The Egyptian Journal of Hospital Medicine (July 2017) Vol.

68 (3), Page 1513-1519

Acute and Chronic Sinusitis Causes and Management

Abdulrahman Faleh N Almutairi1, Rahaf Wajih Shafi2, Shahad Ahmed Albalawi3,
Mohammed Adel Basyuni4, Abdulaziz A. Alzahrnai4, Abdulaziz Abdulilah Alhaifi4,
Adel Ahmed Alshehri4, Muath Ahmad Al-Gadouri4, Ayman Saeed Alghamdi4
1 Medical University of Warsaw, 2 King Abulaziz University Hospital, 3 Tabuk University,
4 Umm Alqura University.
Corresponding author: Dr. Abdulrahman Faleh N Almutairi, Abdulrahmanalmutairi90@gmail.com

ABSTRACT
Sinusitis is categorized by inflammation of the lining of the paranasal sinuses. As the nasal mucosa is
instantaneously involved and as sinusitis infrequently occurs without concurrent rhinitis, rhinosinusitis is
currently the preferred term for this condition. Acute sinusitis is a clinical diagnosis; thus, an understanding
of its presentation is of paramount importance in differentiating this entity from allergic or vasomotor rhinitis
and common upper respiratory infections. No precise clinical sign or symptom is sensitive or specific for
acute sinusitis, so the overall clinical impression should be used to guide management. Chronic sinusitis is an
inflammatory procedure that includes the paranasal sinuses and persists for 12 weeks or longer. The
literature has reinforced that chronic sinusitis is nearly always accompanied by concurrent nasal airway
inflammation and is frequently preceded by rhinitis symptoms; hence, the term chronic rhinosinusitis (CRS)
has evolved to more accurately define this condition. Treatment of sinusitis, whether medical or surgical, is
intended at decreasing inflammation and obstruction in the sinonasal passages. Antibiotics, even though
frequently used in sinusitis, ought to not be managed unless there is suspicion of an acute bacterial infection.
Keywords: Chronic, Rhinosinusitis, Antimicrobial Treatment, Sinus.

INTRODUCTION Chronic sinusitis is one of the more pervasive

Sinusitis is categorized by inflammation of the
lining of the paranasal sinuses. Since the nasal
mucosa is instantaneously included and as sinusitis
infrequently occurs without concurrent rhinitis,
rhinosinusitis is currently the preferred term for this
condition [1, 2]. Numerous classifications, both
clinical and radiological, have been proposed in the
literature to define acute sinusitis. Even though no
consensus on the precise definition presently exists
subacute sinusitis represents a temporal progression
of symptoms for 4-12 weeks. Frequent acute
sinusitis is diagnosed when 2-4 episodes of
infection happen per year with no less than 8 weeks
between episodes and, as in acute sinusitis, the
sinus mucosa completely normalizes between
attacks. Chronic sinusitis is the perseverance of
deceptive symptomatology beyond 12 weeks, with
or without acute intensifications [3]. Acute sinusitis
is a clinical finding; along these lines, a
comprehension of its presentation is of vital
significance in separating this substance from
allergic or vasomotor rhinitis and common upper
respiratory contaminations. No particular clinical
indication or sign is sensitive or particular for acute
sinusitis, so the general clinical impression ought to
be utilized to guide management. To accurately
diagnose and treat contagious disorders of the
paranasal sinuses, the clinician must have
awareness of the developmental milestones. The
improvement of the paranasal sinuses arises in the
third week of gestation and remains until early
adulthood.
chronic ailments in the United States, influencing
people of all age groups. It is an inflammatory
procedure that includes the paranasal sinuses and
perseveres for 12 weeks or more. The literature has
reinforced that chronic sinusitis is quite often joined
by simultaneous nasal airway inflammation and is
frequently preceded by rhinitis symptoms; as a
result, the term chronic rhinosinusitis (CRS) has
developed to all the more precisely depict this
condition. CRS may manifest as one of the three
major clinical syndromes: CRS without nasal
polyps, CRS with nasal polyps, or allergic fungal
rhinosinusitis. These orders have a lot of remedial
importance. Most cases of chronic sinusitis are
extensions of unresolved acute sinusitis;
nevertheless, chronic sinusitis typically
demonstrates inversely from acute sinusitis.
Symptoms of chronic sinusitis include nasal
stuffiness, postnasal drip, facial fullness, and
malaise. Chronic sinusitis can be non-infectious and
associated to allergy, cystic fibrosis,
gastroesophageal reflux, or exposure to
environmental pollutants [4, 5]. Allergic rhinitis,
nonallergic rhinitis, anatomic obstruction in the
ostiomeatal complex, and immunologic ailments
are identified hazard factors for chronic sinusitis.
Medical treatment is focused toward controlling
predisposing factors, treating concomitant
infections, decreasing edema of sinus tissues, and
easing the drainage of sinus secretions. The
objective in surgical treatment is to re-establish
sinus ventilation and to redress mucosal restriction

