Clinical evaluation of physical examination

rhinosinusitis: History and

JAMES A. HADLEY, MD, and STEVEN D. SCHAEFER, MD, Rochester, and New York, New York

O v e r the past 10 to 15 years endoscopic evaluation and sinonasal imaging techniques, particularly comput- ed tomographic (CT) scanning, have revolutionized the diagnosis and treatment of rhinosinusitis. Because rhi- nosinusitis affects so many Americans every year and has a major impact on quality of life, a knowledge of its clinical presentation is essential for diagnosis and dif- ferentiation from the common cold or allergic manifes- tations. 1 This section of the Task Force report discusses the current clinical evaluation of patients with the sus- pected diagnosis of rhinosinusitis. Adjunctive nasal rhinoscopy and endoscopy are discussed, but laborato- ry tests and radiographic imaging techniques are cov- ered in other sections of this publication.

The signs and symptoms of rhinosinusitis include those of an acute upper respiratory infection and those associated with the onset of an allergic rhinitis inflam- matory event. Although most cases of acute rhinosi- nusitis occur after a viral upper respiratory tract infec- tion, cases may also occur in association with barotrau- ma or physical trauma. 2 The clinical history and the physical examination help to differentiate among viral, bacterial, and allergic causes.

SIGNS AND SYMPTOMS

The most common complications in patients with acute rhinosinusitis are headache, nasal congestion, and the production of thick postnasal discharge (Table 1).

Facial pain or pressure is the most pressing symptom bringing patients to a physician for evaluation. The site of the acute facial pain or pressure may help in localiz- ing the infection to a specific paranasal sinus. 3 Maxillary sinusitis may cause infraorbital or cheek dis- comfort. Upper teeth or gum pain is highly specific for

From the Division of Otolaryngology, University of Rochester Medical Center (Dr. Hadley), and the Department of Otolaryngnlogy, New York Eye and Ear Infirmary (Dr. Schaefer).

Reprint requests: James A. Hadley, MD, Rochester Otolaryngology, Group 2561 LacDeVille Blvd., Rochester, NY 14168.

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maxillary sinusitis. Lying down relieves the discomfort in patients with maxillary sinusitis.

Ethmoidal rhinosinusitis, which usually accompa- nies most other categories of rhinosinusitis, may cause tenderness over the lacrimal region, with referred ten- derness to the periorbital and temporal regions. Bending forward or lying supine exacerbates the pain from ethmoidal rhinosinusitis.

Frontal sinusitis may constitute an acute medical problem. One characteristic of acute frontal sinusitis is severe headache localized to the forehead over the orbits, with tenderness produced by pressure on the floor of the frontal sinus.

Discomfort from sphenoidal sinusitis radiates to the occiput and vertex areas. Headache described as a chronic dull ache in the back of head, specifically over the occiput with radiation to the frontal and retro-orbital regions, is a sign of sphenoidal rhinosinusitis. Acute sphenoidal rhinosinusitis may represent a medical emergency, particularly when the infection is near cav- ernous sinus structures (i.e., cranial nerves III, IV, V1, V2, and VI) or when diminished visual acuity is involved.

The symptoms of chronic rhinosinusitis are more subtle, with facial pain and pressure less likely to be primary complications. Nasal congestion with obstruc- tion and the production of thickened nasal secretions are the most common problems. 3-5 Other signs of chronic sinusitis include fatigue, cough, and a sensation of facial fullness with pressure. These low-grade symp- toms are the result of persistent inflammation and obstruction of the outflow tracts of the paranasal sinus- es.

Most patients with rhinosinusitis report a significant change in nasal airflow accompanied by a sensation of congestion. Inflamed mucous membranes in the nose and paranasal sinuses are responsible for the sensation of congestion. The production of thickened secretions causes a feeling of increased postnasal drainage and sore throat. However, physicians should not rely solely on colored nasal drainage as an indication for antibiot- ic therapy. Decongestants may provide some relief of the symptoms, but they have no influence on the reduc- tion of inflammation. Treatment with decongestants

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Table 1. Clinical evaluat ion of rhinosinusitis

Symptom complex Major criteria

Headache Facial pain and pressure Nasal congestion Thick, colored postnasal drainage Olfactory disturbance

Minor criteria Fever Halitosis Children only:

Cough Irritability

and mucoevacuants may help to maintain ostial paten- cy and to reduce inflammation by promoting drainage.

Cough, a nonspecific symptom of rhinosinusitis, may be confused with the onset of an asthmatic condi- tion. This symptom, which is common in children with rhinosinusitis, usually diminishes or is eliminated with treatment of the infection. Cough tends to be more common at night. 6 In acute and chronic flfinosinusitis the cough reflex may be provoked by the p:roduction of chemical mediators, leukotrienes, and other factors that give rise to hronchoconstriction and irrkated neural endings. A vagal reflex, mediated from pressure recep- tors within the paranasal sinuses, may also be institut- ed.

