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The impact of a patient's age on the clinical presentation of

inflammatory paranasal sinus disease☆,☆☆

Nicolas Y. Busaba, MD, FACS⁎

Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, and the Department of Otology and
Laryngology, Harvard Medical School, Boston, MA, USA

ARTI CLE I NFO A BS TRACT

Article history: Objective: To determine the change in the clinical presentation of inflammatory paranasal
Received 10 March 2013 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.
Published by Elsevier Inc.

1. Introduction
Chronic rhinosinusitis (CRS) is one of the most common
chronic illnesses in the United States with increasing inci-
dence and prevalence [1]. Despite its prevalence, the patho-
genesis 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 [2]. The overall incidence of allergy and asthma is

☆
Dr. Nicolas Busaba developed the project, collected the data, analyzed the data, and wrote the manuscript.
☆☆
Financial support: None.
⁎ Corresponding author. Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, 243 Charles Street,
Boston, MA 02114, USA. Tel.: + 1 617 573 3558; fax: +1 617 573 3914.
E-mail address: nicolas_busaba@meei.harvard.edu.

0196-0709/$ – see front matter. Published by Elsevier Inc.

http://dx.doi.org/10.1016/j.amjoto.2013.03.013

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450 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 44 9–4 5 3

highest in children and adolescents and decline substantially outcome. The presenting symptoms included the presence
after the age of 35 years [3]. and characteristics of facial pain/headache (pressure, pulsat-
The ostiomeatal unit (OMU) plays a central role in the ing, pricking or stabbing), rhinorrhea (anterior rhinorrhea and/
development of paranasal sinus disease. The OMU can be or postnasal drip), nasal congestion/obstruction, and dysos-
obstructed by anatomic variants or inflammatory soft tissue mia. We noted the following anatomic variants on physical
[4]. Anatomic variants typically develop around puberty at the examination and CT: septal deviation/spur, paradoxical
time of facial growth and completion of paranasal sinus middle turbinate, concha bullosa, agger nasi cell, and haller
pneumatization [4–7]. Therefore, one would expect that cell. A septal deviation or spur was considered clinically
persons who possess one or more of these anatomic variants relevant when the deviation lateralized the middle turbinate
present with inflammatory paranasal sinus disease at an or impinged into the middle meatus. Surgical outcome was
earlier age compared to those who lack them. measured by a patient questionnaire that measured the
Facial pain and headache are common symptoms of change in the presenting symptoms (better, same, and
inflammatory paranasal sinus disease. Determining the etiol- worse) and which was filled by the patients before and
ogy and hence the appropriate treatment of facial pain and 3 months following the operation.
headache poses a clinical challenge. The headache may have a Statistical analysis using chi-square test was performed to
non-sinugenic etiology but which can co-exist with, and determine differences in the incidence of the above variables
mutually impact the inflammatory paranasal sinus disease. among the three age groups. Statistical significance was set at
The prevalence of migraine, cluster headache, myofascial a p value of < 0.05.
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 3. Results
complex of the paranasal sinus disease. For instance, approx-
