Abstract
Objective
To determine the change in the clinical presentation of inflammatory paranasal sinus disease as a function of a patient’s age.
Study Design and Methods
This is a prospective study of 514 adult patients who presented with inflammatory paranasal sinus disease. The patients were divided into three age groups: group 1 (age: 18–39 years; n = 203), group 2 (age: 40–59 years; n = 213) and group 3 (age greater than 60 years; n = 98). The following data were collected: presenting symptoms, co-morbidities, nasal endoscopy and CT findings, diagnosis, and the outcome of endoscopic sinus surgery (ESS). Statistical analysis was performed using chi-square test, with statistical significance set at p < 0.05.
Results
Among the presenting symptoms, facial pain and rhinorrhea were most common in group 1 ( p < 0.05), while dysosmia was most common in group 3 ( p < 0.05). Environmental allergy, but not asthma, was more prevalent in groups 1 and 2 ( p < 0.05). Anatomic abnormalities that obstructed the ostiomeatal unit (OMU) were more common in groups 1 and 2 ( 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). Patients in group 1 reported higher rate of improvement in olfactory function while patients in group 3 reported higher rate of improvement in rhinorrhea following ESS ( p < 0.05).
Conclusions
Patients in the 18–39-year age group and diagnosed with CRS are more likely to present with facial pain, suffer from environmental allergy, have anatomic abnormalities in the OMU region, and report improvement in their olfaction following ESS. Patients who are 60 years or older are more likely to present with dysosmia, be diagnosed with CRS with nasal polyposis, and report improvement in rhinorrhea following surgery.
1
Introduction
Chronic rhinosinusitis (CRS) is one of the most common chronic illnesses in the United States with increasing incidence and prevalence . Despite its prevalence, the pathogenesis and definition of CRS are still debated. The concept of CRS being primarily an inflammatory disease with recurrent superimposed bacterial infection gained wider acceptance. The inflammation may be triggered by allergic or non-allergic stimuli . The overall incidence of allergy and asthma is highest in children and adolescents and decline substantially after the age of 35 years .
The ostiomeatal unit (OMU) plays a central role in the development of paranasal sinus disease. The OMU can be obstructed by anatomic variants or inflammatory soft tissue . Anatomic variants typically develop around puberty at the time of facial growth and completion of paranasal sinus pneumatization . Therefore, one would expect that persons who possess one or more of these anatomic variants present with inflammatory paranasal sinus disease at an earlier age compared to those who lack them.
Facial pain and headache are common symptoms of inflammatory paranasal sinus disease. Determining the etiology and hence the appropriate treatment of facial pain and headache poses a clinical challenge. The headache may have a non-sinugenic etiology but which can co-exist with, and mutually impact the inflammatory paranasal sinus disease. The prevalence of migraine, cluster headache, myofascial pain, and psychiatric illnesses that can cause or exacerbate facial pain and headache vary with age. The presence of one or more of these illnesses can impact the presenting symptom complex of the paranasal sinus disease. For instance, approximately 90% of patients with migraine headache experience their first attack before the age of 40 years, and the incidence of migraine decreases after that age in both genders . In addition, the prevalence of mental illness that can cause or worsen the headache varies with age .
The purpose of this study is to determine whether the patient’s age at presentation impacts the symptoms, anatomic findings, co-morbidities, diagnosis, and surgical outcome of inflammatory paranasal sinus disease.
2
Materials and methods
The study was approved by the institutional review board of the Massachusetts Eye and Ear Infirmary (IRB Protocol 249667-1).
This is a prospective case series of 514 consecutive adult patients who presented with inflammatory paranasal sinus disease at a single tertiary care facility. The term inflammatory paranasal sinus disease as used in this paper encompasses CRS with polyposis, CRS without polyposis, recurrent acute rhinosinusitis, barosinusitis, antral-choanal polyp, and mucocele/mucopyocele. Since it is often difficult to differentiate clinically between a mucocele and a mucopyocele, the term mucocele is used throughout this paper to refer to both diagnoses. For the patients who required surgery to treat their paranasal sinus disease, we included in this study only those who had a minimum of 3 months of postoperative follow-up.
The patients were divided into three groups based on their age at presentation. Group 1 ( n = 203) comprised patients whose ages ranged between 18 and 39 years, group 2 ( n = 213) comprised patients whose ages ranged between 40 and 59 years, and group 3 ( n = 98) comprised patients whose ages were 60 years and older.
