Question: How do I know if I have sinusitis? How do you diagnose it?
Answer: Your sinus specialist will take a thorough history, asking about the duration and nature of your symptoms and other related factors, other factors relating to functional nasal problems, including environmental allergy, medications (including inappropriate use of over-the-counter nasal decongestant sprays), nasal trauma, and prior nasal surgery.

The patient's history can reveal underlying factors predisposing to chronic sinusitis. Factors that lead to nasal obstruction, and more specifically to obstruction of the narrow sinus drainage pathways, are identified.

These include viral upper respiratory tract infection, allergic rhinitis, vasomotor rhinitis, barotrauma, and mucosal hypertrophy. Furthermore, mechanical obstruction can be caused by nasal polyps, deviated nasal septum, foreign body, trauma, choanal atresia and tumors. Recent dental work or infections can introduce bacteria into the maxillary sinus. Instrumentation of the nose in the hospital such as a nasogastric tube can be a contributing factor. Immunocompromised patients are also at risk. Gastroesophageal reflux disease may be a contributing factor in chronic sinusitis also. All these factors should be kept in mind.

Next, he or she will perform a careful examination including nasal endoscopy. Thorough physical examination includes both the external and the internal nose; intranasal examination is undertaken both before and after topical vasoconstriction. An assessment is made of mucosal appearance, turbinate size, shape, and angulation, obstruction secondary to a deviated septum, and cross-sectional airway competence at the external and internal nasal valve. Hyperemia, edema, crusting, polyps, and purulence in the nasal cavity are also noted and may be indicative of chronic sinusitis. Rigid nasal endoscopy in the office after appropriate topicalization by a skilled endoscopist may be helpful in identifying these physical findings.

Question: Tell me more about nasal endoscopy.
Answer: Nasal endoscopy allows for more detailed examination of the nasal cavities and can be performed with a flexible fiberoptic or rigid endoscope. Endoscopic examination enables the doctor to identify specific areas of blockage, to detect the presence of polyps, and to obtain cultures at specific drainage sites.

The flexible fiberoptic endoscope is useful in certain circumstances because its flexibility allows examination of difficult to examine structures. Examination of the nose and throat all the way down to the vocal cords can be undertaken with a flexible scope. An example photo of a flexible endoscope is shown to the right.

The rigid endoscopes are also advocated for diagnostic purposes by most sinus specialists. The rigid scopes commonly come with 0 degree, 30 degree, 45 degree, or 70 degree fixed angle lenses. Other angled lenses are available.

A topical decongestant and topical anesthesia are first applied. Spraying the nose with 1% Phenylephrine and 2% Tetracaine (Pontocaine) often is sufficient to make the patient comfortable for a complete office exam with nasal endoscopy. If necessary, additional comfort can be effectively achieved by placing a cotton pleget with topical anesthetic agent into the nasal cavity for 5 minutes.

After appropriate decongestion and topical anesthesia, the nasal endoscope is passed into the nasal cavity. Examination of the inferior, middle, and superior turbinates, the septum, the posterior choana, the nasopharynx, the sphenoethmoid recess, the frontal recess, the uncinate process, the hiatus semilunaris, the ethmoid bulla, and accessory ostium is possible with marked accuracy and detail (see ANATOMY section). The quality of the mucosa and secretions are noted. The septum is evaluated for deviations, which can not only cause nasal obstruction but can also impinge on the middle turbinate and lead to narrowing of the middle meatus and the osteomeatal complex.

The middle turbinate is evaluated to see whether its shape and size have caused narrowing of the middle meatus. A paradoxical bend of the middle turbinate can cause narrowing because the convex side protrudes into the lateral nasal wall. A large middle turbinate can cause nasal and osteomeatal complex obstruction. A large middle turbinate may represent a concha bullosa, which is an aerated middle turbinate.

The middle meatus and the ethmoid region are evaluated for the presence of narrowing, mucosal swelling, polyps or polypoid degeneration, and purulent secretions. The inferior turbinate can also be followed all the way back to the choana. The otolaryngologist should carefully note whether it causes obstruction of the nasal cavity.

In the posterior nasal cavity, the sphenoethmoid recess and choana can be evaluated. Finally, the nasopharynx and the torus tubarius are evaluated for lesions or inflammation. Inflammation of the torus tubarius can lead to eustachian tube obstruction and can cause middle ear manifestations. Proper diagnosis of intranasal and sinus disease can only be maximally achieved with a thorough endoscopic examination.

