SAN ANTONIO, TEX—There are so many myths surrounding sinusitis that only one thing about it may be certain: “Everything we think we know about the disease is probably wrong.” This opinion about sinusitis was voiced by Larry C. Borish, MD, at the annual meeting of the American College of Allergy, Asthma and Immunology.[1] At that meeting, Dr. Borish, Richard D. deShazo, MD, and Stewart J. Tepper, MD, discussed many of the myths surrounding sinusitis, focusing especially on chronic sinusitis, allergic fungal sinusitis (AFS), and sinus headache.

CHRONIC SINUSITIS

Dr. Borish, Professor of Medicine and member of the Asthma and Allergic Disease Center at the University of Virginia Health System in Charlottesville, presented five concepts aimed at correcting misconceptions about sinusitis and optimizing treatment of the disease. These include:

Sinusitis cannot be diagnosed with clinical criteria. None of the clinical criteria listed in diagnostic models for sinusitis are at all specific to the disease, asserted Dr. Borish. Cough, for instance, suggests asthma, whereas purulent posterior pharyngeal drainage is more indicative of nasal disease. Facial pain cannot be a symptom of sinusitis because the sinuses have no pain nerves, he added.

Compared with computed tomography (CT), clinical criteria are not much better than random guessing in predicting the presence and severity of sinusitis. “When available, I believe the CT scan is the gold standard” for diagnosing sinusitis, Dr. Borish stressed.

Chronic sinusitis is rarely an infectious disease. The best available studies suggest the lack of an infectious process in most patients with chronic sinusitis; these studies revealed only nonvirulent aerobic and anaerobic organisms—such as Streptococcus veridans, coagulase-negative Staphylococcus aureus, and group B streptococci—in sinus tissue from sinusitis patients. “That is a sign of colonization, not infection,” said Dr. Borish.

Other evidence of noninfectious sinus colonization in these studies included the presence of different organisms in each sinus and the absence of neutrophils in sinus tissue. Neutrophilia is always the exudative response to bacterial infection, he explained.

A few patients, such as those with certain immunologic deficiencies, may have an infection underlying chronic sinusitis, but these patients are the exception, not the rule.

Patients with chronic sinusitis frequently develop acute sinusitis. Chronic sinusitis may not be infectious, but patients with the disease clearly are at increased risk for acute sinus infections. The responsible organisms include all of the usual suspects, such as Hemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis.

Chronic sinusitis is asthma of the upper airway. If chronic sinusitis is not infectious, how should it be defined? As a chronic hyperplastic disease akin to asthma of the upper airway, suggested Dr. Borish, because it involves unregulated eosinophil, fibroblast, goblet cell, and mast cell proliferation in sinus tissue. “If I put in a few alveoli, is there anybody who would not think that that was the asthmatic lung—complete with remodeling?” he asked.

Chronic sinusitis may not be a surgical disease. Because chronic sinusitis so closely resembles asthma, it is as likely as asthma to respond to surgery. Indeed, nasal polyps and hyperplastic tissue have been shown to redevelop one to two years after surgical debulking in most chronic sinusitis patients treated surgically. Corticosteroids, aspirin desensitization, and leukotriene modifiers (particularly zileuton) are among the most effective treatments for chronic sinusitis, said Dr. Borish.

ALLERGIC FUNGAL SINUSITIS

Dr. deShazo, Director of the Division of Allergy/Immunology at the University of Mississippi Medical Center in Jackson, discussed many of the uncertainties regarding the management of AFS. The pathogenesis of AFS in unknown, but there is suspicion that it may be related to the chronic treatment of hyperplastic sinusitis with broad-spectrum antibiotics. Because there is so little evidence about the treatment of this disorder, the standardized approach that he and his colleagues have developed is “based on art, not science,” he acknowledged. Nonetheless, their methods have reduced the rate of recurrent disease requiring further surgery from 100% to about 20% among the 40 AFS patients that they have treated thus far.

The group establishes a diagnosis using clinical, laboratory, and skin test findings. “Patients with allergic fungal sinusitis are almost always atopic, with pansinusitis and positive skin tests to one or more fungi,” said Dr. deShazo.

Also, these patients’ sinuses typically produce an allergic mucin with sparse hyphae that does not invade the sinus mucosa. An eosinophil-containing lymphoplasmocytic infiltrate is usually present in their sinuses as well.

“Nasal cultures for the diagnosis of syndromes of fungal sinusitis are not useful, as fungi may be routinely cultured from the noses of healthy individuals,” Dr. deShazo pointed out. Patients with AFS and asthma should be assumed to have bronchopulmonary mycosis until proven otherwise, he noted.

Dr. deShazo’s group manages AFS in consultation with an otolaryngologist. The first step is surgery to ensure that all fungal material and polyps are removed and that the osteomeatal complex is open and functional. Postoperatively, patients receive oral corticosteroids for two weeks and then are given intranasal corticosteroids for long-term administration. They are also given leukotriene modifiers and immunotherapy for any fungi to which they are allergic. Daily saline lavage is necessary to remove mucoid material from the sinuses.

During the first postoperative year, the patients regularly undergo rhinoscopy to ensure that their airway is open and that polyps and other AFS-related abnormalities have not recurred. Usually, they do not. “However, controversy on the treatment [of AFS] will continue until the pathogenesis of this disease is understood and the treatment options are critically studied,” Dr. deShazo concluded.

SINUS HEADACHE OR MIGRAINE?

The next time a patient complains of sinus headache, consider the possibility that it might actually be a migraine, suggested Dr. Tepper, a neurologist and Director of the New England Center for Headache in Stamford, Connecticut. “At least 90% of patients who present with a sinus headache complaint … meet criteria for migraine-type diagnoses,” he reported.

Migraine is often mistaken for sinusitis-related headache because nearly half of migraines involve autonomic features usually attributed to sinusitis, such as a sinus pain or pressure, runny or stuffy nose, watery eyes, and postnasal drip. The brain does not recognize or localize migraine pain very well and often refers such pain to the neck, face, or head, Dr. Tepper explained.

In reality, headache is infrequently associated with active sinusitis, and sinus headache is not recognized as a disorder by the American Academy of Otolaryngology or other relevant American and European medical societies. Yet, patients complaining of sinus headache are often given prescriptions for antihistamines, corticosteroids, decongestants, or worse, antibiotics. “Antibiotic prescriptions for self-diagnosed sinus headache really constitute a major problem,” Dr. Tepper said. A trial of an antimigraine medication may help establish the correct diagnosis.

—Timothy Begany