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In a 6-month period, 186 new patients with chronic nasal symptoms were evaluated. In addition to history and physical examination, all received sinus radiographs. A subset received epicutaneous skin tests to environmental aeroallergens. Patients were divided into five diagnostic categories to determine if history or physical findings could predict abnormal sinus radiographs. No symptom or group of symptoms proved diagnostic; however, no patient with allergic rhinitis had purulent nasal secretions. Positive skin tests occurred in the absence of typical allergy symptoms. Many patients had received inappropriate prior therapy with either surgery or antibiotics. We conclude that sinus radiographs should be obtained in all patients with chronic nasal symptoms not improved by routine therapy.

Conventional radiographs of the paranasal sinuses were interpreted by two observers and were compared to A-mode ultrasound scans in 100 consecutive patients with classical symptoms of chronic sinusitis. Of the maxillary sinus radiographs 65% were reported as normal by one radiologist. There was poor agreeement between the observers in interpretation of the radiographs and both observers’ interpretations correlated poorly with ultrasound scans. Compared to radiographs, ultrasound had a sensitivity of 31% and specificity of 63% in detecting abnormalities. We suggest that positive imaging tests in chronic sinusitis may not truly reflect the incidence of a pathologic condition and that comparison of images with other parameters (e.g., response to treatment) is needed to ascertain the role of the images in chronic sinusitis.

Syndromes of chronic sinusitis (CS) and nonallergic rhinitis (NAR) are poorly defined. There is a paucity of epidemiologic studies and long-term treatment outcome remains based mainly on anecdotal evidence. Clinical diagnoses must be differentiated from those made solely on radiographic criteria. The role of allergic disease in CS is undetermined. Many factors such as vascular reactivity, cellular infiltration, modifications of nasal secretions, anatomic abnormalities, deficiency of mucociliary clearance, immunodeficiency, and nasal reflexes contribute to symptom pathogenesis. The question whether NAR is a disease or an exaggerated physiologic response is controversial and is addressed in this contribution. Ultimately, enhanced knowledge of the pathophysiology of CS and NAR may lead to novel therapeutic approaches. Patients readily attribute a variety of symptoms such as postnasal drainage, facial fullness or swelling, head pressure, and nasal congestion to the paranasal sinuses. Unfortunately, many practitioners do not adopt a critical attitude to diagnosing sinus pathology and differentiating it from exaggerated physiologic responses to environmental factors. In this paper I will try to highlight some of the difficulties in this area.

SELECTED CASEA 28-YEAR-OLD medical resident presented to the allergy clinic with a two-year history of rhinorrhea, sneezing, and nasal obstruction. His symptoms were worse in the fall, and the nasal obstruction persisted intermittently throughout the winter. Four years previously he had moved to Washington, DC, from rural Oregon. On further questioning, the patient admitted to a decreased sense of smell and some wheezing on exertion. Over-the-counter therapy with various antihistamines and decongestants had produced initial relief, but this was not sustained.For editorial comment see p 267.The results of a physical examination were normal except for a finding of pale, boggy nasal turbinates. Topical nasal decongestion revealed the presence of bilateral nasal polyps. Skin tests were performed by the prick route to a battery of inhalant allergens. Significant positive results were obtained to ragweed, molds, house dust mites, and histamine control.The patient was prescribed a vigorous program