The following data were collected: patient demographics (age and gender), presenting symptoms, co-morbidities (environmental allergy, asthma, and psychiatric illness), anterior rhinoscopy and offie nasal endoscopy findings, paranasal sinus CT findings, diagnosis, operative findings, and surgical outcome. The presenting symptoms included the presence and characteristics of facial pain/headache (pressure, pulsating, pricking or stabbing), rhinorrhea (anterior rhinorrhea and/or postnasal drip), nasal congestion/obstruction, and dysosmia. We noted the following anatomic variants on physical examination and CT: septal deviation/spur, paradoxical middle turbinate, concha bullosa, agger nasi cell, and haller cell. A septal deviation or spur was considered clinically relevant when the deviation lateralized the middle turbinate or impinged into the middle meatus. Surgical outcome was measured by a patient questionnaire that measured the change in the presenting symptoms (better, same, and worse) and which was filled by the patients before and 3 months following the operation.
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.
2
Materials and methods
The study was approved by the institutional review board of the Massachusetts Eye and Ear Infirmary (IRB Protocol 249667-1).
This is a prospective case series of 514 consecutive adult patients who presented with inflammatory paranasal sinus disease at a single tertiary care facility. The term inflammatory paranasal sinus disease as used in this paper encompasses CRS with polyposis, CRS without polyposis, recurrent acute rhinosinusitis, barosinusitis, antral-choanal polyp, and mucocele/mucopyocele. Since it is often difficult to differentiate clinically between a mucocele and a mucopyocele, the term mucocele is used throughout this paper to refer to both diagnoses. For the patients who required surgery to treat their paranasal sinus disease, we included in this study only those who had a minimum of 3 months of postoperative follow-up.
The patients were divided into three groups based on their age at presentation. Group 1 ( n = 203) comprised patients whose ages ranged between 18 and 39 years, group 2 ( n = 213) comprised patients whose ages ranged between 40 and 59 years, and group 3 ( n = 98) comprised patients whose ages were 60 years and older.
The following data were collected: patient demographics (age and gender), presenting symptoms, co-morbidities (environmental allergy, asthma, and psychiatric illness), anterior rhinoscopy and offie nasal endoscopy findings, paranasal sinus CT findings, diagnosis, operative findings, and surgical outcome. The presenting symptoms included the presence and characteristics of facial pain/headache (pressure, pulsating, pricking or stabbing), rhinorrhea (anterior rhinorrhea and/or postnasal drip), nasal congestion/obstruction, and dysosmia. We noted the following anatomic variants on physical examination and CT: septal deviation/spur, paradoxical middle turbinate, concha bullosa, agger nasi cell, and haller cell. A septal deviation or spur was considered clinically relevant when the deviation lateralized the middle turbinate or impinged into the middle meatus. Surgical outcome was measured by a patient questionnaire that measured the change in the presenting symptoms (better, same, and worse) and which was filled by the patients before and 3 months following the operation.
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.
3
Results
A total of 514 adult patients (273 females and 241 males) were enrolled with a mean age of 45.5 years (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/headache, rhinorrhea, and dysosmia showed statistically significant differences among the three age groups. Facial pain, especially pressure or pulsating in nature, was more common in group 1 (i.e. younger patients) compared to groups 2 and 3 ( p < 0.05). Rhinorrhea overall was more common in groups 1 and 2, but purulent rhinorrhea was more common in group 3 ( p < 0.05). Dysosmia was more common in groups 2 and 3 ( p < 0.05). The prevalence of nasal blockage/congestion was comparable among the three groups ( Table 1 ).
| Group 1 ( n = 203), no. (%) | Group2 ( n = 213), no. (%) | Group 3 ( n = 98), no. (%) | |
|---|---|---|---|
| Nasal blockage | 154 (75.9) | 154 (72.3) | 72 (73.5) |
| Rhinorrhea a | 146 (71.9) | 150 (70.4) | 56 (57.1) |
| Facial pain/headache a | 138 (68.0) | 110 (51.6) | 36 (36.7) |
| Dysosmia a | 75 (37.0) | 106 (49.8) | 52 (53.1) |
a Statistically significant difference among the three age groups.
Environmental allergy as determined by a combination of medical history and allergy testing (skin test or radioallergosorbent test) was more common in groups 1 and 2 than in group 3 ( p < 0.05). However, there was no statistically significant difference in the prevalence of asthma among the three groups. Similarly, there was no statistically significant difference in the prevalence of psychiatric illness among the three age groups ( Table 2 ).
