Schematic diagram of motion of a single cilium during the rapid forward

Schematic diagram of motion of a single cilium during the rapid forward

beat

beat

and the slower recovery phase.

and the slower recovery phase.

Schematic diagram of motion of a single cilium during the rapid forward

Schematic diagram of motion of a single cilium during the rapid forward

beat

beat

and the slower recovery phase.

and the slower recovery phase.

Change in host

Change in host

milieu creates

milieu creates

culture

culture

medium for

medium for

bacterial

bacterial

growth in closed

growth in closed

cavity

cavity

Change in host

Change in host

milieu creates

milieu creates

culture

culture

medium for

medium for

bacterial

bacterial

growth in closed

growth in closed

cavity

cavity

Mucosal congestion or anatomic

Mucosal congestion or anatomic

obstruction blocs airflow and drainage

obstruction blocs airflow and drainage

OSTIUM IS CLOSED

OSTIUM IS CLOSED

Mucosal congestion or anatomic

Mucosal congestion or anatomic

obstruction blocs airflow and drainage

obstruction blocs airflow and drainage

OSTIUM IS CLOSED

OSTIUM IS CLOSED

Secretions

Secretions

stagnate

stagnate

Secretions

Secretions

stagnate

stagnate

Mucosal thickening creates

Mucosal thickening creates

further blockage

further blockage

Mucosal thickening creates

Mucosal thickening creates

further blockage

further blockage

Cycle of events that leads to chronic rhinosinusitis

Cycle of events that leads to chronic rhinosinusitis

begins with ostial blockage

begins with ostial blockage

Cycle of events that leads to chronic rhinosinusitis

Cycle of events that leads to chronic rhinosinusitis

begins with ostial blockage

begins with ostial blockage

Secretions thicken;

Secretions thicken;

pH changes

pH changes

Secretions thicken;

Secretions thicken;

pH changes

pH changes

Mucosal gas

Mucosal gas

metabolism changes

metabolism changes

Mucosal gas

Mucosal gas

metabolism changes

metabolism changes

Cilia and epithelium

Cilia and epithelium

are damaged

are damaged

Cilia and epithelium

Cilia and epithelium

are damaged

are damaged

Bacterial infection develops in

Bacterial infection develops in

the sinus cavity

the sinus cavity

Bacterial infection develops in

Bacterial infection develops in

the sinus cavity

the sinus cavity

Retained secretions

Retained secretions

cause tissue

cause tissue

inflammation

inflammation

Retained secretions

Retained secretions

cause tissue

cause tissue

inflammation

inflammation

The expression

The expression

sinusitis

sinusitis

describes an

describes an

inflammatory process present in the paranasal

inflammatory process present in the paranasal

sinuses mucous membrane, due to disturbances

sinuses mucous membrane, due to disturbances

of drainage and ventilation, as a result of

of drainage and ventilation, as a result of

infection, allergy or anatomical variations of the

infection, allergy or anatomical variations of the

lateral nasal wall. This term refers to

lateral nasal wall. This term refers to

pathological changes present both in one sinus

pathological changes present both in one sinus

e. g.

e. g.

maxillary sinusitis

maxillary sinusitis

and also in several

and also in several

paranasal sinuses

paranasal sinuses

(hemipansinusitis,

(hemipansinusitis,

pansinusitis)

pansinusitis)

.

.

The expression

The expression

sinusitis

sinusitis

describes an

describes an

inflammatory process present in the paranasal

inflammatory process present in the paranasal

sinuses mucous membrane, due to disturbances

sinuses mucous membrane, due to disturbances

of drainage and ventilation, as a result of

of drainage and ventilation, as a result of

infection, allergy or anatomical variations of the

infection, allergy or anatomical variations of the

lateral nasal wall. This term refers to

lateral nasal wall. This term refers to

pathological changes present both in one sinus

pathological changes present both in one sinus

e. g.

e. g.

maxillary sinusitis

maxillary sinusitis

and also in several

and also in several

paranasal sinuses

paranasal sinuses

(hemipansinusitis,

(hemipansinusitis,

pansinusitis)

pansinusitis)

.

.

For practical reasons in the daily clinical work both

For practical reasons in the daily clinical work both

terms -

terms -

sinusitis

sinusitis

and

and

rhinosinusitis

rhinosinusitis

are equivalent.

are equivalent.

For practical reasons in the daily clinical work both

For practical reasons in the daily clinical work both

terms -

terms -

sinusitis

sinusitis

and

and

rhinosinusitis

rhinosinusitis

are equivalent.

are equivalent.

