What is Sinusitis ?

Sinusitis in children is almost always associated with rhinitis – it is rare to see sinusitis without inflammation of the nose also.  Most clinicians who treat children with sinusitis therefore refer to “rhinosinusitis,” and treat both the rhinitis and the sinusitis.  Due to the relationship between the lining of the nose and sinuses (respiratory epithelium), and the rest of the respiratory tract and upper digestive tract, the physicians who are most successful at treating these patients use a more holistic approach than simply treating the sinuses.

Some facts about sinusitis:

  • Acute rhinosinusitis (ARS) is considered to be an infection of the sinuses up to 4 weeks.
  • Chronic rhinosinusitis (CRS) is a larger spectrum of pathology (meaning many possible causes).
  • CRS is 12 weeks or more.
  • Children typically have 6-8 viral upper respiratory infections (URI’s) per year.
  • Between 5-10% of these are complicated by acute sinusitis.

The Impact of Sinusitis:

Sinusitis is a pretty big deal in the US:  It is estimated that nearly 40 million people in the United States are affected directly by sinusitis every year, making it THE most common respiratory illness.  The cost, as an underestimate, is a staggering $6 billion per year!  A third of this cost is from sinusitis in children.

Quality of Life:

One out of every three of us will have sinusitis at some time in our lives – 1/3rd of us!  Sinusitis has the greatest negative impact on quality of life (that is, it is the biggest bummer) of ALL of the chronic illnesses like asthma, rheumatoid arthritis, and other chronic disorders (Cunningham et al, 2000).

Causes of Sinusitis?

Despite the large number of people with chronic and recurring sinusitis, the precise causes are still not clear.  Inflammation of the sinuses may follow a simple viral URI (upper respiratory infection) but should be limited to a brief period of 1-2 weeks.

The bacteria that are thought to cause acute and chronic sinusitis are similar to those that are thought to cause acute and chronic otitis (ear infections).  More on the specific ‘bugs’ in a future post.

Physician-scientists are still uncertain why some people experience recurrent or chronic rhinosinusitis, just as they are uncertain why some people experience severe and chronic asthma.  Both illnesses are linked to allergies – that is, they are “co-morbidities”.  The incidence of allergies, asthma, and chronic rhinosinusitis are known to be highest in childhood and adolescence, and to decline with approaching middle age.  Whereas children are known to have relatively immature immune systems, the explanation for their sinusitis is more complex than simply immature immune systems.

“Co-Morbidities” and the Unified Airway:

The link between these co-morbid Chronic Aerodigestive Inflammatory Diseases (CAID) is intriguing, and fits with the “Unified Airway” theory proposed within the last few years.  Simply put, the unified airway theory suggests that the lining of the aerodigestive tract – the upper and lower airway and the GI tract – are subject to the same genetic background, and to similar inflammatory mediators, and that this accounts for the association between asthma, rhinosinusitis, reflux esophagitis, and other chronic inflammatory disorders that afflict the aerodigestive tract.  When treating for chronic sinusitis, most pediatric ENT doctors will also treat for reflux.  This is because any reflux will cause severe inflammation – rhinosinusitis.

Widespread Inflammation:

Proponents of this theory believe that an inflammatory response that originates in the nose (or elsewhere) may extend, through cytokines and other inflammatory mediators, to the sinuses, middle ears, lungs, and elsewhere in the body.  There is strong evidence for this occurring in the case of asthma, where rhinosinusitis will often precede asthma exacerbations; this has been observed in the presence and absence of allergies, so it is not simply an affect of allergies.

Implications for Treatment:

What does this mean for treatment, long term management, and prevention of rhinosinusitis?  It means that sinusitis is best dealt with in the larger context of rhinitis, as well as the rest of the aerodigestive tract.  That is, treat the whole person.  That should not be a novel concept, but oddly seems to be in much of modern medicine.  We will consider treatment options in future posts.

Diagnosis of sinusitis can often be made just from the medical history – that is, the story of how it started, what the symptoms are.  Computed tomography (CT) scan can confirm the diagnosis.


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