1513
Received:2 / 6 /2017 DOI: 10.12816/0039697
Accepted: 11 / 6 /2017
 Acute and Chronic Sinusitis Causes and Management

keeping in mind the end goal to re-establish the Signs and symptoms
mucociliary clearance system. Surgery strives to re- A consensus statement published in 2007 in
establish the functional integrity of the aggravated Otolaryngology-Head and Neck Surgery made solid
mucosal lining. proposals that clinicians ought to differentiate
In 1996, the American Academy of between acute rhinosinusitis produced by bacterial
Otolaryngology-Head & Neck Surgery causes and those occurrences produced by viral
multidisciplinary Rhinosinusitis Task Force (RTF) upper respiratory infections and non-infectious
characterized adult rhinosinusitis diagnostic criteria conditions [10]. The panel proposes that the
[6]
. Main considerations included facial pain or diagnosis of acute bacterial sinusitis be engaged
pressure, nasal obstruction or blockage, nasal when
discharge or purulence or discoloured postnasal  Symptoms or signs of acute rhinosinusitis are
release, hyposmia or anosmia, purulence in nasal present 10 days or more past the beginning of upper
cavity, and fever. In 2003, the RTF’s definition was respiratory symptoms.
revised to require corroborative radiographic or  Symptoms or signs of acute rhinosinusitis intensify
nasal endoscopic or physical examination inside 10 days after an underlying change.
discoveries notwithstanding suggestive history [3, 7]. A background marked by purulent discharges and
The study was done after approval of ethical facial or dental agony are particular side effects that
board of King Abdulaziz university. may point to a bacterial etiology. In a patient in
serious care, acute sinusitis ought to be associated
Causes of sinusitis in the nearness with sepsis of obscure beginning.
Sinusitis is for the most part activated by a viral The 2007 rules [10] were updated in 2015 [11] in view
upper respiratory tract contamination, with just 2% of confirmation from 42 new efficient surveys.
of cases being confounded by bacterial sinusitis.2 They incorporated another calculation to elucidate
About 90% of the patients in the United States are activity explanation connections and extended open
assessed to get an anti-infection from their general doors for careful holding up (without antibiotic
professional, yet much of the time the condition treatment) as starting treatment for intense bacterial
settle without anti-infection agents, regardless of rhinosinusitis. They emphatically prescribed those
the possibility that it is bacterial in origin.3 Most clinicians
broad experts depend on clinical discoveries to  Distinguish presumed acute bacterial rhinosinusitis
make the conclusion. Signs and indications of acute from acute sinusitis caused by viral upper
bacterial sinusitis and those of a delayed viral upper respiratory infections and noninfectious conditions.
respiratory tract disease are firmly comparative,  Confirm a clinical diagnosis of chronic sinusitis
bringing about regular misclassification of viral with objective documentation of sinonasal
cases as bacterial sinusitis. List of frequent and inflammation, which may be accomplished using
infrequent causes for sinusitis (table 1). anterior rhinoscopy, nasal endoscopy, or computed
Table 1. List common and rarer reasons for tomography.
sinusitis Although diagnostic criteria for acute rhinosinusitis
Frequent causes Infrequent causes have been suggested [2], no single sign or symptom
• Viral infection • Cystic fibrosis has tough diagnostic value for bacterial
• Allergic and non- • Neoplasia rhinosinusitis [12]. On the other hand, acute bacterial
allergic rhinitis • Mechanical ventilation rhinosinusitis ought to be associated in patients who
• Anatomical • Use of nasal tubes, show manifestations with viral upper respiratory
variations such as nasogastric tract disease that don't improve following 10 days
Abnormality of the feeding tubes or that exacerbate following 5-7 days.
osteomeatal complex • Samter's triad (aspirin Chronic sinusitis shows more imperceptibly than
Septal deviation sensitivity, rhinitis, acute sinusitis. Be that as it may, it might begin
Concha bullosa asthma) abruptly, as an upper respiratory tract infection or
Hypertrophic middle • Sarcoidosis acute sinusitis that does not resolve, or emerge
turbinates • Wegener's slowly and insidiously over months or years. Every
Cigarette smoking granulomatosis so often, the underlying symptoms might be acute
Diabetes mellitus • Immune deficiency in nature. Unless a suitable history is taken, the
Swimming, diving, • Sinus surgery diagnosis might be missed. The typical symptoms
high altitude climbing • Immotile cilia of acute sinusitis—fever and facial pain—is
Dental infections and syndrome regularly missing in chronic sinusitis. Fever, when
procedures exist, might be low grade.