Another common symptom and one of tile major cri- teria for the diagnosis of rhinosinusitis is a diminished or lost sense of smell. The inflammatory response of the nasal mucosa hinders odorants from migrating to the olfactory placode in the upper recesses of the nasal cav- ity. Chronic rhinosinusifis may predispose', patients to nasal polyposis, which aggravates hyposmia and may lead to anosmia. 7

Fever is more common in the early stages of acute rhinosinusitis. Although fever is more common in chil- dren and adolescents, it may also be present in adult rhi- nosinusitis shortly after an upper respiratory infection.

Knowledge of the seasonal recurrence of symptoms and known triggers of symptoms is helpful in differen- tiating allergic rhinitis from acute rhinosinusitis. In patients with allergy the nasal membranes; respond to provocation by allergens with the release of chemical mediators from the resident mast cells of the nasal mucosa. Histamine is the primary mediator of the early phase leading to rhinorrhea, edema, and the symptoms of sneezing and congestion. Late-phase reactions from the influence of cellular responses prolong :he reaction, giving the impression of persistent nasal congestion.

Patients with allergic rhinitis usually have a history of allergic response. 6 Typical symptoms include a thin watery nasal discharge, intermittent sneezing, and a

Table 2. Physical signs

External physical findings: swelling and erythema Swelling and erythema: maxillary region, ocular or orbital region, and frontal region

Findings on anterior rhinoscopy Hyperemia Edema Crusts Purulence Polyps

After topical nasal decongestion: improvement or worsening of symptoms

Findings on nasal endoscopy* Bluish discoloration of turbinates Purulence at ostiomeatal complex or other sinus ostia Polyp formation, with size and location of polyps noted Septal deflections Concha bullosa Paradoxic turbinates Other anomalies

*Examination with a rigid or flexible nasal endoscope should be a standard part of the physical examination in the specialist's office. Cultures obtained under endoscopic guidance cultures may be obtained to aid in the diagnosis.

runny, itchy nose. Allergic responses can predispose patients to have acute or chronic rhinosinusitis as a result of the inflammatory response and resultant obstruction of the ostia of the paranasal sinuses.

The differential diagnosis of chronic rhinosinusitis includes asthma, gastroesophageal reflux disease, and chronic allergic rhinitis. All of these conditions may exist simultaneously.

PHYSICAL EXAMINATION

In addition to the major symptom complex for rhi- nosinusitis, the physical examination plays a major role in the diagnosis of acute or chronic rhinosinusitis. The examination begins with the facial features. Swelling, erythema, and edema localized over the involved cheekbone or periorbital area may be immediately rec- ognized in the acute forms of the disease (Table 2). These signs are apparent predominantly in the morning, and they improve gradually while the patient is upright. Patients with chronic rhinosinusitis usually have no facial swelling or edema.

The sinuses are palpated to test for tenderness. Percussion of the teeth may direct attention toward an inflamed paranasal sinus.

ANTERIOR RHINOSCOPY

Anterior rhinoscopy is an examination of the nasal cavity performed with a nasal speculum under good illumination. The examination should include visual- ization of the nasal septum to assess for septal deviation causing obstruction and identification of the nasal turbinates and their characteristics.

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Acute rhinosinusitis is characterized by hyperemia of the nasal mucosa and edema. Hyperemia is defined as an increase in the vascularity of the nasal mucosa, so that it appears reddened as opposed to the normal pink color. The presence of nasal crusts represents drying of the nasal mucus or purulence. These crusts may be sparse, or they may involve most of the affected side. Mucopurulent discharge is common in the middle mea- tus (between the inferior and middle turbinates). Purulence located in the middle meatus is found in patients with acute maxillary, ethmoidal, and frontal sinusitis. Purulence located more posteriorly in the superior meatus and sphenoidal recess is characteristic of posterior ethmoidal or sphenoidal sinusitis.

Nasal polyposis predisposes patients to the recurrent symptoms of chronic sinusitis. Polyps present as glis- tening pedunculated masses with a sometimes bluish or yellowish hue that differentiates them from the normal pink-colored nasal mucosa. 7 Polyps may be hidden within the recesses of the middle meatus complex. Therefore despite good illumination, they may not be seen on the routine nasal examination. Polyps are rela- tively common in chronic rhinosinusitis, but they are present only infrequently in acute stages unless the patient has an underlying predisposition for nasal poly- posis.

Topical nasal decongestion with an ct-agonist agent such as phenylephrine hydrochloride is useful in the diagnosis of acute or chronic rhinosinusitis. The reac- tion of mucous membranes to the application of an ct- agonist agent aids in visualizing the recesses of the nasal cavity. After the topical administration of this agent, the physician should look for signs of the improvement of congestion or the worsening of symp- toms.