imately 90% of patients with migraine headache experience A total of 514 adult patients (273 females and 241 males) were
their first attack before the age of 40 years, and the incidence of enrolled with a mean age of 45.5 years (range: 18–86 years).
migraine decreases after that age in both genders [8]. In Group 1 consisted of 203 patients (112 females and 91 males),
addition, the prevalence of mental illness that can cause or group 2 consisted of 213 patients (107 females and 106 males),
worsen the headache varies with age [9]. and group 3 consisted of 98 patients (54 females and 44 males).
The purpose of this study is to determine whether the Among the presenting symptoms, facial pain/headache,
patient's age at presentation impacts the symptoms, anatom- rhinorrhea, and dysosmia showed statistically significant
ic findings, co-morbidities, diagnosis, and surgical outcome of differences among the three age groups. Facial pain, especially
inflammatory paranasal sinus disease. 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
2. Materials and methods purulent rhinorrhea was more common in group 3 (p < 0.05).
Dysosmia was more common in groups 2 and 3 (p < 0.05). The
The study was approved by the institutional review board of the prevalence of nasal blockage/congestion was comparable
Massachusetts Eye and Ear Infirmary (IRB Protocol 249667-1). among the three groups (Table 1).
This is a prospective case series of 514 consecutive adult Environmental allergy as determined by a combination of
patients who presented with inflammatory paranasal sinus medical history and allergy testing (skin test or radioallergo-
disease at a single tertiary care facility. The term inflamma- sorbent test) was more common in groups 1 and 2 than in
tory paranasal sinus disease as used in this paper encom- group 3 (p < 0.05). However, there was no statistically signif-
passes CRS with polyposis, CRS without polyposis, recurrent icant difference in the prevalence of asthma among the three
acute rhinosinusitis, barosinusitis, antral-choanal polyp, and groups. Similarly, there was no statistically significant differ-
mucocele/mucopyocele. Since it is often difficult to differen- ence in the prevalence of psychiatric illness among the three
tiate clinically between a mucocele and a mucopyocele, the age groups (Table 2).
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
Table 1 – Prevalence of presenting symptoms in the three
who had a minimum of 3 months of postoperative follow-up. age groups.
The patients were divided into three groups based on their
Group 1 Group2 Group 3
age at presentation. Group 1 (n = 203) comprised patients
(n = 203), (n = 213), (n = 98),
whose ages ranged between 18 and 39 years, group 2 (n = 213) no. (%) no. (%) no. (%)
comprised patients whose ages ranged between 40 and
Nasal blockage 154 (75.9) 154 (72.3) 72 (73.5)
59 years, and group 3 (n = 98) comprised patients whose
Rhinorrhea a 146 (71.9) 150 (70.4) 56 (57.1)
ages were 60 years and older.
Facial pain/headache a 138 (68.0) 110 (51.6) 36 (36.7)
The following data were collected: patient demographics Dysosmia a 75 (37.0) 106 (49.8) 52 (53.1)
(age and gender), presenting symptoms, co-morbidities (en-
vironmental allergy, asthma, and psychiatric illness), anterior Group 1: age range 18–39 years; group 2: age range 40–59 years;
group 3: age ≥ 60 years.
rhinoscopy and offie nasal endoscopy findings, paranasal a
Statistically significant difference among the three age groups.
sinus CT findings, diagnosis, operative findings, and surgical