Radiology and the Sinuses

Question: When should I have an X-ray, and what kind of X-ray should I have?
Answer: When an x-ray must be done to evaluate chronic sinusitis, the imaging procedure of choice is the computerized tomography (CT) scan, which is recommended in evaluating the extent and severity of disease in chronic sinusitis.

Question: Tell me about sinus CT scans.
Answer: Sinus CT (computer tomography) scans allow doctors to visualize the pathology within the sinuses and depict normal and abnormal anatomy. CT scans are an immense improvement over plain film sinus depiction and can give reliable reproducible information.

Question: Tell me a little more about computer tomography.
Answer: X-ray computer tomography, or CT scan, is an invaluable tool in the evaluation of the sinuses. One of the primary strengths of sinus CT imaging is improved contrast resolution -- the ability to depict bone/air and bone/soft tissue interfaces. Another primary strength of CT scans is improved spatial resolution -- the ability to depict very small structures.

The sinus specialist hopes to obtain numerous specific pieces of information from CT scans of patients with sinus disease. This information includes the status of the bony walls, the nature of material within the sinuses, and the status of the adjacent normal structures. The status of the bony walls of the sinuses is important both in benign sinus disease and also in sinus tumors.

It takes newer generation scanners only minutes to provide high-resolution images of tissue slabs that are only a few millimeters thick. CT scans in the coronal plane provide the endoscopic sinus surgeon with a road map in performing sinus surgery, to improve efficacy and safety.

Shown here is a CT scan of a patient with sinusitis. On a CT, air appears black and swollen tissue and mucus appear gray. You can see that this patient has blockage of the maxillary and ethmoid sinuses.

Question: Can I have a "normal" sinus CT scan and still require surgical treatment?
Answer: The decision to operate on a patient's sinuses is complex. Although imaging helps the surgeon make that decision, it is not made on the imaging findings alone. Equally important are the patient's history and physical findings on endoscopy. The surgeon must consider the entire clinical picture in determining the best recommendation for the patient's care. Computer tomography in combination with the patient's history and physical examination findings, especially nasal endoscopy, are the most effective method of diagnosing surgical disease.

The scientific literature does suggest that CT scans can underreport sinus disease. Findings in surgery are at times seen to be greater than that suggested by the CT scan. Endoscopic sinus surgery performed on patients with near normal or normal CT images is not without precedent and is not without justification.

Question: I was in the emergency room with acute sinusitis and I had an x-ray. How useful is this x-ray?
Answer: A "plain x-ray" may be helpful in evaluating the patient suspected of having acute sinusitis. Beyond that, these plain x-rays have limited value for evaluation of sinusitis.

The CT scan is now the gold standard and has replaced plain x-rays as the imaging study of choice in chronic sinusitis. CT scans, especially the coronal images, are useful in imaging the underlying sinus anatomy in detail. The combination of nasal endoscopy and CT scans in the evaluation of chronic sinus disease allows for precise diagnosis and treatment.

Question: Tell me a little bit more about plain films.
Answer: It is notable that plain films of the sinuses in children can be especially misleading. Using CT as the gold standard, plain films have had a false negative rate of 45% and a false positive rate of 35% in infants and children. With these discouraging numbers it is clear that the choice of plain films is fraught with error. Computer tomography offers an improved sensitivity and specificity but it has its drawbacks, namely higher cost, somewhat increased radiation exposure, and the frequent necessity of sedation to perform these exams in children.

Question: Tell me a little bit more about the threat of radiation.
Answer: Whenever taking x-rays, there is the concern about radiation exposure. Much improvement has been made in this area in recent years. The finely collimated beams used in thin section CT, and the increased sensitivity of radiation detectors, have allowed the specialist to significantly refine the technique necessary to provide high-quality images and reduce the radiation exposure to the patient. However, even reduced radiation with modern CT scans entails greater radiation exposure than that in "traditional" radiography. With regard to radiation exposure, the lens of the eye and the thyroid gland are primary organs of concern. It remains prudent to use x-ray or CT exam only if the results will alter clinical management.

Question: What is the role of an ultrasound.
Answer: Ultrasonography has been used in Europe, typically as a confirmation of the presence of fluid in the sinuses and in acute sinusitis. However, it appears to be of fairly limited usefulness in the evaluation and treatment of chronic sinusitis.