1514
 Abdulrahman Almutairi et al.

Acute sinusitis symptoms Chronic sinusitis symptoms

Fever Nasal obstruction, blockage, congestion, stuffiness
Cough Sneezing
Hyposmia/anosmia Nasal discharge (of any character from thin to thick and from
Nasal congestion clear to purulent)
Nasal drainage Postnasal drip
Fatigue Chronic unproductive cough (primarily in children)
Maxillary dental pain Sore throat
Postnasal drip Stuffy ears
Facial pain or pressure (especially Fetid breath
unilateral) Malaise
Ear fullness/pressure Easy fatigability
Anorexia
Exacerbation of asthma
Dental pain (upper teeth)
Visual disturbances
Unpleasant taste
Fever of unknown origin
Hyposmia or anosmia (more with nasal polyposis)
Facial fullness, discomfort, pain, and headache (more with
nasal polyposis)

Treatment of sinusitis in an outpatient setting. For safe cases, there might

Antimicrobial Treatment
Antimicrobial treatment is the backbone of medical
treatment in sinusitis. Choice of antibiotic depends
on whether the sinusitis is acute, chronic, or
recurrent. The AAAAI 2005 practice parameter
states that choice of antibiotic ought to be based on
anticipated effectiveness, cost, and side effects [4].
Antibiotics are shown for sinusitis that is believed
to be bacterial, including sinusitis that is extreme or
includes the frontal, ethmoid, or sphenoid sinuses,
since this kind of sinusitis is more inclined to
confusions [13]. Penicillins, cephalosporins, and
macrolides appear to be similarly strong. A 5-to 10-
day regimen of amoxicillin 500 mg 3 times each
day is suggested as first-line treatment [14, 15]. One
examination proposes that a solitary measurement
of 2 g of broadened discharge azithromycin might
be more viable than a 10-day course of
amoxicillin/clavulanate [16]. However, azithromycin
is not likely a decent decision in sinusitis since
manifestations may enhance simply because of the
calming adequacy of the specialist and on the
grounds that it has poor viability against S
pneumoniae and H influenzae. The danger of
unfavorable impacts ought to be weighed against
the seriousness of illness and patient comorbidities
before starting antibiotic treatment.
A sufficient antibiotic trial in CRS more often than
not comprises of at least 3 a month of treatment,
ideally culture coordinated. Oral antibiotic
regimens are by and large used to treat endless
sinusitis, since this condition is principally treated
be a part for intravenous antibiotic treatment.
Restorative regimens incorporate the blend of
penicillin (eg, amoxicillin) in addition to a beta-
lactamase inhibitor (eg, clavulanic corrosive), a mix
of metronidazole in addition to a macrolide or a
moment or third-era cephalosporin, and the fresher
quinolones (eg, moxifloxacin). These specialists (or
comparable ones) are accessible in oral and
parenteral structures. Other successful
antimicrobials are accessible just in parenteral
frame (eg, cefoxitin, cefotetan). On the off chance
that high-impact gram-negative living beings (eg,
Pseudomonas aeruginosa) are included, parenteral
treatment with an aminoglycoside, a fourth-era
cephalosporin (cefepime or ceftazidime), or oral or
parenteral treatment with a fluoroquinolone (just in
postpubertal patients) is included. Parenteral
treatment with a carbapenem (ie, imipenem,
meropenem) is more costly however gives scope to
most potential pathogens, the two anaerobes and
aerobes. Specialists that give scope to MRSA ought
to be directed. A few choices incorporate antibiotic
medications, trimethoprim-sulfamethoxazole or
linezolid, which are added to different regimens
that cover anaerobes. Parenteral antimicrobials
successful against MRSA incorporate vancomycin,
linezolid, and daptomycin.
A prospective study of 125 adults with great side
effects of CRS who experienced nasal endoscopy
and sinus CT. Extreme indications happened
frequently in more youthful patients with ordinary

1515
 Acute and Chronic Sinusitis Causes and Management
CT outputs of the sinus than in those with positive
CT discoveries. Change in light of anti-microbial
was comparable for patients with positive CT
discoveries and those with ordinary CT examines.
The creators inferred that most side effects thought
to be regular for CRS turned out to be nonspecific,
and they propose that target proof of
mucopurulence surveyed by endoscopy or CT
ought to be gotten if a delayed course of anti-
infection agents is being considered [17]. Overall,
