Schematic diagram of motion of a single cilium during the rapid forward beat and the slower recovery phase.

Change in host milieu creates culture medium for bacterial medium for bacterial growth in closed cavity growth in closed cavity Change in host milieu creates culture medium for bacterial medium for bacterial growth in closed cavity growth in closed cavity Mucosal congestion or anatomic obstruction blocs airflow and drainage OSTIUM IS CLOSED Mucosal congestion or anatomic obstruction blocs airflow and drainage OSTIUM IS CLOSED Secretions stagnate Mucosal thickening creates further blockage Cycle of events that leads to chronic rhinosinusitis begins with ostial blockage begins with ostial blockage Cycle of events that leads to chronic rhinosinusitis begins with ostial blockage begins with ostial blockage Secretions thicken; pH changes pH changes Secretions thicken; pH changes pH changes Mucosal gas metabolism changes metabolism changes Mucosal gas metabolism changes metabolism changes Cilia and epithelium are damaged are damaged Cilia and epithelium are damaged are damaged Bacterial infection develops in the sinus cavity Retained secretions cause tissue inflammation cause tissue inflammation Retained secretions cause tissue inflammation cause tissue inflammation

The expression sinusitis describes an inflammatory process present in the paranasal sinuses mucous membrane, due to disturbances of drainage and ventilation, as a result of infection, allergy or anatomical variations of the lateral nasal wall. This term refers to pathological changes present both in one sinus e. g. maxillary sinusitis and also in several paranasal sinuses (hemipansinusitis, pansinusitis).

For practical reasons in the daily clinical work both terms - sinusitis and rhinosinusitis are equivalent.

Two classifications of chronic rhinosinusitis are currently proposed in rhinological literature. The classification introduced by Kern in 1984 is based on the duration of the disease process and corresponding morphological changes in the mucosa of the sinuses: Acute purulent rhinosinusitis - lasting up to 3 weeks, with one or several sinuses involved. Acute purulent rhinosinusitis - lasting up to 3 weeks, with one or several sinuses involved. Subacute purulent rhinosinusitis - lasting up to 3 weeks to 3 months. Morphological changes in the mucosa which occur within that time are usually reversible. Subacute purulent rhinosinusitis - lasting up to 3 weeks to 3 months. Morphological changes in the mucosa which occur within that time are usually reversible. Chronic purulent rhinosinusitis - lasting over 3 months. This formof the disease process is thought to be a result of untreated or improperly treated acute inflammation. Surgery to remove irreversibly changed mucosa is recommended. Chronic purulent rhinosinusitis - lasting over 3 months. This formof the disease process is thought to be a result of untreated or improperly treated acute inflammation. Surgery to remove irreversibly changed mucosa is recommended. Two classifications of chronic rhinosinusitis are currently proposed in rhinological literature. The classification introduced by Kern in 1984 is based on the duration of the disease process and corresponding morphological changes in the mucosa of the sinuses: Acute purulent rhinosinusitis - lasting up to 3 weeks, with one or several sinuses involved. Acute purulent rhinosinusitis - lasting up to 3 weeks, with one or several sinuses involved. Subacute purulent rhinosinusitis - lasting up to 3 weeks to 3 months. Morphological changes in the mucosa which occur within that time are usually reversible. Subacute purulent rhinosinusitis - lasting up to 3 weeks to 3 months. Morphological changes in the mucosa which occur within that time are usually reversible. Chronic purulent rhinosinusitis - lasting over 3 months. This formof the disease process is thought to be a result of untreated or improperly treated acute inflammation. Surgery to remove irreversibly changed mucosa is recommended. Chronic purulent rhinosinusitis - lasting over 3 months. This formof the disease process is thought to be a result of untreated or improperly treated acute inflammation. Surgery to remove irreversibly changed mucosa is recommended.

