Chapter 9
Rhinitis and sinusitis

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Rhinitis and sinusitis are among the most common medical conditions and are frequently associated. In Western societies an estimated 10% to 25% of the population have allergic rhinitis, with 30 to 60 million persons being affected annually in the United States. It is estimated that sinusitis affects 31 million patients annually in the United States. Both rhinitis and sinusitis can significantly decrease quality of life, aggravate comorbid conditions, and require significant direct medical expenditures. Both conditions also create even greater indirect costs to society by causing lost work and school days and reduced workplace productivity and school learning. Management of allergic rhinitis involves avoidance, many pharmacologic options, and, in appropriately selected patients, allergen immunotherapy. Various types of nonallergic rhinitis are treated with avoidance measures and a more limited repertoire of medications. For purposes of this review, sinusitis and rhinosinusitis are synonymous terms. An acute upper respiratory illness of less than approximately 7 days' duration is most commonly caused by viral illness (viral rhinosinusitis), whereas acute bacterial sinusitis becomes more likely beyond 7 to 10 days. Although the mainstay of management of acute bacterial sinusitis is antibiotics, treatment of chronic sinusitis is less straightforward because only some chronic sinusitis cases have an infectious basis. Chronic rhinosinusitis (CRS) has been subdivided into 3 types, namely CRS without nasal polyps, CRS with nasal polyps, and allergic fungal rhinosinusitis. Depending on the type of CRS present, a variety of medical and surgical approaches might be required.

Section snippets

Background

Although semantically, the term rhinitis implies inflammation of the nasal mucous membranes, inflammatory cell infiltrates are not characteristic of all disorders considered to be rhinitis. As a clinical term, rhinitis refers to a heterogeneous group of nasal disorders characterized by 1 or more of the following symptoms: sneezing, nasal itching, rhinorrhea, and nasal congestion.1 Rhinitis can be caused by allergic, nonallergic, infectious, hormonal, occupational, and other factors.1, 2

Sinus anatomy and physiology

Normal sinus function requires (1) patency of each sinus ostia, (2) normal mucociliary function, and (3) normal systemic and local immune function. Epithelial cilia in the sinuses normally beat mucus in an ordered fashion toward the ostia that communicate with the nasal cavity. The maxillary, anterior ethmoid, and frontal sinuses drain through a comparatively narrow drainage pathway, the ostiomeatal unit (complex), which communicates into the middle meatus, a space between the inferior and

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    Disclosure of potential conflict of interest: M. S. Dykewicz is an advisor for Alcon, Boehringer Ingelheim, and Ista; is on the speakers' bureau for Merck and Sanofi-Aventis; is on the Board of Directors for the American Board of Allergy and Immunology; is on the Board of Directors and is a member of the Rhinitis Committee for the American Academy of Allergy, Asthma & Immunology; and is Vice Chair and on the Committee on Rhinitis and Sinusitis for the American College of Allergy, Asthma & Immunology. D. L. Hamilos has received research support from Merck and the Flight Attendant Medical Research Institute and has served an as expert witness on the topics of anaphylaxis and occupational asthma.

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