there is minimal solid confirmation that
fundamental anti-microbial treatment offers much
change in the personal satisfaction among grown-
ups with perpetual sinusitis without polyps [18]. It is
helpful to tailor treatment to the clinical sort of
CRS [19]. CRS without nasal polyps is treated with
prednisone 20-40 mg day by day decreased more
than 10 days in addition to an intranasal steroid.
Anti-microbial treatment is frequently required for
up to a month and a half or more and ought not to
be stopped until the point when the patient is
asymptomatic. Discontinuation of antimicrobial
therapy prior to complete resolution increases the
probability of relapse. Difficult-to-treat chronic
sinusitis is associated with nasal polyps, asthma,
and aspirin-exacerbated respiratory disease [20].
In summary, daily saline irrigation with topical
cortical steroid therapy is to be considered main
therapy for chronic sinusitis. In patients with nasal
polyposis, systemic corticosteroids (3 weeks),
doxycycline (3 weeks), and/or a leukotriene
antagonist ought to be considered. In patients
without nasal polyps, 3 months of a macrolide
antibiotic may be useful [21].
Symptomatic Treatment
Symptoms may be relieved with topical
decongestants, topical steroids, antibiotics, nasal
saline, topical cromolyn, or mucolytics.
Symptomatic or adjunctive therapies may include
the following:
 Humidification/vaporizer
 Balanced nutrition
 Smoking cessation
 Warm compresses
 Adequate hydration
 Nonnarcotic analgesia
Beginning oral steroid treatment took after by
topical steroid treatment was observed to be more
successful than topical steroid treatment alone in
diminishing polyp measure and enhancing olfaction
in patients with CRS in any event direct nasal
polyposis [22]. The seriousness of all indications was
diminished [23]. Steam inhalation and nasal saline
1516
irrigation can support by moistening dry secretions,
decreasing mucosal edema, and decreasing mucous
viscosity. A modern review concluded that low-
volume (5 mL) nebulized saline spray was not more
helpful than intranasal steroids. Larger volume (150
mL) was slightly more efficacious than placebo [24].
Catalano et al. assessed balloon dilation for the
treatment of chronic frontal sinusitis in 20 patients
with advanced sinus disease in whom medical
therapy had failed and thus required operative
intervention. Preoperative and postoperative CT
scans were matched. There were no substantial
complications from balloon dilation, and there was
substantial improvement in patients with certain
subsets of CRS [25].
Surgical Treatment
Surgical care is utilized as an adjunct to medical
treatment in some cases. Surgical care is generally
saved for cases that are headstrong to medicinal
treatment and for patients with anatomic check.
Preoperative CT discoveries preceding sinus
surgery might be poor indicators of surgical results
[26]
. The objective in surgical treatment is to restore
sinus ventilation and to adjust mucosal resistance
with a specific end goal to re-establish the
mucociliary leeway framework. Surgery endeavors
to re-establish the practical respectability of the
aggravated mucosal covering. Late advances in
endoscopic innovation and a superior
comprehension of the significance of the
ostiomeatal complex in the pathophysiology of
sinusitis have prompted the foundation of utilitarian
endoscopic sinus surgery (FESS) as the surgical
method of decision for the treatment of endless
sinusitis [27].
FESS simplifies the removal of disease in key
areas, re-establishes adequate aeration and drainage
of the sinuses by establishing patency of the
ostiomeatal complex, debulks severe polyposis, and
causes less harm to normal nasal functioning. FESS
is effective in re-establishing sinus health, with
complete or at least moderate relief of symptoms in
80-90% of patients. Supportive medical treatment is
instituted preoperatively and postoperatively.
Occupational exposure might affect FESS results.
Symptoms might persevere with work-related
exposure to inhaled agents, and revision surgery
might be required [28]. In patients who have
experienced endoscopic sinus surgery, add up to
and coordinate social insurance costs, anti-
microbial use, and the aggregate number of imaging
thinks about performed diminished after surgery for
no less than 3 years. Be that as it may, the
utilization of oral corticosteroids did not change [29].
 Abdulrahman Almutairi et al.

