The Many Faces of Rhinosinusitis: Case Challenges

Gordon H. Sun, MD, MS

September 22, 2015

Diagnosis and Management of CRS

To diagnose CRS, the patient must exhibit at least 12 weeks of two or more of the following symptoms: mucopurulent rhinorrhea or postnasal drainage; nasal obstruction; facial pain, pressure, or fullness; or reduced sense of smell (hyposmia). Moreover, the patient must demonstrate objective signs of sinonasal inflammation, including mucopurulent drainage or edema of the middle meatus or anterior ethmoid sinuses, sinonasal polyposis, or radiographic evidence of paranasal sinus inflammation.[2]

The three primary modalities for objectively confirming sinonasal inflammation are anterior rhinoscopy, nasal endoscopy, and CT. Anterior rhinoscopy is the simplest and least expensive technique. It can be performed with an otoscope or a nasal speculum paired with a light source, and is the method most commonly available in the primary care setting. This technique permits reasonable visualization of the anterior one-third of the nasal vaults and is often sufficient in the presence of large intranasal polyps or gross purulence. However, nasal endoscopy is superior to anterior rhinoscopy because it permits visualization of the posterior nasal vaults, the nasopharynx, and sinus drainage pathways, reducing the possibility of misdiagnosis.[9]

Nasal endoscopy can be performed concurrently with aspiration of purulent secretions for microbiological analysis. Disadvantages of nasal endoscopy include its higher cost and discomfort to the patient. Medicare reimbursement rates in 2014 for diagnostic nasal endoscopy (Current Procedure Terminology code 31231) ranged from $66 to $212.[10,11] Patient discomfort is often mitigated through the use of nasal anesthetic and decongestant sprays. Of interest, however, a recent Cochrane systematic review of topical anesthesia or vasoconstrictor preparations before flexible fiber-optic nasopharyngoscopy and laryngoscopy found no evidence that the medications were effective in reducing pain.[12,13] Furthermore, many primary care providers are not trained in nasal endoscopic techniques, thus requiring consultation with an otolaryngologist.

Many authorities consider CT to be the reference standard for obtaining evidence of sinonasal inflammation in patients with CRS.[14,15,16] Although CT findings do not always correlate with CRS symptom severity,[17] CT improves diagnostic accuracy. Because the findings of this technique correlate with the presence or absence of CRS in patients with certain clinical symptoms, CT can be used to objectively quantify the extent of sinonasal inflammation, and CT displays certain anatomical features and abnormalities more effectively than endoscopy or rhinoscopy.[1,15,18] CT is also useful if endoscopic sinus surgery is being planned.[19]

Although the risk for radiation-induced damage to surrounding head and neck structures during sinus CT can vary on the basis of equipment specifications and local radiologic protocols,[20] overall radiation dose received is considered very low.[21,22] Given the high cost of CT compared with rhinoscopy and endoscopy, Wuister and colleagues[16] advocate using nasal endoscopy as the first-line confirmatory modality, and reserving CT for patients with a prolonged or complicated CRS course.

Although MRI does have the advantage of not exposing patients to the ionizing radiation of CT, MRI is not preferred over CT for standard imaging of CRS owing to higher cost, longer imaging time, inability to effectively characterize bony anatomy, and risk for overdiagnosis.[1,22,23] Nonetheless, there are instances in which MRI can supplement the workup of patients with sinonasal disease. For example, MRI should be performed if there is concern about complications from sinonasal disease extension and to differentiate typical CRS from neoplastic processes or other disorders that might mimic CRS.[1,23]

Clinical Presentation: Fourth Case—Desperately Seeking Relief

A 21-year-old undergraduate student visited the university health clinic for treatment of chronic bilateral nasal congestion, intermittent yellowish postnasal drip, and pressure in her forehead and cheeks. The patient had a tonsillectomy at age 7 years but no other significant medical history; she was a nonsmoker and rarely drank alcohol. A diagnosis of CRS without polyps had previously been confirmed with CT of the sinuses. She underwent allergy testing last week that found only mild reactions to dust and cat dander, and she started taking cetirizine daily on the recommendation of her allergist.

The patient sought a more comprehensive plan for controlling her symptoms. She was not interested in considering endoscopic sinus surgery at this time.

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