Population Covered By The Guidance
This pathway provides guidance on the imaging of patients with chronic sinusitis.
Lead Researcher: Sian Chin
Experts & Contributors: Ravinder Dhillon, Peter Friedland, Andrew Thompson
Editorial Panel: Editorial Panel
Link to Editorial Panel
Date reviewed: July 2018
Date Published: March 2019
Chronic Sinusitis
Chronic Sinusitis
Chronic Sinusitis
- Chronic rhinosinusitis is a clinical diagnosis and is defined as rhinosinusitis lasting >12 weeks that includes two or more of the following signs and symptoms:
- Mucopurulent drainage (anterior, posterior, or both)
- Nasal obstruction (congestion)
- Facial pain-pressure-fullness, or
- Decreased sense of smell
- Plain radiography has limited value for imaging the paranasal sinuses and routine use is not indicated
- CT without IV contrast is the imaging modality of choice
- Significant unilateral disease is suspicious for neoplasm or inverted papilloma and warrants further evaluation
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Kirsch CFE, Bykowski J, Aulino JM, Berger KL, Choudhri AF, Conley DB, et al. ACR appropriateness criteria((R)) sinonasal disease. J Am Coll Radiol. 2017;14(11s):S550-s9. (Guidelines). View the reference
- Setzen G, Ferguson BJ, Han JK, Rhee JS, Cornelius RS, Froum SJ, et al. Clinical consensus statement: appropriate use of computed tomography for paranasal sinus disease. Otolaryngol Head Neck Surg. 2012;147(5):808-16. (Guidelines). View the reference
- Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Ashok Kumar K, Kramper M, et al. Clinical practice guideline (update): adult sinusitis. Otolaryngol Head Neck Surg. 2015;152(2 Suppl):S1-s39. (Guideline). View the reference
- Kandukuri R, Phatak S. Evaluation of sinonasal diseases by computed tomography. Journal of Clinical and Diagnostic Research : JCDR. 2016;10(11):TC09-TC12. (Level II-III evidence). View the reference
- Holbrook EH, Brown CL, Lyden ER, Leopold DA. Lack of significant correlation between rhinosinusitis symptoms and specific regions of sinus computer tomography scans. Am J Rhinol. 2005;19(4):382-7. (Level II evidence). View the reference
- Falco JJ, Thomas AJ, Quin X, Ashby S, Mace JC, Deconde AS, et al. Lack of correlation between patient reported location and severity of facial pain and radiographic burden of disease in chronic rhinosinusitis. International forum of allergy & rhinology. 2016;6(11):1173-81. (Level II-III evidence). View the reference <
- Yeo NK, Park WJ, Ryu IS, Lim HW, Song YJ. Is facial or head pain related to the location of lesions on computed tomography in chronic rhinosinusitis?. Ann Otol Rhinol Laryngol. 2017;126(8):589-96. (Level II-III evidence). View the reference
- Greguric T, Trkulja V, Baudoin T, Grgic MV, Smigovec I, Kalogjera L. Association between computed tomography findings and clinical symptoms in chronic rhinosinusitis with and without nasal polyps. Eur Arch Otorhinolaryngol. 2017;274(5):2165-73. (Level II evidence). View the reference
- Stewart MG, Sicard MW, Piccirillo JF, Diaz-Marchan PJ. Severity staging in chronic sinusitis: are CT scan findings related to patient symptoms? Am J Rhinol. 1999;13(3):161-7. (Level II-III evidence). View the reference
- Lund VJ, Mackay IS. Staging in rhinosinusitus. Rhinology. 1993;31(4):183-4. (Level II-III evidence). View the reference
- Hopkins C, Browne JP, Slack R, Lund V, Brown P. The Lund-Mackay staging system for chronic rhinosinusitis: how is it used and what does it predict? Otolaryngol Head Neck Surg. 2007;137(4):555-61. (Level II evidence). View the reference
- Aribandi M, McCoy VA, Bazan C. Imaging features of invasive and noninvasive fungal sinusitis: a review. Radiographics. 2007;27(5):1283-96. (Review article). View the reference
- Joshi VM, Sansi R. Imaging in sinonasal inflammatory disease. Neuroimaging Clin N Am. 2015;25(4):549-68. (Review article). View the reference
Pathway User Guide
Yellow Boxes Denotes extra information. Some contain single or multiple white sub-boxes, click a white box to reveal detailed information in a pop-up.
White Boxes: Denotes standard pathway steps. (If inside a yellow box, they open a specific pop-up).
Zoom & Pan Controls: Use + / − or the slider to zoom. Reset returns to default. Tick Panning to drag the diagram when zoomed.
Blue “View Full Screen” Button: Opens the whole diagram in a large, full-screen pop-up window. Use Close to exit.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
|---|---|---|
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Disclaimer
Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.
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Computed Tomography (CT)
Coronal non-contrast CT scan
Imaging modality of choice to objectively confirm the clinical diagnosis of chronic rhinosinusitis
- CT without contrast is the imaging modality of choice for evaluating chronic rhinosinusitis
- Role of CT:
- Objective confirmation of the clinical diagnosis; anterior rhinoscopy or nasal endoscopy may also be used
- Surgical planning
- Screen for other causes for symptoms such as neoplasm or atypical infections
- Assess for complications
- CT has a high false positive rate and up to 40% of asymptomatic adults will demonstrate abnormalities on sinus CT and imaging findings correlate poorly with symptom location and severity, so the diagnosis of chronic rhinosinusitis requires clinical criteria as well as objective evidence
- The Lund-Mackay score is a simple tool to assess the extent of disease in chronic rhinosinusitis based on sinus opacification. It has been proposed that patients undergoing endoscopic sinus surgery should have a minimum score of 4. There is usually involvement of multiple sinuses, if not pansinusitis and rhinitis
- Other findings in chronic rhinosinusitis are diverse which include mucosal thickening, sclerosis of bony walls and intrasinus calcifications
- Magnetic resonance imaging may be useful in the specialist evaluation of complicated sinusitis, intraorbital and intracranial manifestations of aggressive sinusitis, and sinonasal neoplasms