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Table 2 – Prevalence of co-morbidities in the various age Table 4 – Number and percentage of patients who
groups. reported improvement in their presenting symptoms
following surgery.
Group 1 Group 2 Group 3
(n = 203), (n = 213), (n = 98), Group 1, Group 2, Group 3,
no. (%) no. (%) no. (%) no. (%) no. (%) no. (%)

Mental illness 14 (6.9) 19 (8.9) 4 (4.1) Nasal blockage 164 (98.2) 167 (94.4) 78 (96.3)
Allergy a 124 (61.1) 134 (62.9) 42 (42.9) Rhinorrhea a 138 (86.3) 143 (82.2) 74 (93.7)
Asthma 49 (24.1) 57 (26.8) 18 (18.4) Facial pain/Headache 153 (94.4) 159 (91.4) 71 (89.9)
Dysosmia a 135 (84.9) 126 (72.4) 58 (75.3)
Group 1: age range 18–39 years; group 2: age range 40–59 years;
group 3: age ≥ 60 years. Group 1: age range 18–39 years; group 2: age range 40–59 years;
a
Statistically significant difference among the three age groups. group 3: age ≥ 60 years.
a
Statistically significant difference among the three age groups.

The prevalence of anatomic variants/anomalies that can

conceivably obstruct the OMU was calculated. These were environmental allergy had CRS with polyposis, while 63.4% of
septal deviation/spur, paradoxical middle turbinate, concha the 112 patients in group 2 with environmental allergy had CRS
bullosa, haller cell, and agger nasi cell. The prevalence of these with polyposis, and 76.5 % of the 34 patients in group 3 with
variants when studied individually was higher in groups 1 and environmental allergy had CRS with polyposis. The difference
2, but the difference in the prevalence among the three age between groups 1 and 3 was statistically significant (p < 0.05).
groups did not reach statistical significance. However, when Table 4 details the number and percentage of patients in
the anatomic variants were lumped together, their combined each group that demonstrated improvement in their present-
prevalence was 62.6%, 58.7% and 46.9% for groups 1, 2 and 3 ing symptoms following ESS. Nasal blockage/congestion was
respectively. The difference in the combined prevalence reported as “improved” by 98.2%, 94.4% and 96.3 % of patients
between groups 1 and 3 and between groups 2 and 3 reached in groups 1, 2 and 3 respectively. Rhinorrhea was reported as
statistical significance (p < 0.05). The difference between “improved” by 86.3%, 82.2% and 93.7% of patients in group 1, 2
groups 1 and 2 did not reach statistical significance. The and 3 respectively. Facial pain and/or headache was reported
results were similar irrespective of the diagnosis. as “improved” by 94.4%, 91.4% and 89.9% of patients in group 1,
Table 3 details the prevalence of the various diagnoses 2 and 3 respectively. Olfactory function was reported as
within each age group. The most common diagnosis in group “improved” by 84.9%, 72.4% and 75.3% of patients in group 1,
1 was CRS without polyposis (42.9 % in group 1 compared to 2 and 3 respectively. Patients in group 1 reported a higher rate
31.0 % in group 2 and 25.4 % in group 3), while the most of improvement in olfactory function, while patients in group
common diagnosis in groups 2 and 3 was CRS with polyposis 3 reported a higher rate of improvement in rhinorrhea
(44.6% and 45.9% respectively, compared to 30.5 % in group 1; (p < 0.05). The difference in the percentages of patients who
p < 0.05). The prevalence of recurrent acute rhinosinusitis, reported improvement in the other symptoms (nasal block-
barosinusitis, antral-choanal polyp, and mucocele was com- age/congestion and facial pain/headache) among the three
parable among the three age groups. age groups did not reach statistical significance. Similar
The majority of patients who had CRS with polyposis in the findings were noted when data pertaining to the subset of
three groups had environmental allergy (77.4% in group 1, 74.7% patients who were diagnosed with CRS with and without
in group 2, and 59.1% in group 3). However, the presence of nasal polyposis were analyzed (Table 5).
environmental allergy was more likely to be associated with
nasal polyposis in patients older than 40 years (groups 2 and 3).
A little less than half (49.5 %) of the 97 patients in group 1 with
Table 5 – Number and percentage of patients who
reported improvement in their presenting symptoms
following surgery.
Group 1, Group 2, Group 3,
Table 3 – Diagnosis of the chronic inflammatory paranasal
no. (%) no. (%) no. (%)
sinus disease among the three age groups.
Group 1 Group 2 Group 3 CRS without polyposis n = 87 n = 66 n = 25
(n = 203), (n = 213), (n = 98), Nasal blockage 86 (98.8) 63 (95.5) 24 (96.0)
no. (%) no. (%) no. (%) Rhinorrhea a 70 (80.5) 51 (77.2) 23 (92.0)
Facial pain 80 (91.9) 58 (87.9) 22 (88.0)
CRS without polyposis a 87 (42.9) 66 (31.0) 25 (25.4) Dysosmia a 73 (83.9) 49 (74.2) 18 (72.0)
CRS with polyposis a 62 (30.5) 95 (44.6) 45 (45.9) CRS with polyposis n = 62 n = 95 n = 45
Mucocele 19 (9.4) 25 (11.7) 13 (13.3) Nasal blockage 61 (98.4) 91 (95.8) 43 (95.6)
Recurrent acute rhinosinusitis 26 (12.8) 24 (11.3) 11 (11.2) Rhinorrhea a 53 (85.5) 81 (85.3) 42 (93.3)
Barosinusitis 6 (3.0) 2 (1.0) 2 (2.0) Facial pain 57 (92.0) 89 (93.7) 41 (91.1)
Antral-choanal polyp 3 (1.5) 1 (0.5) 2 (2.0) Dysosmia a 53 (85.5) 59 (71.1) 25 (71.4)

Group 1: age range 18–39 years; group 2: age range 40–59 years; Group 1: age range 18–39 years; group 2: age range 40–59 years;
group 3: age ≥ 60 years. CRS: chronic rhinosinusitis. group 3: age ≥ 60 years. CRS: chronic rhinosinusitis.
a a
Statistically significant difference among the three age groups. Statistically significant difference among the three age groups.

