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

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

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

Change in host milieu Change in host milieu creates culturecreates culture

medium for bacterialmedium for bacterial growth in closed cavitygrowth in closed cavity

Change in host milieu Change in host milieu creates culturecreates culture

medium for bacterialmedium for bacterial growth in closed cavitygrowth in closed cavity

Mucosal congestion or anatomicMucosal congestion or anatomicobstruction blocs airflow and drainageobstruction blocs airflow and drainage

OSTIUM IS CLOSEDOSTIUM IS CLOSED

Mucosal congestion or anatomicMucosal congestion or anatomicobstruction blocs airflow and drainageobstruction blocs airflow and drainage

OSTIUM IS CLOSEDOSTIUM IS CLOSED

Secretions stagnateSecretions stagnateSecretions stagnateSecretions stagnate

Mucosal thickening creates Mucosal thickening creates further blockagefurther blockage

Mucosal thickening creates Mucosal thickening creates further blockagefurther blockage

Cycle of events that leads to chronic rhinosinusitisCycle of events that leads to chronic rhinosinusitis begins with ostial blockagebegins with ostial blockage

Cycle of events that leads to chronic rhinosinusitisCycle of events that leads to chronic rhinosinusitis begins with ostial blockagebegins with ostial blockage

Secretions thicken;Secretions thicken; pH changespH changes

Secretions thicken;Secretions thicken; pH changespH changes

Mucosal gasMucosal gas metabolism changesmetabolism changes

Mucosal gasMucosal gas metabolism changesmetabolism changes

Cilia and epitheliumCilia and epithelium are damagedare damaged

Cilia and epitheliumCilia and epithelium are damagedare damaged

Bacterial infection develops in the Bacterial infection develops in the sinus cavitysinus cavity

Bacterial infection develops in the Bacterial infection develops in the sinus cavitysinus cavity

Retained secretionsRetained secretions

cause tissue inflammationcause tissue inflammation

Retained secretionsRetained secretions

cause tissue inflammationcause tissue inflammation

The expression The expression sinusitis sinusitis describes an inflammatory describes an inflammatory

process present in the paranasal sinuses mucous process present in the paranasal sinuses mucous

membrane, due to disturbances of drainage and membrane, due to disturbances of drainage and

ventilation, as a result of infection, allergy or anatomical ventilation, as a result of infection, allergy or anatomical

variations of the lateral nasal wall. This term refers to variations of the lateral nasal wall. This term refers to

pathological changes present both in one sinus e. g. pathological changes present both in one sinus e. g.

maxillary sinusitismaxillary sinusitis and also in several paranasal and also in several paranasal

sinuses sinuses (hemipansinusitis, pansinusitis)(hemipansinusitis, pansinusitis)..

The expression The expression sinusitis sinusitis describes an inflammatory describes an inflammatory

process present in the paranasal sinuses mucous process present in the paranasal sinuses mucous

membrane, due to disturbances of drainage and membrane, due to disturbances of drainage and

ventilation, as a result of infection, allergy or anatomical ventilation, as a result of infection, allergy or anatomical

variations of the lateral nasal wall. This term refers to variations of the lateral nasal wall. This term refers to

pathological changes present both in one sinus e. g. pathological changes present both in one sinus e. g.

maxillary sinusitismaxillary sinusitis and also in several paranasal and also in several paranasal

sinuses sinuses (hemipansinusitis, pansinusitis)(hemipansinusitis, pansinusitis)..

For practical reasons in the daily clinical work both terms For practical reasons in the daily clinical work both terms

- - sinusitissinusitis and and rhinosinusitisrhinosinusitis are equivalent. are equivalent.

For practical reasons in the daily clinical work both terms For practical reasons in the daily clinical work both terms

- - sinusitissinusitis and and rhinosinusitisrhinosinusitis are equivalent. are equivalent.

