Clinical evaluation of rhinosinusitis: History and physical examination JAMES A. HADLEY,MD, and STEVEND. SCHAEFER,MD, Rochester, and New York, New York
O v e r the past 10 to 15 years endoscopic evaluation and sinonasal imaging techniques, particularly computed tomographic (CT) scanning, have revolutionized the diagnosis and treatment of rhinosinusitis. Because rhinosinusitis affects so many Americans every year and has a major impact on quality of life, a knowledge of its clinical presentation is essential for diagnosis and differentiation from the common cold or allergic manifestations. 1 This section of the Task Force report discusses the current clinical evaluation of patients with the suspected diagnosis of rhinosinusitis. Adjunctive nasal rhinoscopy and endoscopy are discussed, but laboratory tests and radiographic imaging techniques are covered in other sections of this publication. The signs and symptoms of rhinosinusitis include those of an acute upper respiratory infection and those associated with the onset of an allergic rhinitis inflammatory event. Although most cases of acute rhinosinusitis occur after a viral upper respiratory tract infection, cases may also occur in association with barotrauma or physical trauma. 2 The clinical history and the physical examination help to differentiate among viral, bacterial, and allergic causes. SIGNS AND SYMPTOMS
The most common complications in patients with acute rhinosinusitis are headache, nasal congestion, and the production of thick postnasal discharge (Table 1). Facial pain or pressure is the most pressing symptom bringing patients to a physician for evaluation. The site of the acute facial pain or pressure may help in localizing the infection to a specific paranasal sinus. 3 Maxillary sinusitis may cause infraorbital or cheek discomfort. Upper teeth or gum pain is highly specific for
From the Division of Otolaryngology, University of Rochester Medical Center (Dr. Hadley), and the Department of Otolaryngnlogy, New York Eye and Ear Infirmary (Dr. Schaefer). Reprint requests: James A. Hadley, MD, Rochester Otolaryngology, Group 2561 LacDeVille Blvd., Rochester, NY 14168. Otolaryngol Head Neck Surg 1997; 117:$8-S 11. Copyright © 1997 by the American Academy of OtolaryngologyHead and Neck Surgery Foundation, Inc. 0194-5998/97/$5.00 + 0 23/0/83509 $8
maxillary sinusitis. Lying down relieves the discomfort in patients with maxillary sinusitis. Ethmoidal rhinosinusitis, which usually accompanies most other categories of rhinosinusitis, may cause tenderness over the lacrimal region, with referred tenderness to the periorbital and temporal regions. Bending forward or lying supine exacerbates the pain from ethmoidal rhinosinusitis. Frontal sinusitis may constitute an acute medical problem. One characteristic of acute frontal sinusitis is severe headache localized to the forehead over the orbits, with tenderness produced by pressure on the floor of the frontal sinus. Discomfort from sphenoidal sinusitis radiates to the occiput and vertex areas. Headache described as a chronic dull ache in the back of head, specifically over the occiput with radiation to the frontal and retro-orbital regions, is a sign of sphenoidal rhinosinusitis. Acute sphenoidal rhinosinusitis may represent a medical emergency, particularly when the infection is near cavernous sinus structures (i.e., cranial nerves III, IV, V1, V2, and VI) or when diminished visual acuity is involved. The symptoms of chronic rhinosinusitis are more subtle, with facial pain and pressure less likely to be primary complications. Nasal congestion with obstruction and the production of thickened nasal secretions are the most common problems. 3-5 Other signs of chronic sinusitis include fatigue, cough, and a sensation of facial fullness with pressure. These low-grade symptoms are the result of persistent inflammation and obstruction of the outflow tracts of the paranasal sinuses. Most patients with rhinosinusitis report a significant change in nasal airflow accompanied by a sensation of congestion. Inflamed mucous membranes in the nose and paranasal sinuses are responsible for the sensation of congestion. The production of thickened secretions causes a feeling of increased postnasal drainage and sore throat. However, physicians should not rely solely on colored nasal drainage as an indication for antibiotic therapy. Decongestants may provide some relief of the symptoms, but they have no influence on the reduction of inflammation. Treatment with decongestants
