ENT (Otorhinolaryngology) · MU Sofia

22. Chronic rhinosinusitis with or without polyps. Odontogenic sinusitis.

Explains chronic rhinosinusitis as a syndrome defined by duration and symptoms plus objective findings, then covers its two phenotypes with and without nasal polyps, the underlying mechanisms such as ostial obstruction, biofilms and endotypes, predisposing conditions, clinical features, endoscopy and CT findings with the Lund-Mackay score, medical, biologic and surgical treatment, complications and differentials. It then turns to odontogenic sinusitis from maxillary tooth roots, covering anaerobic causes, oro-antral fistula, dental imaging, source control with extraction or root treatment, antibiotics and drainage.

Inside: 8 sections · 6 labelled pictures · 16 flashcards · 9 min

Topic 22 of 52 in the MU Sofia syllabus for ENT (Otorhinolaryngology) (Medicine, Year 4). The free AceMed note covers it in 8 sections, about 1,372 words (9 min of reading), with 16 flashcards.

In this note

  1. Chronic rhinosinusitis with or without polyps. Odontogenic sinusitis.
  2. Chronic Rhinosinusitis (CRS)
  3. Etiopathogenesis
  4. Classification
  5. Clinical Picture
  6. Paraclinical and Radiological Examinations
  7. Treatment Options
  8. Odontogenic Sinusitis (OS)

Chronic Rhinosinusitis (CRS)

1. Definition: inflammation of the nose and paranasal sinuses lasting > 12 weeks, with ≥2 symptoms, one of which must be nasal obstruction or nasal discharge ±

Facial pain/pressure

Reduced smell

, PLUS objective findings on endoscopy or CT.

Two major phenotypes:

  • CRSsNP – chronic rhinosinusitis without nasal polyps
  • CRSwNP – chronic rhinosinusitis with nasal polyps

Etiopathogenesis

CRS is a complex syndrome, not simply a prolonged infection, driven by a cycle of inflammation, impaired drainage, and microbial involvement.

Key Mechanisms

  1. 1. Ostial Obstruction and Mucociliary Dysfunction: Similar to ARS, failure of the Ostio-Meatal Complex (OMC) to drain due to structural or mucosal swelling is key. In CRS, the damage to the mucociliary escalator becomes chronic, leading to persistent stasis.
  2. 2. Biofilm Formation: Bacteria (often S. aureus, P. aeruginosa) can exist in protective biofilms on the sinus mucosa. These biofilms are highly resistant to antibiotics and host defenses, contributing to chronic inflammation.
  3. 3. Immune and Inflammatory Dysregulation:
  • TH2 Endotype (Typical in CRSwNP): Characterized by high levels of TH2 cytokines (IL-4, 5, 13), recruitment of eosinophils, and high IgE levels, leading to polyp formation. Often seen with asthma and AERD.
  • TH1/Neutrophilic Endotype (Typical in CRSsNP): Characterized by neutrophilic inflammation and a less prominent allergic/eosinophilic component.

Predisposing Factors

  • Allergic Rhinitis
  • Asthma (Strong association)
  • Aspirin-Exacerbated Respiratory Disease (Samter's Triad: asthma + nasal polyps + aspirin intolerance)
  • Immunodeficiencies (eg, CVID, IgA deficiency)
  • Cystic Fibrosis (CF)
  • Systemic vasculitis (eg, Granulomatosis with Polyangiitis - GPA)
  • Anatomical defects (eg, septal deviation, concha bullosa).

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