Two classifications of chronic rhinosinusitis are currently proposed in Two classifications of chronic rhinosinusitis are currently proposed in

rhinological literature. The classification introduced by Kern in 1984 is rhinological literature. The classification introduced by Kern in 1984 is

based on the duration of the disease process and corresponding based on the duration of the disease process and corresponding

morphological changes in the mucosa of the sinuses:morphological changes in the mucosa of the sinuses:

Acute purulent rhinosinusitisAcute purulent rhinosinusitis - lasting up to 3 weeks, with one or - lasting up to 3 weeks, with one or several several

sinuses involved.sinuses involved.

Subacute purulent rhinosinusitisSubacute purulent rhinosinusitis - lasting up to 3 weeks to 3 - lasting up to 3 weeks to 3 months.months.

Morphological changes in the mucosa which occur withinMorphological changes in the mucosa which occur within that time are that time are

usually reversible.usually reversible.

Chronic purulent rhinosinusitisChronic purulent rhinosinusitis - lasting over 3 months. This form - lasting over 3 months. This form ofof the the

disease process is thought to be a result of untreated ordisease process is thought to be a result of untreated or improperly treated improperly treated

acute inflammation. Surgery to removeacute inflammation. Surgery to remove irreversibly changed mucosa is irreversibly changed mucosa is

recommended.recommended.

Two classifications of chronic rhinosinusitis are currently proposed in Two classifications of chronic rhinosinusitis are currently proposed in

rhinological literature. The classification introduced by Kern in 1984 is rhinological literature. The classification introduced by Kern in 1984 is

based on the duration of the disease process and corresponding based on the duration of the disease process and corresponding

morphological changes in the mucosa of the sinuses:morphological changes in the mucosa of the sinuses:

Acute purulent rhinosinusitisAcute purulent rhinosinusitis - lasting up to 3 weeks, with one or - lasting up to 3 weeks, with one or several several

sinuses involved.sinuses involved.

Subacute purulent rhinosinusitisSubacute purulent rhinosinusitis - lasting up to 3 weeks to 3 - lasting up to 3 weeks to 3 months.months.

Morphological changes in the mucosa which occur withinMorphological changes in the mucosa which occur within that time are that time are

usually reversible.usually reversible.

Chronic purulent rhinosinusitisChronic purulent rhinosinusitis - lasting over 3 months. This form - lasting over 3 months. This form ofof the the

disease process is thought to be a result of untreated ordisease process is thought to be a result of untreated or improperly treated improperly treated

acute inflammation. Surgery to removeacute inflammation. Surgery to remove irreversibly changed mucosa is irreversibly changed mucosa is

recommended.recommended.

The 1995 International Conference on Sinus Disease classification of The 1995 International Conference on Sinus Disease classification of

rhinosinusitis is based on an assessment of the extent of rhinosinusitis is based on an assessment of the extent of

pathophysiological processes involving the mucosa of the sinuses and the pathophysiological processes involving the mucosa of the sinuses and the

nasal cavity:nasal cavity:

Acute rhinosinusitis is defined as an episodic inflammatoryAcute rhinosinusitis is defined as an episodic inflammatory process which process which

does not leave any significant persistent damage ofdoes not leave any significant persistent damage of the mucosa after the mucosa after

conservative treatment.conservative treatment.

Acute recurrent rhinosinusitis refers to repeated episodes of acuteAcute recurrent rhinosinusitis refers to repeated episodes of acute

inflammation with complete recovery after conservativeinflammation with complete recovery after conservative treatment, causing treatment, causing

no persistent damage of the mucosa.no persistent damage of the mucosa.

Chronic rhinosinusitis is defined as persistent inflammation whichChronic rhinosinusitis is defined as persistent inflammation which cannot cannot

be cured with conservative treatment.be cured with conservative treatment.

The 1995 International Conference on Sinus Disease classification of The 1995 International Conference on Sinus Disease classification of

rhinosinusitis is based on an assessment of the extent of rhinosinusitis is based on an assessment of the extent of

pathophysiological processes involving the mucosa of the sinuses and the pathophysiological processes involving the mucosa of the sinuses and the

nasal cavity:nasal cavity:

Acute rhinosinusitis is defined as an episodic inflammatoryAcute rhinosinusitis is defined as an episodic inflammatory process which process which

does not leave any significant persistent damage ofdoes not leave any significant persistent damage of the mucosa after the mucosa after

conservative treatment.conservative treatment.