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Table 1. Clinical evaluation of rhinosinusitis Symptom complex
Major criteria Headache Facial pain and pressure Nasal congestion Thick, colored postnasal drainage Olfactory disturbance Minor criteria Fever Halitosis Children only: Cough Irritability
and mucoevacuants may help to maintain ostial patency and to reduce inflammation by promoting drainage. Cough, a nonspecific symptom of rhinosinusitis, may be confused with the onset of an asthmatic condition. This symptom, which is common in children with rhinosinusitis, usually diminishes or is eliminated with treatment of the infection. Cough tends to be more common at night. 6 In acute and chronic flfinosinusitis the cough reflex may be provoked by the p:roduction of chemical mediators, leukotrienes, and other factors that give rise to hronchoconstriction and irrkated neural endings. A vagal reflex, mediated from pressure receptors within the paranasal sinuses, may also be instituted. Another common symptom and one of tile major criteria for the diagnosis of rhinosinusitis is a diminished or lost sense of smell. The inflammatory response of the nasal mucosa hinders odorants from migrating to the olfactory placode in the upper recesses of the nasal cavity. Chronic rhinosinusifis may predispose', patients to nasal polyposis, which aggravates hyposmia and may lead to anosmia. 7 Fever is more common in the early stages of acute rhinosinusitis. Although fever is more common in children and adolescents, it may also be present in adult rhinosinusitis shortly after an upper respiratory infection. Knowledge of the seasonal recurrence of symptoms and known triggers of symptoms is helpful in differentiating allergic rhinitis from acute rhinosinusitis. In patients with allergy the nasal membranes; respond to provocation by allergens with the release of chemical mediators from the resident mast cells of the nasal mucosa. Histamine is the primary mediator of the early phase leading to rhinorrhea, edema, and the symptoms of sneezing and congestion. Late-phase reactions from the influence of cellular responses prolong :he reaction, giving the impression of persistent nasal congestion. Patients with allergic rhinitis usually have a history of allergic response. 6 Typical symptoms include a thin watery nasal discharge, intermittent sneezing, and a
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Table 2. Physical signs External physical findings: swelling and erythema Swelling and erythema: maxillary region, ocular or orbital region, and frontal region Findings on anterior rhinoscopy Hyperemia Edema Crusts Purulence Polyps After topical nasal decongestion: improvement or worsening of symptoms Findings on nasal endoscopy* Bluish discoloration of turbinates Purulence at ostiomeatal complex or other sinus ostia Polyp formation, with size and location of polyps noted Septal deflections Concha bullosa Paradoxic turbinates Other anomalies *Examinationwith a rigid or flexible nasal endoscope should be a standard part of the physical examinationin the specialist'soffice. Cultures obtained under endoscopic guidance cultures may be obtained to aid in the diagnosis.
runny, itchy nose. Allergic responses can predispose patients to have acute or chronic rhinosinusitis as a result of the inflammatory response and resultant obstruction of the ostia of the paranasal sinuses. The differential diagnosis of chronic rhinosinusitis includes asthma, gastroesophageal reflux disease, and chronic allergic rhinitis. All of these conditions may exist simultaneously. PHYSICAL EXAMINATION
In addition to the major symptom complex for rhinosinusitis, the physical examination plays a major role in the diagnosis of acute or chronic rhinosinusitis. The examination begins with the facial features. Swelling, erythema, and edema localized over the involved cheekbone or periorbital area may be immediately recognized in the acute forms of the disease (Table 2). These signs are apparent predominantly in the morning, and they improve gradually while the patient is upright. Patients with chronic rhinosinusitis usually have no facial swelling or edema. The sinuses are palpated to test for tenderness. Percussion of the teeth may direct attention toward an inflamed paranasal sinus. ANTERIOR RHINOSCOPY
Anterior rhinoscopy is an examination of the nasal cavity performed with a nasal speculum under good illumination. The examination should include visualization of the nasal septum to assess for septal deviation causing obstruction and identification of the nasal turbinates and their characteristics.
