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Sinusitis Symptoms Differ with Age

Rhinosinusitis, more commonly known as sinusitis, is one of the most common chronic illnesses in the United States. Despite the overwhelmingly large number of people affected by sinusitis, the cause and exact definition of chronic sinusitis is still being debated. Inflammation of the sinuses may be triggered by both allergic or non-allergic substances and the overall incidence of allergy and asthma is known to be highest in children and adolescence but decline substantially after age 35. New research examines the link between age and sinus disease symptoms.

The role of the osteomeatal unit (OMU), or bony channel in the sinuses, is the main area where infections develop. The OMU can be blocked by variations in the anatomic structure of the area or by soft tissue due to inflammation. Exactly what role the anatomic structural variants play in development of chronic sinusitis is controversial. These variants, including non-traumatic septal deviation, typically develop around the time of facial growth during puberty and completion of paranasal sinus pneumatization (the development of air cells such as those of the mastoid and ethmoidal bones). Because of this, you might expect that people who have one or more of these anatomic variants develop inflammatory paranasal sinus disease (sinusitis) at an earlier age compared to those who lack the anatomic variants.

Symptoms and Cause of Paranasal Sinus Disease
Symptoms of inflammatory paranasal sinus disease include facial pain or pressure, headache, nasal drainage (anterior rhinorrhea or postnasal drip), nasal obstruction, dysosmia, and/or visual changes. Because headaches and facial pain can be caused by several factors, determining the appropriate treatment can be a challenge to physicians. While a headache can have a cause that is not paranasal sinus-related it may still can co-exist with, and mutually impact the inflammatory paranasal sinus disease. The prevalence of migraine, myofascial pain, cluster headache, and psychiatric illnesses that can cause or exacerbate facial pain and headache vary depending upon the age of the patient. For instance, about 90 percent of patients with migraine headache experience their first migraine before age 40 and the incidence of migraine decreases after age 40 in both males and females. The presence of one or more of these illnesses can impact the presenting symptom-complex of the paranasal sinus disease.

Research Regarding Age and Sinusitis Symptoms
Because of the trend apparent with age in relation to sinus symptoms, a team from Massachusetts Eye and Ear Infirmary and Harvard Medical School chose to do a prospective study to determine the age factors. The purpose of this study, “The Impact of a Patient’s Age on the Clinical Presenation of Inflammatory Sinus Disease”, was to determine the impact of the patient’s age on the symptoms, anatomic findings, co-morbidities, diagnosis, and surgical outcome of inflammatory paranasal sinus disease. The authors of the study are Nicolas Y. Busaba MD, Hyeijung Shin MD, and Salah D. Salman MD, all representing the the Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, and the Department of Otolaryngology and Laryngology, Harvard Medical School, Boston, Massachusetts. Dr. Busaba is also affiliated with the Division of Otolaryngology, VA Boston HealthCare System. Their findings were presented at the 109th Annual Meeting & OTO EXPO of the American Academy of Otolaryngology—Head and Neck Surgery Foundation, on September 25-28, 2005, at the Los Angeles Convention Center, Los Angeles, CA.

Methodology: This prospective study looked at 514 adult patients with inflammatory paranasal sinus disease at a single tertiary care facility. The term inflammatory paranasal sinus disease is used to encompass CRS, CRS with polyposis, recurrent acute rhinosinusitis, barosinusitis, mucoceles or mucopyoceles, and antral-choanal polyp. The patients were grouped off into three groups based on their age at presentation. Group 1 (n=203) comprised of patients whose ages were between 18 and 39 years, group 2 (n=213) comprised of patients whose ages were between 40 and 59 years, and group 3 (n=98) comprised of patients whose ages were 60 years or older.

The following data were collected: patient demographics (age and gender), presenting symptoms, co-morbidities (environmental allergy, asthma, and psychiatric illness), physical examination and nasal endoscopy findings, computed tomography (CT) findings, diagnosis, operative findings, and surgical outcome. The presenting symptoms were facial pain / headache (pressure, pulsating, pricking or stabbing pain), nasal drainage (anterior rhinorrhea and/or postnasal drip), nasal congestion / obstruction, and dysosmia. The researchers noted the following anatomic variants on physical examination and CT: septal deviation / spur, paradoxical middle turbinate, concha bullosa, agger nasi cells, and haller cells. Surgical outcome was based on a questionnaire that was filled by the patients eight weeks to three months following the operation and that asked about change in the presenting symptoms: better, same, or worse.

Statistical analysis using chi square test was performed to determine differences in the incidence of the above variables among the three age groups. Statistical significance was set at a p value of < 0.05.

Results: A total of 514 adult patients (273 women and 241 men) were evaluated in this study. The mean age was 45.5 years old (range: 18-86 years). Group 1 consisted of 203 patients (112 females and 91 males), group 2 consisted of 213 patients (107 females and 106 males), and group 3 consisted of 98 patients (54 females and 44 males).

Among the presenting symptoms, facial pain and rhinorrhea (nasal discharge) were most common among group 1 and least common among group 3 patients (p < 0.05), while dysosmia (altered sense of smell) was most common among group 3 patients (p < 0.05). Environmental allergy, but not asthma, was more prevalent in groups 1 and 2 compared to group 3 (p < 0.05). There was no statistically significant difference in the prevalence of psychiatric illness among the three groups. Anatomic abnormalities combined (septal deviation, paradoxical middle turbinate, concha bullosa, haller cell, agger nasi cell) were more common in groups 1 and 2 compared to group 3 (p < 0.05). Chronic rhinosinusitis (CRS) without polyposis was the most common diagnosis in group 1 and CRS with polyposis was the most common diagnosis in groups 2 and 3 (p < 0.05). There was no difference in the relative prevalence of antral-choanal polyp, barosinusitis and mucocele among the groups. The vast majority of the patients in the study and in all age groups reported improvement in all the presenting symptoms following surgery. However, group 3 patients reported more improvement in nasal drainage following endoscopic sinus surgery (p<0.05), while group 1 patients reported higher rate of improvement in olfactory function (p < 0.05). There was no statistically significant difference in the improvement of other presenting symptoms including facial pain among the groups.

Conclusions: The clinical presentation of inflammatory paranasal sinus disease varies with age. The younger patients are more likely to complain of facial pain or headache, have allergic rhinitis, and have anatomic obstruction of the OMU. The older patients report more dysosmia on presentation and are more likely to have nasal polyposis. The vast majority of the patients in the study and in all age groups reported improvement in all the presenting symptoms following surgery; however, olfactory function is more likely to improve in the younger patients, while nasal drainage is more likely to improve in the older patients.


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