The 1995 International Conference on Sinus Disease classification of rhinosinusitis is based on an assessment of the extent of pathophysiological processes involving the mucosa of the sinuses and the nasal cavity: Acute rhinosinusitis is defined as an episodic inflammatory process which does not leave any significant persistent damage of the mucosa after conservative treatment. Acute rhinosinusitis is defined as an episodic inflammatory process which does not leave any significant persistent damage of the mucosa after conservative treatment. Acute recurrent rhinosinusitis refers to repeated episodes of acute inflammation with complete recovery after conservative treatment, causing no persistent damage of the mucosa. Acute recurrent rhinosinusitis refers to repeated episodes of acute inflammation with complete recovery after conservative treatment, causing no persistent damage of the mucosa. Chronic rhinosinusitis is defined as persistent inflammation which cannot be cured with conservative treatment. Chronic rhinosinusitis is defined as persistent inflammation which cannot be cured with conservative treatment. The 1995 International Conference on Sinus Disease classification of rhinosinusitis is based on an assessment of the extent of pathophysiological processes involving the mucosa of the sinuses and the nasal cavity: Acute rhinosinusitis is defined as an episodic inflammatory process which does not leave any significant persistent damage of the mucosa after conservative treatment. Acute rhinosinusitis is defined as an episodic inflammatory process which does not leave any significant persistent damage of the mucosa after conservative treatment. Acute recurrent rhinosinusitis refers to repeated episodes of acute inflammation with complete recovery after conservative treatment, causing no persistent damage of the mucosa. Acute recurrent rhinosinusitis refers to repeated episodes of acute inflammation with complete recovery after conservative treatment, causing no persistent damage of the mucosa. Chronic rhinosinusitis is defined as persistent inflammation which cannot be cured with conservative treatment. Chronic rhinosinusitis is defined as persistent inflammation which cannot be cured with conservative treatment.

The patient may complain of: nasal blockage or congestion; nasal blockage or congestion; nasal discharge - serous, seropurulent, purulent; nasal discharge - serous, seropurulent, purulent; postnasal discharge; postnasal discharge; pain or pressure in the orbital region, pain or pressure in the region of the sinus affected by inflammation; pain or pressure in the orbital region, pain or pressure in the region of the sinus affected by inflammation; headache; headache; toothache. toothache. nasal blockage or congestion; nasal blockage or congestion; nasal discharge - serous, seropurulent, purulent; nasal discharge - serous, seropurulent, purulent; postnasal discharge; postnasal discharge; pain or pressure in the orbital region, pain or pressure in the region of the sinus affected by inflammation; pain or pressure in the orbital region, pain or pressure in the region of the sinus affected by inflammation; headache; headache; toothache. toothache.

Physical examination reveals: oedema and reddening of the nasal cavities mucosa; oedema and reddening of the nasal cavities mucosa; oedema of the skin in the region of the root of the nose and in the region of the palpebras; oedema of the skin in the region of the root of the nose and in the region of the palpebras; mucous, mucopurulent or purulent secretion in the nasal cavities; mucous, mucopurulent or purulent secretion in the nasal cavities; mucous or purulent secretion in the nasopharynx; mucous or purulent secretion in the nasopharynx; purulent secretion on the lateral wall of the nasal cavity; purulent secretion on the lateral wall of the nasal cavity; painfulness of the cheek when exerting pressure on the canine fossa (in the maxillary sinusitis) and when exerting pressure on the upper wall of the orbit (in the frontal sinusitis). painfulness of the cheek when exerting pressure on the canine fossa (in the maxillary sinusitis) and when exerting pressure on the upper wall of the orbit (in the frontal sinusitis). oedema and reddening of the nasal cavities mucosa; oedema and reddening of the nasal cavities mucosa; oedema of the skin in the region of the root of the nose and in the region of the palpebras; oedema of the skin in the region of the root of the nose and in the region of the palpebras; mucous, mucopurulent or purulent secretion in the nasal cavities; mucous, mucopurulent or purulent secretion in the nasal cavities; mucous or purulent secretion in the nasopharynx; mucous or purulent secretion in the nasopharynx; purulent secretion on the lateral wall of the nasal cavity; purulent secretion on the lateral wall of the nasal cavity; painfulness of the cheek when exerting pressure on the canine fossa (in the maxillary sinusitis) and when exerting pressure on the upper wall of the orbit (in the frontal sinusitis). painfulness of the cheek when exerting pressure on the canine fossa (in the maxillary sinusitis) and when exerting pressure on the upper wall of the orbit (in the frontal sinusitis).