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Acute rhinosinusitis is characterized by hyperemia of the nasal mucosa and edema. Hyperemia is defined as an increase in the vascularity of the nasal mucosa, so that it appears reddened as opposed to the normal pink color. The presence of nasal crusts represents drying of the nasal mucus or purulence. These crusts may be sparse, or they may involve most of the affected side. Mucopurulent discharge is common in the middle meatus (between the inferior and middle turbinates). Purulence located in the middle meatus is found in patients with acute maxillary, ethmoidal, and frontal sinusitis. Purulence located more posteriorly in the superior meatus and sphenoidal recess is characteristic of posterior ethmoidal or sphenoidal sinusitis. Nasal polyposis predisposes patients to the recurrent symptoms of chronic sinusitis. Polyps present as glistening pedunculated masses with a sometimes bluish or yellowish hue that differentiates them from the normal pink-colored nasal mucosa. 7 Polyps may be hidden within the recesses of the middle meatus complex. Therefore despite good illumination, they may not be seen on the routine nasal examination. Polyps are relatively common in chronic rhinosinusitis, but they are present only infrequently in acute stages unless the patient has an underlying predisposition for nasal polyposis. Topical nasal decongestion with an ct-agonist agent such as phenylephrine hydrochloride is useful in the diagnosis of acute or chronic rhinosinusitis. The reaction of mucous membranes to the application of an ctagonist agent aids in visualizing the recesses of the nasal cavity. After the topical administration of this agent, the physician should look for signs of the improvement of congestion or the worsening of symptoms. Nasal cultures obtained without endoscopy are not specific for the identification of bacteria responsible for acute rhinosinusitis. 8-1° These cultures are frequently contaminated with Staphylococcus aureus and are not well correlated with the results of paranasal sinus aspiration. NASAL ENDOSCOPY
Nasal endoscopy has revolutionized the diagnosis and treatment of rhinosinusitis, a'4 As standard procedure patients with a history of recurrent acute or chronic rhinosinusitis should be examined with a rigid or flexible nasal endoscope in the specialist's office. The concepts of rigid nasal endoscopy are difficult to learn in the primary care office, and the technique requires extensive training and expertise. Nasal endoscopy provides reliable visualization of all accessible areas of the sinus drainage pathways.
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Thus endoscopic examination should be performed before evaluation by CT scanning. After the nasal cavity is anesthetized with a topical agent, the rigid endoscope is advanced to visualize the middle turbinate, which is displaced medially. Nasal endoscopy should visualize all regions of the ostiomeatal complex to appreciate subtle signs of obstruction and to detect nasal polyps hidden from routine nasal examination. The procedure is easily performed with the use of topical anesthesia in adults and adolescents and in cooperative children. During nasal endoscopy the physician should look specifically for purulence at the ostiomeatal complex and the sphenoethmoidal recess, polyp formation at the junction of opposing mucosal surfaces, structural abnormalities that predispose patients to recurrent rhinosinusitis, and other findings. Appropriate directed nasal cultures obtained with nasal endoscopy may correlate better with those obtained by sinus aspiration. Cultures directed with endoscopy are obtained with a microculturette that is directed into the appropriate sinus ostia. SYSTEMATIC NASAL ENDOSCOPY