Acute recurrent rhinosinusitis refers to repeated episodes of acuteAcute recurrent rhinosinusitis refers to repeated episodes of acute

inflammation with complete recovery after conservativeinflammation with complete recovery after conservative treatment, causing treatment, causing

no persistent damage of the mucosa.no persistent damage of the mucosa.

Chronic rhinosinusitis is defined as persistent inflammation whichChronic rhinosinusitis is defined as persistent inflammation which cannot cannot

be cured with conservative treatment.be cured with conservative treatment.

The patient may complain of:The patient may complain of:The patient may complain of:The patient may complain of:

nasal blockage or congestion;nasal blockage or congestion;

nasal discharge - serous, seropurulent,nasal discharge - serous, seropurulent, purulent;purulent;

postnasal discharge;postnasal discharge;

pain or pressure in the orbital region, pain orpain or pressure in the orbital region, pain or pressure in the region of the sinus affected bypressure in the region of the sinus affected by inflammation;inflammation;

headache;headache;

toothache.toothache.

nasal blockage or congestion;nasal blockage or congestion;

nasal discharge - serous, seropurulent,nasal discharge - serous, seropurulent, purulent;purulent;

postnasal discharge;postnasal discharge;

pain or pressure in the orbital region, pain orpain or pressure in the orbital region, pain or pressure in the region of the sinus affected bypressure in the region of the sinus affected by inflammation;inflammation;

headache;headache;

toothache.toothache.

Physical examination reveals:Physical examination reveals:Physical examination reveals: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 inoedema of the skin in the region of the root of the nose and in the the

region of the palpebras;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 caninepainfulness of the cheek when exerting pressure on the canine

fossa (in the maxillary sinusitis) and when exerting pressure onfossa (in the maxillary sinusitis) and when exerting pressure on the the

upper wall of the orbit (in the frontal sinusitis).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 inoedema of the skin in the region of the root of the nose and in the the

region of the palpebras;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 caninepainfulness of the cheek when exerting pressure on the canine

fossa (in the maxillary sinusitis) and when exerting pressure onfossa (in the maxillary sinusitis) and when exerting pressure on the the

upper wall of the orbit (in the frontal sinusitis).upper wall of the orbit (in the frontal sinusitis).

Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis

Anatomic: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 middle nasal concha,

of the uncinate process,of the uncinate process,

of the ridge of the nose,of the ridge of the nose,

of the ethmoidal bulla,of the ethmoidal bulla,

of the Haller’s cels;of the Haller’s cels;

Morphological:Morphological: nasal polyps;nasal polyps; nasal tumours;nasal tumours; adenoids.adenoids.

Anatomic: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 middle nasal concha,

of the uncinate process,of the uncinate process,

of the ridge of the nose,of the ridge of the nose,

of the ethmoidal bulla,of the ethmoidal bulla,

of the Haller’s cels;of the Haller’s cels;

Morphological: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 Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis Factors predisposing recurrences of acute rhinosinusitis

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

Supplementary treatmentSupplementary treatmentSupplementary treatmentSupplementary treatment

1.1. DecongestantsDecongestants should ensure restoration of the patency of the should ensure restoration of the patency of the

ostio-meatal complex and thereby the sinuses ostia.ostio-meatal complex and thereby the sinuses ostia.

2.2. Mucolytic drugsMucolytic drugs act on the retained in the sinuses secretion in such act on the retained in the sinuses secretion in such

a way that it becomes more liquid thus easier to move.a way that it becomes more liquid thus easier to move.

3.3. Corticosteroids are recommended Corticosteroids are recommended first of all in the therapy offirst of all in the therapy of

chronic inflammation.chronic inflammation.

4.4. Recommendation for the administration of Recommendation for the administration of antihistaminesantihistamines requires requires

comprehensive reasoning, because allergy plays a far smaller rolecomprehensive reasoning, because allergy plays a far smaller role

in the pathogenesis of rhinosinusitis than it is assumed.in the pathogenesis of rhinosinusitis than it is assumed.