Figure 1. Sinus CT scan showing the frontal and sphenoid sinuses.

Acute Maxillary Sinusitis

Numerous techniques have been defined for
drainage of the maxillary sinus. The inferior meatus
and canine fossae are optimal drainage sites on
account of their ease of availability and
comparatively thin well-vascularized bone.
Preoperative imaging is important to record the
nearness of acute sinusitis and to direct surgical 
arranging. Place conscious patients in the sitting
position to consider waste of the sinus substance 
into a provided basin. Secure the airway and 
suction the oropharynx amid sinus puncture
performed on oblivious patients. In patients in the
emergency unit, of the sinus might be attempted
with cut to guarantee proceeded with sufficient
drainage.
Three main surgical options are available for
chronic maxillary sinusitis:
Endoscopic uncinectomy with or without maxillary
antrostomy
Caldwell-Luc procedure
Inferior antrostomy (naso-antral window).

Figure 2. Scan of Maxillary Sinusitis

1517
 Acute and Chronic Sinusitis Causes and Management
Fungal Sinusitis
The desired treatment for chronic fungal sinusitis is
surgical debridement. Mycetomas or fungus balls
are best treated by means of surgical exclusion.
Allergic fungal sinusitis, which generally manifests
as nasal polyps and allergic sinusitis, is treated by
means of systemic steroids and surgical removal of
polyps and mucinous secretions. Prolonged
postoperative tapering doses of prednisone and
anterior nasal glucocorticoid steroids are specified
to suppress the symptoms of fungal CRS.
Few literatures has recommended that topical
antifungals might have a role in the treatment of
CRS [30]; nevertheless, this treatment residues
controversial, and further studies have not
reinforced this method. A recent assessment that
included 6 studies (N = 380) showed no statistically
important benefit of topical or systemic antifungals
over placebo for the treatment of CRS [31].
CONCLUSION
Several therapies have been proven by studies with
a high level of evidence to improve clinical
symptoms and objective results. Several therapies
still need validation over well-conducted studies, in
which randomized controlled trials may be a
difficult task due to confounding factors and trial
participation. Although it remains a challenge to
cure the root cause of sinusitis, an algorithm of
multidrug regimen and endoscopic sinus surgery
after fully implemented medication can help to
reduce the disease burden and advance the quality
of life of this group of patients.
REFERENCES
1. American Academy of Pediatrics (2001):
Subcommittee on Management of Sinusitis and
Committee on Quality Management. Clinical practice
guideline: management of sinusitis. Pediatrics,
108(3):798-808.
2.Lanza DC and Kennedy DW (1997): Adult