To diagnose and evaluate the extent of sinonasal disorders, the nasal endoscopist requires appropriate equipment and a systematic approach to the nasal examination. 4 Appropriate equipment includes at least one 0-degree telescope or one wide-angle 25-degree telescope, a fiberoptic light source, and a light cord. The telescopes are manufactured in diameters of 4.0 and 2.7 mm. The smaller scopes are recommended for use in children or in patients with difficult nasal anatomy such as a deviated nasal septum. Because the sinuses and nose are elements of the upper aerodigestive tract, the examination of this region should be performed in the context of a complete examination of the head and neck. Unless contraindicated, topical vasoconstrictive and anesthetic agents should be used to enhance visualization of the nose; some investigators recommend examining the nose both before and after the administration of these agents. Otoscopy and examination of the other regions of the head and neck can be performed first, thereby allowing several minutes for the topical agent to enhance the nasal examination. The nose should then be systematically examined. One approach is to divide the examination into three regions. The inferior examination consists of passing a 0-degree endoscope along the floor of the nose to visualize the orifice of the nasolacrimal duct, the inferolateral nasal wall, the eustachian tube orifice, and the nasopharynx. The second passage should be at approx-
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imately a 30-degree angle from the floor of the nose to examine the sphenoethmoidal recess, the middle meatus, and the sphenoidal ostium. Then the superior passage should be directed toward the frontal recess to examine these cells, the attachment of the middle turbinate, and the superior recess between the middle turbinate and the nasal septum. Endoscopic findings can be divided iJlto allergic or inflammatory, infectious, and anatomic. Nonspecific allergic and inflammatory findings include a bluish discoloration and b o g g y distention o f the nasal mucosa. Inflamed red mucous membranes may a{so be seen. 11 Nasal polyps reflect an inflammatory process, which correlates positively with allergy testing in 50% of patients. Infectious findings include purulent secretions draining from the involved sinus(es), fungal hyphae, inspissated secretions from allergic fungal rhinosinusitis, and loss of nasal tissue from invasive bacterial and fungal pathogens. Physical findings in the acquired immunodeficiency syndrome are nonspecific. Anatomic findings should be viewed in the context of the patient's specific problem. F o r example, a concha bullosa or a deviated septum is significant when lhe structure obstructs the outflow of a specific sinus.
CONCLUSION Because rhinosinusitis is an illness with a significant impact on quality of life, 1,12 it must be appropriately diagnosed and treated. The physician needs to properly assess the patient's history and symptoms and then progress through a structured physical examination to
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look for signs that lead to an appropriate diagnosis. Proper medical treatment is based on the findings of a sound history and a careful physical examination. Although imaging techniques can accurately show the inflammation within sinus ostia, they are relatively expensive to use for following a patient's response to therapy.
REFERENCES 1. Glicldich R, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngic care. Otolaryngol Head Neck Surg 1995;113:104-9. (grade A) 2. Donald PJ, Gluckman JL, Rice DH. The sinuses. New York: Raven Press, 1995. (grade B) 3. Druce HM. Diagnosis of sinusitis in adults: history, physical examination, nasal cytology, echo, and rhinoscope. J Allergy Clin Immunol 1992;90:436-41. (grade B) 4. Kennedy DW, Zinreich J, Rosenbaum AE, et al. Functional endoscopic sinus surgery. Arch Otolaryngol t985; 111:576-82. (grade A) 5. Stafford CT. The clinician's view of sinusitis. Otolaryngol Head Neck Surg 1990;103(5 Part 2):870-5. (grade B) 6. Watd ER. Epidemiology, pathology and etiology of sinusitis. Pediatr Infect Dis 1988;6:95-9. (grade B) 7. Larsen PL, Tos M. Origin of nasal polyps. Laryngoscope 1991;101:305-!2. (grade B) 8. Gwaltney JM, Jones JG, Kennedy DW. Medical management of sinusitis: educational goals and management guidelines. Ann Otol Rhinol Laryngol 1995;167(Suppt 22):30. (grade A) 9. Evans FO, Snyder JB, Mower WE, et al. Sinusitis of the maxiilary annum. N Engl J Med 1975;293:7t5. (grade B) 10. Wald E, Milmoe GJ, Bower A, et al, Acute maxillary sinusitis in children. N Engl J Med 1981;304:749. (grade B) 11. Fornadley JA, Corey JR Osguthorpe JD, et al. Allergic rhinitis: clinical practice guideline. Otolaryngol Head Neck Surg 1996;l 15:1i5-21. (grade A) 12. Williams JW Jr, Simel DL, Roberts L. Clinical evaluation for sinusitis: making the diagnosis by history and physical examination. Ann Intern Med 1992;117:705-10. (grade B)