Two classifications of chronic rhinosinusitis are currently proposed

Two classifications of chronic rhinosinusitis are currently proposed

in rhinological literature. The classification introduced by Kern in

in rhinological literature. The classification introduced by Kern in

1984 is based on the duration of the disease process and

1984 is based on the duration of the disease process and

corresponding morphological changes in the mucosa of the

corresponding morphological changes in the mucosa of the

sinuses:

sinuses:



Acute purulent rhinosinusitis

Acute purulent rhinosinusitis

- lasting up to 3 weeks, with one or

- lasting up to 3 weeks, with one or

several sinuses involved.

several sinuses involved.



Subacute purulent rhinosinusitis

Subacute 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 within

Morphological changes in the mucosa which occur within

that time are usually reversible.

that time are usually reversible.



Chronic purulent rhinosinusitis

Chronic purulent rhinosinusitis

- lasting over 3 months. This form

- lasting over 3 months. This form

of

of

the disease process is thought to be a result of untreated or

the disease process is thought to be a result of untreated or

improperly treated acute inflammation. Surgery to remove

improperly treated acute inflammation. Surgery to remove

irreversibly changed mucosa is recommended.

irreversibly changed mucosa is recommended.

Two classifications of chronic rhinosinusitis are currently proposed

Two classifications of chronic rhinosinusitis are currently proposed

in rhinological literature. The classification introduced by Kern in

in rhinological literature. The classification introduced by Kern in

1984 is based on the duration of the disease process and

1984 is based on the duration of the disease process and

corresponding morphological changes in the mucosa of the

corresponding morphological changes in the mucosa of the

sinuses:

sinuses:



Acute purulent rhinosinusitis

Acute purulent rhinosinusitis

- lasting up to 3 weeks, with one or

- lasting up to 3 weeks, with one or

several sinuses involved.

several sinuses involved.



Subacute purulent rhinosinusitis

Subacute 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 within

Morphological changes in the mucosa which occur within

that time are usually reversible.

that time are usually reversible.



Chronic purulent rhinosinusitis

Chronic purulent rhinosinusitis

- lasting over 3 months. This form

- lasting over 3 months. This form

of

of

the disease process is thought to be a result of untreated or

the disease process is thought to be a result of untreated or

improperly treated acute inflammation. Surgery to remove

improperly treated acute inflammation. Surgery to remove

irreversibly changed mucosa is recommended.

irreversibly changed mucosa is recommended.

The 1995 International Conference on Sinus Disease classification

The 1995 International Conference on Sinus Disease classification

of rhinosinusitis is based on an assessment of the extent of

of rhinosinusitis is based on an assessment of the extent of

pathophysiological processes involving the mucosa of the

pathophysiological processes involving the mucosa of the

sinuses and the nasal cavity:

sinuses and the nasal cavity:



Acute rhinosinusitis is defined as an episodic inflammatory

Acute rhinosinusitis is defined as an episodic inflammatory

process which does not leave any significant persistent damage

process which does not leave any significant persistent damage

of

of

the mucosa after conservative treatment.

the mucosa after conservative treatment.



Acute recurrent rhinosinusitis refers to repeated episodes of

Acute recurrent rhinosinusitis refers to repeated episodes of

acute

acute

inflammation with complete recovery after conservative

inflammation with complete recovery after conservative

treatment, causing no persistent damage of the mucosa.

treatment, causing no persistent damage of the mucosa.



Chronic rhinosinusitis is defined as persistent inflammation which

Chronic rhinosinusitis is defined as persistent inflammation which

cannot be cured with conservative treatment.

cannot be cured with conservative treatment.

The 1995 International Conference on Sinus Disease classification

The 1995 International Conference on Sinus Disease classification

of rhinosinusitis is based on an assessment of the extent of

of rhinosinusitis is based on an assessment of the extent of

pathophysiological processes involving the mucosa of the

pathophysiological processes involving the mucosa of the

sinuses and the nasal cavity:

sinuses and the nasal cavity:



Acute rhinosinusitis is defined as an episodic inflammatory

Acute rhinosinusitis is defined as an episodic inflammatory

process which does not leave any significant persistent damage

process which does not leave any significant persistent damage

of

of

the mucosa after conservative treatment.

the mucosa after conservative treatment.



Acute recurrent rhinosinusitis refers to repeated episodes of

Acute recurrent rhinosinusitis refers to repeated episodes of

acute

acute

inflammation with complete recovery after conservative

inflammation with complete recovery after conservative

treatment, causing no persistent damage of the mucosa.

treatment, causing no persistent damage of the mucosa.



Chronic rhinosinusitis is defined as persistent inflammation which

Chronic rhinosinusitis is defined as persistent inflammation which

cannot be cured with conservative treatment.

cannot be cured with conservative treatment.