rhinosinusitis defined. Otolaryngol Head Neck Surg.
117(3 Pt 2):S1-7.
3.Meltzer EO, Hamilos DL, Hadley JA et al.
(2004):Rhinosinusitis: Establishing definitions for
clinical research and patient care. Otolaryngol Head
Neck Surg.,131(6):S1-62.
4.Slavin RG, Spector SL, Bernstein IL et al.
(2005):The diagnosis and management of sinusitis: a
practice parameter update. J Allergy Clin Immunol.,
116(6):S13-47.
5.American Academy of Pediatrics - Subcommittee
on Management of Sinusitis and Committee on
Quality Management(2001): Clinical practice
guideline: management of sinusitis. Pediatrics,
108(3):798-808.
1518
6.Report of the Rhinosinusitis Task Force Committee
Meeting(1997): Alexandria, Virginia, Otolaryngol Head
Neck Surg. , 117(3 Pt 2):S1-68.
7.Benninger MS, Ferguson BJ, Hadley JA et
al.(2003): Adult chronic rhinosinusitis: definitions,
diagnosis, epidemiology, and pathophysiology.
Otolaryngol Head Neck Surg. , 129(3):S1-32.
8.Agency for Health Care Policy and Research(1999):
Diagnosis and treatment of acute bacterial rhinosinusitis.
Evid Rep Technol Assess (Summ), 9:1-5.
9.Scheid DC, Hamm RM(2004): Acute bacterial
rhinosinusitis in adults: part I. Evaluation. J Am Fam
Phys .,70:1685-92.
10.Rosenfeld RM, Andes D, Bhattacharyya N,
Cheung D, Eisenberg S, Ganiats TG et al.(2007):
Clinical practice guideline: adult sinusitis. Otolaryngol
Head Neck Surg. , 137(3):S1-31.
11.Rosenfeld RM, Piccirillo JF, Chandrasekhar SS,
Brook I, Ashok Kumar K, Kramper M et al.
(2015):Clinical practice guideline (update): adult
sinusitis. Otolaryngol Head Neck Surg. , 152 (2):S1-S39.
12.Hickner JM, Bartlett JG, Besser RE, Gonzales R,
Hoffman JR, Sande MA(2001):Principles of
appropriate antibiotic use for acute rhinosinusitis in
adults: background. Ann Intern Med. , 134(6):498-505.
13.Falagas ME, Giannopoulou KP, Vardakas KZ,
Dimopoulos G, Karageorgopoulos DE(2008):
Comparison of antibiotics with placebo for treatment of
acute sinusitis: a meta-analysis of randomised controlled
trials. Lancet Infect Dis., 8(9):543-52.
14.Chow AW, Benninger MS, Brook I, Brozek JL,
Goldstein EJ, Hicks LA et al. (2012):IDSA Clinical
Practice Guideline for Acute Bacterial Rhinosinusitis in
Children and Adults. Clin Infect Dis. , 54(8):e72-e112.
15.National Guidelines Clearinghouse. Clinical
practice guideline (2016): adult sinusitis. National
Guidelines Clearinghouse. Available at
:http://guideline.gov/content.aspx?id=12385.
16.Marple BF, Roberts CS, Frytak JR, Schabert VF,
Wegner JC, Bhattacharyya H et al.
(2010):Azithromycin extended release vs
amoxicillin/clavulanate: symptom resolution in acute
sinusitis. Am J Otolaryngol ., 31(1):1-8.
17.Ferguson BJ, Narita M, Yu VL, Wagener MM,
Gwaltney JM (2012): Prospective observational study
of chronic rhinosinusitis: environmental triggers and