Factors predisposing recurrences of acute rhinosinusitis  Anatomic: deviation of the nasal septum; deviation of the nasal septum; anatomical variations of the nasal lateral wall: anatomical variations of the nasal lateral wall:  of the middle nasal concha,  of the uncinate process,  of the ridge of the nose,  of the ethmoidal bulla,  of the Haller’s cels; Morphological: nasal polyps; nasal polyps; nasal tumours; nasal tumours; adenoids. adenoids.Anatomic: deviation of the nasal septum; deviation of the nasal septum; anatomical variations of the nasal lateral wall: anatomical variations of the nasal lateral wall:  of the middle nasal concha,  of the uncinate process,  of the ridge of the nose,  of the ethmoidal bulla,  of the Haller’s cels; Morphological: nasal polyps; nasal polyps; nasal tumours; nasal tumours; adenoids. adenoids.

Oedemas of the mucosa: infection; allergy; rhinitis vasomotorica; rhinitis medicamentosa; hormonal disturbances. Traumas: local traumas; barotrauma; foreign bodies; iatrogenic. Constitutional: syndromes of ciliary disturbances; cystic fibrosis; immunological deficiencies. Factors predisposing recurrences of acute rhinosinusitis 

The most often used antibiotics in the therapy of rhinosiusitis The most often used antibiotics in the therapy of rhinosiusitis

Supplementary treatment 1.Decongestants should ensure restoration of the patency of the ostio- meatal complex and thereby the sinuses ostia. 2.Mucolytic drugs act on the retained in the sinuses secretion in such a way that it becomes more liquid thus easier to move. 3.Corticosteroids are recommended first of all in the therapy of chronic inflammation. 4.Recommendation for the administration of antihistamines requires comprehensive reasoning, because allergy plays a far smaller role in the pathogenesis of rhinosinusitis than it is assumed. 1.Decongestants should ensure restoration of the patency of the ostio- meatal complex and thereby the sinuses ostia. 2.Mucolytic drugs act on the retained in the sinuses secretion in such a way that it becomes more liquid thus easier to move. 3.Corticosteroids are recommended first of all in the therapy of chronic inflammation. 4.Recommendation for the administration of antihistamines requires comprehensive reasoning, because allergy plays a far smaller role in the pathogenesis of rhinosinusitis than it is assumed.

Criteria for chronic rhinosinusitis  In adults 8 weeks of persistent symptoms and sings or Four episodes per year of recurrent acute sinusitis, each lasting at least 10 days in association with Persistent changes on computer tomography 4 weeks after medical therapy without intervening acute infection In adults 8 weeks of persistent symptoms and sings or Four episodes per year of recurrent acute sinusitis, each lasting at least 10 days in association with Persistent changes on computer tomography 4 weeks after medical therapy without intervening acute infection

Criteria for chronic rhinosinusitis  In children 12 weeks of persistent symptoms and sings or: Six episodes per year of recurrent acute sinusitis, each lasting at least 10 days in association with Persistent changes on computer tomography 4 weeks after medical therapy without intervening acute infection In children 12 weeks of persistent symptoms and sings or: Six episodes per year of recurrent acute sinusitis, each lasting at least 10 days in association with Persistent changes on computer tomography 4 weeks after medical therapy without intervening acute infection

Criteria for chronic rhinosinusitis  Symptoms and sings Adults and children Major Nasal congestion Nasal discharge Headache Facial pain or pressure Olfactory disturbance MinorFeverHalitiosis Children only CoughIrritability Symptoms and sings Adults and children Major Nasal congestion Nasal discharge Headache Facial pain or pressure Olfactory disturbance MinorFeverHalitiosis Children only CoughIrritability

The most often isolated microorganisms in rhinosiusitis The most often isolated microorganisms in rhinosiusitis Streptococcus pneumoniae Haemophilus influenzae Streptococcus pyogenes Staphylococcus aureus Anaerobes:BacteroidesFusobacteriumPeptostreptococcus Alpha- and beta-haemolytic streptococci Other Gram-negative bacterias Streptococcus pneumoniae Haemophilus influenzae Streptococcus pyogenes Staphylococcus aureus Anaerobes:BacteroidesFusobacteriumPeptostreptococcus Alpha- and beta-haemolytic streptococci Other Gram-negative bacterias

Surgical indications