Nasal cultures obtained without endoscopy are not specific for the identification of bacteria responsible for acute rhinosinusitis. 8-1° These cultures are frequently contaminated with Staphylococcus aureus and are not well correlated with the results of paranasal sinus aspi- ration.

NASAL ENDOSCOPY

Nasal endoscopy has revolutionized the diagnosis and treatment of rhinosinusitis, a'4 As standard proce- dure patients with a history of recurrent acute or chron- ic rhinosinusitis should be examined with a rigid or flexible nasal endoscope in the specialist's office. The concepts of rigid nasal endoscopy are difficult to learn in the primary care office, and the technique requires extensive training and expertise.

Nasal endoscopy provides reliable visualization of all accessible areas of the sinus drainage pathways.

Thus endoscopic examination should be performed before evaluation by CT scanning. After the nasal cav- ity is anesthetized with a topical agent, the rigid endo- scope is advanced to visualize the middle turbinate, which is displaced medially. Nasal endoscopy should visualize all regions of the ostiomeatal complex to appreciate subtle signs of obstruction and to detect nasal polyps hidden from routine nasal examination. The procedure is easily performed with the use of topi- cal anesthesia in adults and adolescents and in cooper- ative children.

During nasal endoscopy the physician should look specifically for purulence at the ostiomeatal complex and the sphenoethmoidal recess, polyp formation at the junction of opposing mucosal surfaces, structural abnormalities that predispose patients to recurrent rhi- nosinusitis, and other findings. Appropriate directed nasal cultures obtained with nasal endoscopy may cor- relate better with those obtained by sinus aspiration. Cultures directed with endoscopy are obtained with a microculturette that is directed into the appropriate sinus ostia.

SYSTEMATIC NASAL ENDOSCOPY

To diagnose and evaluate the extent of sinonasal dis- orders, the nasal endoscopist requires appropriate equipment and a systematic approach to the nasal examination. 4 Appropriate equipment includes at least one 0-degree telescope or one wide-angle 25-degree telescope, a fiberoptic light source, and a light cord. The telescopes are manufactured in diameters of 4.0 and 2.7 mm. The smaller scopes are recommended for use in children or in patients with difficult nasal anato- my such as a deviated nasal septum.

Because the sinuses and nose are elements of the upper aerodigestive tract, the examination of this region should be performed in the context of a com- plete examination of the head and neck. Unless con- traindicated, topical vasoconstrictive and anesthetic agents should be used to enhance visualization of the nose; some investigators recommend examining the nose both before and after the administration of these agents. Otoscopy and examination of the other regions of the head and neck can be performed first, thereby allowing several minutes for the topical agent to enhance the nasal examination. The nose should then be systematically examined.

One approach is to divide the examination into three regions. The inferior examination consists of passing a 0-degree endoscope along the floor of the nose to visu- alize the orifice of the nasolacrimal duct, the inferolat- eral nasal wall, the eustachian tube orifice, and the nasopharynx. The second passage should be at approx-

Otolaryngology- Head and Neck Surgery Volume 117 Number 3 Part 2 HADLEY and SCHAEFER S! 1

imately a 30-degree angle from the floor of the nose to

examine the sphenoethmoidal recess, the middle mea- tus, and the sphenoidal ostium. Then the superior pas- sage should be directed toward the frontal recess to examine these cells, the attachment of the middle turbinate, and the superior recess between the middle turbinate and the nasal septum.

Endoscopic findings can be divided iJlto allergic or inflammatory, infectious, and anatomic. Nonspecif ic

allergic and inf lammatory findings include a bluish dis- coloration and boggy distention of the nasal mucosa. Inflamed red mucous membranes may a{so be seen. 11 Nasal polyps reflect an inf lammatory process, which correlates posit ively with allergy testing in 50% of patients. Infectious findings include purulent secretions draining from the involved sinus(es), fungal hyphae, inspissated secretions from allergic fungal rhinosinusi- tis, and loss of nasal tissue from invasive bacterial and fungal pathogens. Physical findings in the acquired immunodeficiency syndrome are nonspecific. Anatomic

findings should be viewed in the context of the patient 's specific problem. For example, a concha bullosa or a deviated septum is significant when lhe structure obstructs the outflow of a specific sinus.

CONCLUSION

Because rhinosinusitis is an illness with a significant impact on quality of life, 1,12 it must be appropriately

diagnosed and treated. The physician needs to properly assess the patient 's history and symptoms and then progress through a structured physical examination to

look for signs that lead to an appropriate diagnosis. Proper medical treatment is based on the findings of a sound history and a careful physical examination. Although imaging techniques can accurately show the inflammation within sinus ostia, they are relatively expensive to use for following a patient 's response to

therapy.

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