The etiology of chronic sinusitis is multifactorial.

The interaction between many systemic, local host,

and environmental factors contribute to sinus inflammation and to the pathophysiology of the disease.
Systemic factors include genetic diseases such as cystic fibrosis, conditions that cause
immunodeficiency, autoimmune disease, idiopathic conditions such as Samter triad (aspirin-
exacerbated respiratory disease), and acid reflux. Local host factors include sinonasal anatomic
abnormalities, iatrogenic conditions such as scarring due to prior sinus surgery, neoplasm, or the
presence of a foreign body, among others. Possible environmental factors that may contribute to the
condition include the presence of biofilms and bacterial infection, as well as fungal infection, allergy,
environmental pollutants, and smoking.

Increasing evidence shows that biofilms are critical to the pathophysiology of chronic infections
including chronic sinusitis. Recent advances in methods for biofilm identification and molecular
biology offer new insights into the role of biofilms in chronic sinusitis.[11]

Currently, etiologic studies of sinusitis are increasingly focusing on ostiomeatal obstruction, allergies,
polyps, occult and subtle immunodeficiency states, and dental diseases. Microorganisms are more
often recognized as secondary invaders. Any disease process or toxin that affects cilia has a negative
effect on CRS.

Bacterial involvement

The bacteria presumed to be involved in CRS differ from those involved in acute rhinosinusitis. The
following bacteria have been reported in samples obtained through endoscopy or sinus puncture in
patients with chronic sinusitis.
 Staphylococcus aureus (both methicillin-susceptible S aureus [MSSA] and methicillin-
resistant S aureus [MRSA] strains)
 Coagulase-negative staphylococci
 H influenzae
 M catarrhalis
 S pneumoniae
 Streptococcus intermedius
 Pseudomonas aeruginosa
 Nocardia species
 Anaerobic bacteria ( Peptostreptococcus, Prevotella, Porphyromonas, Bacteroides,
Fusobacterium species
 Microaerophilic streptococci

In contrast with the well-established roles of microbes in the etiology of acute sinusitis, the exact roles
of all of these microbes in the etiology of chronic sinusitis are uncertain. Various researchers disagree
on the microbial etiology of chronic sinusitis. Much of the disagreement may be explained by
methodology. Studies that have used adequate methods for recovery of anaerobes have
demonstrated their prominence in chronic sinusitis, while those that did not use such methods have
failed to recover them. When proper techniques are used, anaerobic bacteria can be recovered in 50-
70% of specimens.The variable growth of microbes in samples may also be due to prior exposure of
various broad-spectrum antibiotics in patients involved in the studies.

Jyonouchi et al successfully induced chronic sinusitis in rabbits via intrasinus inoculation of

Bacteroides fragilis. The authors subsequently identified immunoglobulin G (IgG) antibodies against
this organism in the infected animals. In addition, IgG antibodies to anaerobic organisms have been
observed in patients with chronic sinusitis. These findings further support a role for anaerobes in
chronic sinusitis.

Microbiologic studies of chronic sinusitis often show that the infection is polymicrobial, with isolation of
1-6 isolates per specimen. The microbial flora of chronic sinusitis is affected by previous antibiotic
administration, past vaccinations, and the presence of normal flora that can suppress the emergence
of pathogenic species.
In some cases, the baseline chronic sinusitis worsens suddenly or causes new symptoms. This acute
exacerbation of chronic sinusitis is often polymicrobial as well, with anaerobic bacteria predominating.
However, aerobic bacteria that are usually associated with acute sinusitis (eg, S pneumoniae, H
influenzae,M catarrhalis) may emerge.

S aureus infection is associated with the development of persistent severe inflammatory disease of
the upper airway, including chronic sinusitis with nasal polyps. Gram-negative facultative and aerobic
bacteria, including P aeruginosa, are more often isolated in patients with chronic sinusitis who have
undergone endoscopic sinus surgery.

Fungal involvement
The following fungi have been reported in samples obtained with endoscopy or sinus puncture in
patients with chronic sinusitis :
 Aspergillus species
 Cryptococcus neoformans
 Candida species
 Sporothrix schenckii
 Alternaria species

To see complete information on Fungal Sinusitis, please go to the main article by clicking here.

Risk factors
The following conditions and risk factors predispose patients to the development of chronic sinusitis:
 Anatomic abnormalities of the ostiomeatal complex (eg, septal deviation, concha bullosa,
deviation of uncinate
 process, Haller cells)
 Allergic rhinitis
 [22]
 Aspirin sensitivity
 Asthma
 Nasal polyps
 Nonallergic rhinitis (eg, vasomotor rhinitis, rhinitis medicamentosa, cocaine abuse)
 Defects in mucociliary clearance
 Nasotracheal intubation
 Nasogastric intubation
 Hormonal (eg, puberty, pregnancy, oral contraception)
 Obstruction by tumor
 Immunologic disorders (eg, common variable immunodeficiency, immunoglobulin A [IgA]
deficiency, IgG subclass
 deficiency, AIDS)
 Cystic fibrosis
 Primary ciliary dyskinesia, Kartagener syndrome
 Wegener granulomatosis
 Repeated viral upper respiratory tract infections
 Smoking
 Environmental irritants and pollutants
 Gastroesophageal reflux disease (GERD). The reflux of gastric contents may play a
contributing role in some cases
 of CRS; this relationship still needs to be better defined
 Periodontitis/significant dental disease
 Systemic diseases (ie, granulomatosis with polyangiitis (Wegener granulomatosis), Churg-
Strauss vasculitis,
 sarcoidosis)
 Yellow nail syndrome

Epidemiology
Chronic sinusitis is one of the more prevalent chronic illnesses in the United States, affecting persons
of all age groups. The overall prevalence of CRS in the United States is 146 per 1000 population. For
unknown reasons, the incidence of this disease appears to be increasing yearly. This results in a
conservative estimate of 18-22 million physician visits in the United States each year and a direct
treatment cost of $3.4-5 billion annually.[23] Chronic sinusitis is the fifth most common disease treated
with antibiotics. Up to 64% of patients with AIDS develop chronic sinusitis.

International prevalence
Chronic sinusitis is a common disease worldwide, particularly in places with high levels of
atmospheric pollution. In the Northern Hemisphere, damp temperate climates along with higher
concentrations of pollens are associated with a higher prevalence of chronic sinusitis.

Rhinosinusitis in children
Rhinosinusitis is more common in the pediatric population because this term includes both acute and
chronic infection and both viral and bacterial disease. This is likely secondary to an increased
frequency of exposure to upper respiratory tract infections in the pediatric population.