The patient may complain

The patient may complain

of:

of:

The patient may complain

The patient may complain

of:

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

pain or pressure in the orbital region, pain

or

or

pressure in the region of the sinus

pressure in the region of the sinus

affected by

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

pain or pressure in the orbital region, pain

or

or

pressure in the region of the sinus

pressure in the region of the sinus

affected by

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

oedema of the skin in the region of the root of the nose and

in

in

the region of the palpebras;

the region of the palpebras;



mucous, mucopurulent or purulent secretion in the nasal

mucous, mucopurulent or purulent secretion in the nasal

cavities;

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

painfulness of the cheek when exerting pressure on the

canine

canine

fossa (in the maxillary sinusitis) and when exerting

fossa (in the maxillary sinusitis) and when exerting

pressure on

pressure on

the upper wall of the orbit (in the frontal

the upper wall of the orbit (in the frontal

sinusitis).

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

oedema of the skin in the region of the root of the nose and

in

in

the region of the palpebras;

the region of the palpebras;



mucous, mucopurulent or purulent secretion in the nasal

mucous, mucopurulent or purulent secretion in the nasal

cavities;

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

painfulness of the cheek when exerting pressure on the

canine

canine

fossa (in the maxillary sinusitis) and when exerting

fossa (in the maxillary sinusitis) and when exerting

pressure on

pressure on

the upper wall of the orbit (in the frontal

the upper wall of the orbit (in the frontal

sinusitis).

sinusitis).

Factors predisposing recurrences of acute

Factors predisposing recurrences of acute

rhinosinusitis

rhinosinusitis





Factors predisposing recurrences of acute

Factors predisposing recurrences of acute

rhinosinusitis

rhinosinusitis





Anatomic:

Anatomic:



deviation of the nasal septum;

deviation of the nasal septum;



anatomical variations of the nasal lateral

anatomical variations of the nasal lateral

wall:

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

anatomical variations of the nasal lateral

wall:

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

Factors predisposing recurrences of acute

rhinosinusitis

rhinosinusitis





Factors predisposing recurrences of acute

Factors predisposing recurrences of acute

rhinosinusitis

rhinosinusitis





The most often used antibiotics in the therapy of

The most often used antibiotics in the therapy of

rhinosiusitis

rhinosiusitis

The most often used antibiotics in the therapy of

The most often used antibiotics in the therapy of

rhinosiusitis

rhinosiusitis

Supplementary

Supplementary

treatment

treatment

Supplementary

Supplementary

treatment

treatment

1.

1.

Decongestants

Decongestants

should ensure restoration of the patency of

should ensure restoration of the patency of

the

the

ostio-meatal complex and thereby the sinuses ostia.

ostio-meatal complex and thereby the sinuses ostia.

2.

2.

Mucolytic drugs

Mucolytic drugs

act on the retained in the sinuses secretion

act on the retained in the sinuses secretion

in such

in such

a way that it becomes more liquid thus easier to

a way that it becomes more liquid thus easier to

move.

move.

3.

3.

Corticosteroids are recommended

Corticosteroids are recommended

first of all in the therapy

first of all in the therapy

of

of

chronic inflammation.

chronic inflammation.

4.

4.

Recommendation for the administration of

Recommendation for the administration of

antihistamines

antihistamines

requires

requires

comprehensive reasoning, because allergy plays a

comprehensive reasoning, because allergy plays a

far smaller role

far smaller role

in the pathogenesis of rhinosinusitis than it

in the pathogenesis of rhinosinusitis than it

is assumed.

is assumed.

1.

1.

Decongestants

Decongestants

should ensure restoration of the patency of

should ensure restoration of the patency of

the

the

ostio-meatal complex and thereby the sinuses ostia.

ostio-meatal complex and thereby the sinuses ostia.

2.

2.

Mucolytic drugs

Mucolytic drugs

act on the retained in the sinuses secretion

act on the retained in the sinuses secretion

in such

in such

a way that it becomes more liquid thus easier to

a way that it becomes more liquid thus easier to

move.

move.

3.

3.

Corticosteroids are recommended

Corticosteroids are recommended

first of all in the therapy

first of all in the therapy

of

of

chronic inflammation.

chronic inflammation.

4.

4.

Recommendation for the administration of

Recommendation for the administration of

antihistamines

antihistamines

requires

requires

comprehensive reasoning, because allergy plays a

comprehensive reasoning, because allergy plays a

far smaller role

far smaller role

in the pathogenesis of rhinosinusitis than it

in the pathogenesis of rhinosinusitis than it

is assumed.

is assumed.