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452 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 4 ( 2 0 13 ) 44 9–4 5 3
4. Discussion
Common symptoms of CRS are nasal congestion/obstruction,
rhinorrhea (anterior rhinorrhea or postnasal drip), dysosmia,
and facial pain or headache. Some of these symptoms overlap
with those of rhinitis and vascular headache, both of which are
more prevalent in younger population. Accordingly, the
symptom complex at presentation can be age dependent.
Rhinorrhea was a more common symptom among the younger
patients included in our study (groups 1 and 2) which can be
attributed to the concomitant allergic rhinitis which was more
frequent among the younger patients in our sample. In
addition, more of our younger patients (groups 1 and 2)
complained of facial pain and/or headache. Sinus-related
headache can mimic and often be confused with headache
caused by other etiologies, most notably vascular headache. In
addition, vascular headache can at times be associated with
rhinorrhea and nasal congestion that further confounds the
clinical picture. Approximately 90% of patients with migraine
headache experience their first attack before their 40th
birthday [8], and therefore would fall into group 1 based on
our age classification. The severity and incidence of headache
can also be altered by mental illness, such as depression.
Mental illness overall is more common in the younger
population [9], but this was not the case in our study sample.
Several published papers stressed the central role played
by obstruction of the OMU in the pathogensis of CRS without
polyposis, and hence advocated endoscopic sinus surgery
(ESS) [10–12]. The OMU can be blocked by anatomic variants
such as septal deviation or spur, paradoxical middle turbinate,
concha bullosa, haller cell, or agger nasi cell. However, the role
of anatomy in the pathogenesis of CRS without polyposis
remains controversial [5,13]. Our data indirectly demonstrate
that anatomic obstruction does not play a major role in the
pathogenesis of CRS without polyposis, barosinusitis, and
mucocele. The above-listed anatomic variants, besides trau-
matic septal deviation, are developmental and occur around
puberty with the completion of paranasal sinus pneumatiza-
tion and facial growth. Their incidence is not expected to
increase with age beyond puberty, and therefore their
prevalence should be constant in the various adult age groups.
One would expect that persons who acquire one or more of
these variants to present with CRS without polyposis at an
early age if these variants were critical in the pathogenesis of
the disease. As a corollary, a higher percentage of the younger
patients who are diagnosed with CRS without polyposis are
expected to exhibit one or more of these anatomic variants.
This was not the case in our study since the prevalence of
these variants was similar among the three age groups.
Various etiologies were proposed as playing a role in the
pathogenesis of paranasal sinus mucocele including obstruc-
tion of the OMU and sinus ostia, allergy, infection, develop-
mental, and trauma. Allergic rhinitis and anatomic variants that
can obstruct the OMU or sinus ostia were more common in the
younger patients (groups 1 and 2) but the relative prevalence of
mucocele and barosinusitis was similar in the various age
groups including in our study. Our data point to a minor role
played by either allergy or anatomic obstruction; instead, the
data suggest an intrinsic pathology within the affected sinus.
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The onset of allergic rhinitis and asthma peaks in in-
dividuals who are younger than 35 years of age [2,3]. The role
of environmental allergy in the pathogenesis of CRS is known.
Therefore, one can postulate that patients who suffer from
atopic disease (allergic rhinitis or asthma) are expected to
develop CRS not long after its onset. Our data support this
theory. A higher percentage of the younger patients in our
study population (groups 1 and 2) suffered from allergic
rhinitis and/or asthma than the older patients (group 3).
An intriguing finding in our data was the higher prevalence
of polyposis in patients who present at an older age (group 3)
compared to patients who present at a younger age (group 1)
despite the higher percentage in the latter group who had a
positive history of allergic rhinitis and asthma. As our data
suggest, nasal polyposis occurs at an increasing frequency
with advancing age. Moreover, polyposis in the older patients
can be triggered in response to non-atopic disease since more
than 40 % of the patients 60 years and older with nasal
polyposis in this study did not have allergic rhinitis. Plausible
explanations for these findings are the chronicity of the
disease in the elder patients and the possible age-related
changes in the histopathology of the paranasal sinus lining.
Both explanations require further research.
The recent emphasis on the inflammatory rather than
infectious nature of CRS casts doubt on the role of surgery and
advocates more aggressive and longer medical therapy [14–
16]. However, the benefit of ESS in treating inflammatory
paranasal sinus disease by improving the scores of disease-
specific and general health outcome measures is evident in
the medical literature [17]. Our data support the role of ESS.
The vast majority of patients enrolled in our study and in all
age groups reported improvement in their presenting symp-
toms following surgery. The two symptoms that improved the
most in all age groups are nasal obstruction and facial pain/
headache. Nasal obstruction is typically anatomic and there-
fore is expected to improve with surgery. The high percentage
of patients (91.01%) in group 1 who reported improvement in
facial pain and headache following surgery is noteworthy
since these patients were the most likely to complain of facial
pain and headache at presentation. Olfactory function was the
least likely among the studied symptoms to improve follow-
ing surgery, especially in the older patients. The surgery has
the potential to damage the olfactory neuroepithelium or
create scar tissue that can limit the airflow to the olfactory
cleft. On the other hand, a higher percentage of the older
patients reported improvement in rhinorrhea compared to the
younger patients. As stated earlier, allergic rhinitis was more
common in the younger patients in our study. Accordingly,
the rhinorrhea that was reported by these younger patients
was more likely caused by the rhinitis rather than sinusitis
component of their disease, and hence not expected to
respond to ESS. Additional studies that focus on the impact
of the patient's age on the surgical outcome using validated
disease-specific and general health surveys are needed.
5. Conclusion
The clinical presentation of inflammatory paranasal sinus
disease varies with age. The younger patients are more likely
 AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y –H EA D A N D N E CK ME D I CI N E AN D SUR G E RY 3 4 ( 2 0 13 ) 44 9–4 5 3
to complain of facial pain or headache, have allergic rhinitis
and asthma, have anatomic obstruction of the OMU, and be
diagnosed with CRS without polyposis. Older patients are
more likely to complain of dysosmia, and be diagnosed with
CRS with polyposis. The vast majority of the patients in the
three age groups reported improvement in all of their
presenting symptoms following surgery; however, olfactory
function is more likely to improve in younger patients and
rhinorrhea is more likely to improve in the older patients.
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