 Sinusitis is one of the most common health care complaints in the United States accounting for nearly 25 million physician visits in 1993. The diagnosis of acute sinusitis is usually not difficult but the diagnosis of chronic sinusitis may be more challenging because nomenclature is not clear and the symptoms may be vague. Symptoms of chronic sinusitis can vary from mild headaches around the eyes and yellow to green phlegm in the throat to severe facial pain, headaches, chronic yellow-green nasal discharge, nasal congestion, chronic throat drainage, sore throats, and cough. The diagnosis of chronic sinusitis is made on the basis of the history and the physical exam, and may be confirmed by x-rays and cultures of the pus. Standard sinus x-rays are sufficient for the diagnosis of acute sinusitis in adults but are of limited value in the diagnosis of chronic sinusitis in adults and in most types of sinusitis in children. Computed tomography (CT) scans are reserved for the evaluation of patients with chronic sinusitis.
Antibiotics are the mainstay of treatment for both acute and chronic sinusitis. In acute, uncomplicated sinusitis, antibiotics combined with decongestants are effective in most cases. In recurrent sinusitis and in chronic sinusitis (persistence of the infection for longer than 3 months) the patient should be evaluated for predisposing anatomical factors using CT scans and nasal endoscopy.
Recent studies of the underlying cause of chronic sinusitis has shown that the clearance of mucus from the maxillary, frontal, and anterior ethmoid sinuses is directed toward a structure called the ostiomeatal complex, which is an anatomical region about the size of a dime that is located about an inch inside the nose on the lateral wall. Inflammation of the nasal lining secondary to a viral upper respiratory infection, congestion of this lining due to allergic rhinitis, and/or anatomical abnormalities such as a markedly deviated septum or an enlarged air cell in the middle turbinate (that part of the nose that hangs in the nasal passage like a curtain) may cause obstruction in the region of the ostiomeatal complex.
Recent technological advances have provided us with the tools to diagnose chronic sinusitis more accurately and to treat it more effectively. CT scans of the sinuses provide a much more detailed view of sinus anatomy and sinus disease than do the standard sinus x-rays. One of the most significant advances in the management of patients with sinusitis is the use of endoscopes to supplement the physical examination of the nose. Sinus endoscopes are rigid fiberoptic instruments the size of a straw that are inserted into the nose to provide the physician with a magnified view of the anatomy. The tips of these endoscopes can be angled to provide a "look around the corner." These endoscopes can be used both for diagnosis and for surgical treatment.
When medical treatment fails or when complications of sinusitis develop, surgical treatment should be considered. Although standard sinus operations are still indicated for certain conditions, functional endoscopic sinus surgery (FESS) has superseded most other sinus operations over the past few years. FESS was developed in Europe and brought to this country in the mid 1980's. Advances in instrumentation, specifically the development of the rigid fiberoptic nasal endoscope, combined with improved imaging using high resolution CT scans lead to the development of the FESS procedure. The other important development was the recognition of the importance of the ostiomeatal complex in the development of chronic sinusitis. In functional endoscopic sinus surgery the drainage of the sinuses is enhanced by enlarging the natural openings of the sinuses and the lining of the sinuses is preserved. In contrast, the older sinus operations are more destructive and usually involve removal of sinus lining and creating nonphysiological drainage patterns. The purpose of endoscopic sinus surgery is to remove disease in the target areas, such as the ostiomeatal complex, allowing normal mucociliary flow to be restored. The advantages of the endoscopic approach over more traditional approaches are the following: restores the natural drainage patterns in the nose and sinuses, no external incisions, and usually is performed as outpatient surgery.
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