1.1. DecongestantsDecongestants should ensure restoration of the patency of the should ensure restoration of the patency of the

ostio-meatal complex and thereby the sinuses ostia.ostio-meatal complex and thereby the sinuses ostia.

2.2. Mucolytic drugsMucolytic drugs act on the retained in the sinuses secretion in such act on the retained in the sinuses secretion in such

a way that it becomes more liquid thus easier to move.a way that it becomes more liquid thus easier to move.

3.3. Corticosteroids are recommended Corticosteroids are recommended first of all in the therapy offirst of all in the therapy of

chronic inflammation.chronic inflammation.

4.4. Recommendation for the administration of Recommendation for the administration of antihistaminesantihistamines requires requires

comprehensive reasoning, because allergy plays a far smaller rolecomprehensive reasoning, because allergy plays a far smaller role

in the pathogenesis of rhinosinusitis than it is assumed.in the pathogenesis of rhinosinusitis than it is assumed.

Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis Criteria for chronic rhinosinusitis

In adultsIn adults

8 weeks of persistent symptoms and sings8 weeks of persistent symptoms and sings

oror

Four episodes per year of recurrent acute sinusitis, each Four episodes per year of recurrent acute sinusitis, each

lasting at least 10 dayslasting at least 10 days

in association within association with

Persistent changes on computer tomography 4 weeksPersistent changes on computer tomography 4 weeks

after medical therapy without intervening acute infectionafter medical therapy without intervening acute infection

In adultsIn adults


oror

Four episodes per year of recurrent acute sinusitis, each Four episodes per year of recurrent acute sinusitis, each






In childrenIn children


or:or:

Six episodes per year of recurrent acute sinusitis, eachSix episodes per year of recurrent acute sinusitis, each





In childrenIn children


or:or:

Six episodes per year of recurrent acute sinusitis, eachSix episodes per year of recurrent acute sinusitis, each






Symptoms and singsSymptoms and sings

Adults and childrenAdults and childrenMajorMajor

Nasal congestionNasal congestionNasal dischargeNasal dischargeHeadacheHeadacheFacial pain or pressureFacial pain or pressureOlfactory disturbanceOlfactory disturbance

MinorMinorFeverFeverHalitiosisHalitiosis

Children onlyChildren onlyCoughCoughIrritabilityIrritability

Symptoms and singsSymptoms and sings

Adults and childrenAdults and childrenMajorMajor

Nasal congestionNasal congestionNasal dischargeNasal dischargeHeadacheHeadacheFacial pain or pressureFacial pain or pressureOlfactory disturbanceOlfactory disturbance

MinorMinorFeverFeverHalitiosisHalitiosis

Children onlyChildren onlyCoughCoughIrritabilityIrritability

The most often isolated microorganisms in rhinosiusitisThe most often isolated microorganisms in rhinosiusitis

Streptococcus pneumoniaeStreptococcus pneumoniae

Haemophilus influenzaeHaemophilus influenzae

Streptococcus pyogenesStreptococcus pyogenes

Staphylococcus aureusStaphylococcus aureus

Anaerobes:Anaerobes:

BacteroidesBacteroides

FusobacteriumFusobacterium

PeptostreptococcusPeptostreptococcus

Alpha- and beta-haemolytic streptococciAlpha- and beta-haemolytic streptococci

Other Gram-negative bacteriasOther Gram-negative bacterias

Streptococcus pneumoniaeStreptococcus pneumoniae

Haemophilus influenzaeHaemophilus influenzae

Streptococcus pyogenesStreptococcus pyogenes

Staphylococcus aureusStaphylococcus aureus

Anaerobes:Anaerobes:

BacteroidesBacteroides

FusobacteriumFusobacterium

PeptostreptococcusPeptostreptococcus

Alpha- and beta-haemolytic streptococciAlpha- and beta-haemolytic streptococci

Other Gram-negative bacteriasOther Gram-negative bacterias

Surgical indicationsSurgical indicationsSurgical indicationsSurgical indications

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

Documents

acute rhinosinusitis

acute recurrent rhinosinusitis

nasal blockage

nasal cavitypainfulness

disease process

lateral nasal wall

conservative treatment

persistent inflammation