Acute and chronic rhinosinusitis

Overview & Definition

Picture a four-year-old brought in with what sounds like an ordinary cold — a runny nose and a cough for the last twelve days. The family expected it to have settled by now, but the nasal discharge has stayed thick and the cough has not gone, and in the last two days the child has become more miserable with a fever returning. The temptation is to call it "just a cold that is dragging on" and to reach for an antibiotic; the skill is to recognise that the persistent, unremitting course and the late worsening mark the transition from a viral rhinosinusitis, which needs no antibiotic, to an acute bacterial rhinosinusitis, which does. [1]

The term rhinosinusitis is deliberate. The mucosa lining the nasal cavity and that lining the paranasal sinuses are one continuous sheet, and an inflammation that affects one almost always affects the other — which is why nearly every viral upper-respiratory infection briefly involves the sinuses. Rhinosinusitis is therefore defined as symptomatic inflammation of both the nose and the paranasal sinuses: a combination of nasal blockage, discharge, facial pressure or hyposmia. The paranasal sinuses — the maxillary, ethmoid, frontal and sphenoid — are paired, air-filled mucosal outpouchings that drain through narrow ostia into the nasal cavity, all converging at the ostiomeatal complex. [6]

The classification that examiners expect is by duration. Acute rhinosinusitis lasts under twelve weeks and is further split into acute viral (the common cold, by far the commonest) and acute bacterial. Chronic rhinosinusitis lasts twelve weeks or more and reflects persistently impaired mucociliary clearance rather than simple infection; it overlaps heavily with adenoidal hypertrophy, allergic rhinitis and, in a minority, with cystic fibrosis, primary ciliary dyskinesia and immunodeficiency. Recurrent acute rhinosinusitis describes separate acute episodes separated by symptom-free intervals. [6] [7]

Most rhinosinusitis is viral and self-limiting, and the modern challenge is stewardship — reserving antibiotics for the bacterial patterns and reserving imaging for the complication. The danger lies in the orbital and intracranial spread that can follow when an obstructed sinus infects and erodes: a swollen eye in a febrile child, or a severe headache with meningism, turns a routine upper-airway problem into a sight- and life-threatening emergency. The task is layered — make the bacterial diagnosis on clinical grounds, give the right antibiotic, and watch for the red flags that demand imaging and a multidisciplinary response. [4] [11]