in CRS [23

]. This is likely a reflection of the lack of
randomized trials designed directly to compare medical
with surgical management of CRS. Furthermore, the defi-
nitions of CRS were likely inconsistent in early studies
because of the lack of consensus in the past. A number of
studies in the literature have established the effectiveness
of surgical therapy in the short term [39,40] and the long
term [41–43] for subjective improvement of symptoms as
well as ostial patency in patients with medically refractory
CRS. Randomized controlled trials assessing the compara-
tive efficacy of medical and surgical treatment of CRS
should be an area of future research focus.
Conclusion
Rhinosinusitis is a common medical problem with sig-
nificant symptoms that interferes with patient’s quality of
life as well as loss of work productivity, which presents
major medical and social concerns. AVRS is initially
treated with supportive measures and nasal corticoster-
oids. Antibiotics should be reserved for patients whose
symptoms worsen or persist on the topical intranasal
steroids. CRS is a more difficult disease to treat because
of its varying underlying pathophysiology. With any acute
increase in symptoms, treatment is similar to that for
ARS. The initial management of CRS symptoms is
medical, including longer periods of oral antibiotics, nasal
 208 General otolaryngology
irrigations, nasal steroids, or oral steroids. Surgery is
reserved for refractory cases.
References and recommended reading
Papers of particular interest, published within the annual period of review, have
been highlighted as:

of special interest


of outstanding interest
Additional references related to this topic can also be found in the Current
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