antibiotic implications. Clin Infect Dis. , 54(1):62-8.
18.Head K, Chong LY, Piromchai P, Hopkins C,
Philpott C, Schilder AG et al. (2016):Systemic and
topical antibiotics for chronic rhinosinusitis. Cochrane
Database Syst Rev. , 4:CD011994.
19.Piromchai P, Thanaviratananich S, Laopaiboon
M(2011): Systemic antibiotics for chronic rhinosinusitis
without nasal polyps in adults. Cochrane Database Syst
Rev. , CD008233.
https://www.ncbi.nlm.nih.gov/pubmed/21563166
20.López-Chacón M, Mullol J, Pujols L(2015):
Clinical and biological markers of difficult-to-treat
severe chronic rhinosinusitis. Curr Allergy Asthma Rep.
, 15 (5):19.
 Abdulrahman Almutairi et al.
21.Rudmik L, Soler ZM(2015): Medical Therapies for
Adult Chronic Sinusitis: A Systematic Review. JAMA. ,
314 (9):926-39.
22.Vaidyanathan S, Barnes M, Williamson P,
Hopkinson P, Donnan PT, Lipworth
B(2011):Treatment of chronic rhinosinusitis with nasal
polyposis with oral steroids followed by topical steroids:
a randomized trial. Ann Intern Med. , 154(5):293-302.
23.Chong LY, Head K, Hopkins C, Philpott C,
Schilder AG, Burton MJ(2016): Intranasal steroids
versus placebo or no intervention for chronic
rhinosinusitis. Cochrane Database Syst Rev. ,
4:CD011996.
24.Chong LY, Head K, Hopkins C, Philpott C, Glew
S, Scadding G et al. (2016):Saline irrigation for chronic
rhinosinusitis. Cochrane Database Syst Rev.,
4:CD011995.
25.Catalano PJ, Payne SC(2009): Balloon dilation of
the frontal recess in patients with chronic frontal sinusitis
and advanced sinus disease: an initial report. Ann Otol
Rhinol Laryngol. , 118(2):107-12.
26.Bhattacharyya N(2006): Radiographic stage fails to
predict symptom outcomes after endoscopic sinus
1519
surgery for chronic rhinosinusitis. Laryngoscope. 2006.
116(1):18-22.
27.Welch KC, Stankiewicz JA(2009): A contemporary
review of endoscopic sinus surgery: techniques, tools,
and outcomes. Laryngoscope,119(11):2258-68.
28.Hox V, Delrue S, Scheers H, Adams E, Keirsbilck
S, Jorissen M et al.(2012): Negative impact of
occupational exposure on surgical outcome in patients
with rhinosinusitis. Allergy.
https://www.ncbi.nlm.nih.gov/pubmed/22229752
29.Purcell PL, Beck S, Davis GE(2015): The impact of
endoscopic sinus surgery on total direct healthcare costs
among patients with chronic rhinosinusitis. Int Forum
Allergy Rhinol. , 5 (6):498-505.
30.Ponikau JU, Sherris DA, Weaver A, Kita H(2005):
Treatment of chronic rhinosinusitis with intranasal
amphotericin B: a randomized, placebo-controlled,
double-blind pilot trial. J Allergy Clin Immunol.
,115(1):125-31.
31.Sacks PL, Harvey RJ, Rimmer J, Gallagher RM,
Sacks R(2011): Topical and systemic antifungal therapy
for the symptomatic treatment of chronic rhinosinusitis.
Cochrane Database Syst Rev. , CD008263.
https://www.ncbi.nlm.nih.gov/pubmed/21833965