Criteria for chronic rhinosinusitis

Criteria for chronic rhinosinusitis





Criteria for chronic rhinosinusitis

Criteria for chronic rhinosinusitis





In adults

In adults

8 weeks of persistent symptoms and sings

8 weeks of persistent symptoms and sings

or

or

Four episodes per year of recurrent acute sinusitis,

Four episodes per year of recurrent acute sinusitis,

each

each

lasting at least 10 days

lasting at least 10 days

in association with

in association with

Persistent changes on computer tomography 4

Persistent changes on computer tomography 4

weeks

weeks

after medical therapy without intervening acute

after medical therapy without intervening acute

infection

infection

In adults

In adults

8 weeks of persistent symptoms and sings

8 weeks of persistent symptoms and sings

or

or

Four episodes per year of recurrent acute sinusitis,

Four episodes per year of recurrent acute sinusitis,

each

each

lasting at least 10 days

lasting at least 10 days

in association with

in association with

Persistent changes on computer tomography 4

Persistent changes on computer tomography 4

weeks

weeks

after medical therapy without intervening acute

after medical therapy without intervening acute

infection

infection

Criteria for chronic rhinosinusitis

Criteria for chronic rhinosinusitis





Criteria for chronic rhinosinusitis

Criteria for chronic rhinosinusitis





In children

In children

12 weeks of persistent symptoms and sings

12 weeks of persistent symptoms and sings

or:

or:

Six episodes per year of recurrent acute sinusitis,

Six episodes per year of recurrent acute sinusitis,

each

each

lasting at least 10 days

lasting at least 10 days

in association with

in association with

Persistent changes on computer tomography 4

Persistent changes on computer tomography 4

weeks

weeks

after medical therapy without intervening acute

after medical therapy without intervening acute

infection

infection

In children

In children

12 weeks of persistent symptoms and sings

12 weeks of persistent symptoms and sings

or:

or:

Six episodes per year of recurrent acute sinusitis,

Six episodes per year of recurrent acute sinusitis,

each

each

lasting at least 10 days

lasting at least 10 days

in association with

in association with

Persistent changes on computer tomography 4

Persistent changes on computer tomography 4

weeks

weeks

after medical therapy without intervening acute

after medical therapy without intervening acute

infection

infection

Criteria for chronic rhinosinusitis

Criteria for chronic rhinosinusitis





Criteria for chronic rhinosinusitis

Criteria for chronic rhinosinusitis





Symptoms and sings

Symptoms and sings

Adults and children

Adults and children

Major

Major

Nasal congestion

Nasal congestion

Nasal discharge

Nasal discharge

Headache

Headache

Facial pain or pressure

Facial pain or pressure

Olfactory disturbance

Olfactory disturbance

Minor

Minor

Fever

Fever

Halitiosis

Halitiosis

Children only

Children only

Cough

Cough

Irritability

Irritability

Symptoms and sings

Symptoms and sings

Adults and children

Adults and children

Major

Major

Nasal congestion

Nasal congestion

Nasal discharge

Nasal discharge

Headache

Headache

Facial pain or pressure

Facial pain or pressure

Olfactory disturbance

Olfactory disturbance

Minor

Minor

Fever

Fever

Halitiosis

Halitiosis

Children only

Children only

Cough

Cough

Irritability

Irritability

The most often isolated microorganisms in

The most often isolated microorganisms in

rhinosiusitis

rhinosiusitis

Streptococcus pneumoniae

Streptococcus pneumoniae

Haemophilus influenzae

Haemophilus influenzae

Streptococcus pyogenes

Streptococcus pyogenes

Staphylococcus aureus

Staphylococcus aureus

Anaerobes:

Anaerobes:

Bacteroides

Bacteroides

Fusobacterium

Fusobacterium

Peptostreptococcus

Peptostreptococcus

Alpha- and beta-haemolytic

Alpha- and beta-haemolytic

streptococci

streptococci

Other Gram-negative bacterias

Other Gram-negative bacterias

Streptococcus pneumoniae

Streptococcus pneumoniae

Haemophilus influenzae

Haemophilus influenzae

Streptococcus pyogenes

Streptococcus pyogenes

Staphylococcus aureus

Staphylococcus aureus

Anaerobes:

Anaerobes:

Bacteroides

Bacteroides

Fusobacterium

Fusobacterium

Peptostreptococcus

Peptostreptococcus

Alpha- and beta-haemolytic

Alpha- and beta-haemolytic

streptococci

streptococci

Other Gram-negative bacterias

Other Gram-negative bacterias

Surgical indications

Surgical indications

Surgical indications

Surgical indications