Fortnightly Review: Diagnosis and management of sinusitis

doi:10.1136/bmj.309.6966.1415

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Kathryn L Evans

Gloucester Royal Hospital, Gloucester GL1 3NN Kathyrn L Evans, consultant ear, nose, and throat surgeon.

Sinusitis is an important source of morbidity and loss of income and may exacerbate chest disease.1 2 3 Most uncomplicated acute sinusitis is managed in Britain in primary care, whereas most chronic sinusitis is managed by rhinologists. Patients commonly seek advice on recurring symptoms of rhinorrhoea, congestion, intermittent facial pain, and postnasal drip, and it is important to distinguish chronic sinusitis from rhinitis.

The course and character of sinusitis are influenced by (a) repeated episodes of mucosal oedema and hypersecretion in response to infection or allergy; and (b) anatomical variants which may impair sinus ventilation and mucociliary clearance. A broader understanding of these factors helps to direct medical management either alone or with surgery.4

Paranasal sinuses

The paranasal sinuses comprise four paired cavities: the frontal, maxillary, ethmoid, and sphenoid sinuses. Each is lined with ciliated pseudostratified columnar epithelium and has a narrow ostium that opens into the nasal cavity. The ostia of the frontal, maxillary, and anterior ethmoid sinuses open into the ostiomeatal complex, which lies in the middle meatus, lateral to the middle turbinate. The posterior ethmoid and sphenoid sinuses open into the superior meatus and sphenoethmoid recess respectively. The anatomy is variable and has been extensively reviewed.5

A protective mucous blanket, which envelops bacteria and other irritants, covers the respiratory cilia and is moved constantly along predetermined pathways to the sinus ostia. In the frontal sinus mucus passes up along the intersinus septum, then across the roof of the sinus before returning across the sinus floor to the frontal recess and the middle meatus.6 In the maxillary sinus mucus is moved from the floor of the sinus radially and up the walls of the sinus to the superiorly placed ostium (fig 1).

FIG 1

Mucociliary pathways in the maxillary and frontal sinuses