Amrita Journal of Medicine

Vol. 8, No: 1 Jan - Jun 2012. Page 1 - 44

revIeW artIcLe

Chronic Rhinosinusitis An Overview

N.V Deepthi*, U.K. Menon*, K. Madhumita*
ABstract
Chronic rhinosinusitis (CRS) is a common condition with significant social implications due to the loss of working hours. The common pathophysiologic denominator for virtually all forms of CRS is inflammation, for which extensive pharmacotherapy is available. Unfortunately, not all patients are cured or achieve control of their symptoms even with maximal medical management. In such cases, functional endoscopic sinus surgery (FESS) is warranted. Management modalities, although varied, can be rewarding in the compliant patient. However, there is significant variability and a lack of standardization of guidelines with respect to the above modalities. This article attempts to give the readers an overview of the methodology of investigations and treatment of this ubiquitous ENT problem. Key words: Chronic rhinitis, sinusitis, CT scan Paranasal sinuses, surgery

INTRODUCTiON Chronic rhinosinusitis (CRS) is one of the most frequent otorhinolaryngologic diseases encountered in everyday practice. It is thus a common enough medical condition, but one in which the diagnosis and prognosis depend on symptoms, signs, clinical judgement and radiological evaluation. This is often not very straightforward; numerous investigators have attempted to characterize this condition based on various factors. Some of these are as follows: Symptom scores, Computed Tomography scores, Endoscopic findings, Surgical findings, Culture results and Histopathology results. CRS is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses of at least 12 consecutive weeks duration. In addition, osteitis of the underlying bone can occur. Several factors, both intrinsic and extrinsic contribute to the development of CRS. The management approach to a patient presenting with CRS is in a logical stepwise fashion with the goal of maximizing his/her medical management and symptom relief. In the setting of failure of medical management, functional endoscopic sinus surgery (FESS) is now the widely accepted surgical modality.
*Dept. of ENT, AIMS, Kochi.

Methods Information used to write this paper has been collected essentially as part of a post-graduate dissertation accepted by the National Board of Examination. Standard texts, articles from indexed Journals and various sources in the electronic data bases using the key words chronic rhinosinusitis, nasal polyposis and functional endoscopic sinus surgery were used to do the background study. Preference was given to more recent studies. Incidence Chronic rhinosinusitis (CRS) is a common disease affecting over 30 million individuals globally each year with more than 200,000 people annually requiring surgical intervention1. It is reported to be more prevalent than arthritis or hypertension, affecting between 5% and 15% of studied populations2 according to western literature. It is a common problem that exacts a high cost in terms of direct health care as well as lost productivity.

DeFiNiTiON
Rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses. Chronic rhinosinusitis is a group of disorders characterized by

inflammation of the mucosa of the nose and paranasal sinuses of at least 12 consecutive weeks duration3. Aetiological factors A] Host factors: Systemic host factors Allergy, Immunodeficiency, Genetic/Congenital, Mucociliary dysfunction etc Local host factors Anatomic, neoplastic and acquired mucociliary dysfunction B] Environmental: Microorganisms, noxious chemicals, pollutants, smoke, medications etc C] Other Associated Factors: Asthma, allergy, dental disease, polyposis, cystic fibrosis, and immunodeficiency syndromes3. Pathophysiology The essential pathology in CRS consists of inadequate or blocked drainage of the paranasal sinuses [PNS] leading to stasis and/or secondary infection. The site of block is invariably the area that has been described as the ostiomeatal complex[OMC]. The normal anatomical-physiological system of the air-filled PNS, draining their secretions and mucus via small ostia into a relatively small area in the lateral wall of the nose {Figure 1}, is liable to assault and that too rather easily,

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Mucociliary clearance of frontal sinus

nusitis, more than 4 weeks but less than 12 weeks. As earlier stated, the RSTF further defined chronic rhinosinusitis as lasting more than 12 weeks7 The major and minor symptoms and signs suggested by RSTF are given in Table 1. TABLE 1 Factors associated with diagnosis of rhinosinusitis3 (Requires two major factors or one major and two minor factors) Major factors Minor factors Headache Facial pain/pressure (this alone does not constitute a suggestive history for rhinosinusitis in the absence of another major nasal symptom or sign) Nasal obstruction/ blockage Nasal discharge/ purulence/ Discoloured postnasal drainage

Osteomeatal complex

Mucociliary clearance of maxillary sinus

Fluid collected in sinus

Cilia drain sinuses by propelling mucus toward natural ostia (mucocilisty clearance)

Fever (all non-acute)

Fig. 1: Schematic representation of ostiomeatal complex and normal mucociliary clearance

Halitosis Fatigue Dental pain Cough

by a host of factors. Most of these have been mentioned in the earlier list. One or many of them can contribute to disrupt either the anatomy or the physiology of the PNS system. Recent findings Rhinologic literature has suggested the involvement of a significant inflammatory component that has been largely attributed to cytokines and inflammatory cells mediated by the adaptive immune system4. Recent papers have implicated staphylococcal super antigens, bacterial biofilms, and fungal colonization as key elements in CRS5. Clinical features, standardized In August 1996, the American Academy of OtolaryngologyHead and Neck Surgery (AAOHNS) convened a multidisciplinary Rhinosinusitis Task Force (RSTF) to confront difficult issues related to defining, staging, and research of rhinosinusitis5. The resulting article Adult Rhinosinusitis Defined, emerged in 1997 and was endorsed by the AAO-HNS, the American Academy of Otolaryngologic Allergy (AAOA), and the American Rhinologic Society (ARS)6. The article Adult Rhinosinusitis Defined characterizes rhinosinusitis into 5 separate clinical categories: acute, sub acute, chronic, recurrent acute and acute exacerbation of CRS. Acute rhinosinusitis is a clinical condition lasting less than 4 weeks; sub acute rhinosi-

Hyposmia/ anosmia Purulence in nasal cavity on examination Fever (in acute sinusitis alone does not constitute a strongly suggestive history for rhinosinusitis in the absence of another major nasal symptom or sign)

Ear pain/pressure/ fullness

MeASUReS FOR DiAGNOSiNG CRS FOR ADULT CLiNiCAL CARe

History: Duration of disease is qualified by continuous symptoms for > 12 consecutive weeks or > 12 weeks of physical findings Clinical examination: One of these signs of inflammation must be present and identified in association with ongoing symptoms consistent with CRS a. Discoloured nasal drainage arising from the nasal passages, nasal polyps, or polypoid swelling

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as identified on physical examination, either by anterior rhinoscopy in the decongested nose or by nasal endoscopy. {Figure 2}

Chronic Rhinosinusitis An Overview

c) An air-fluid level - more predictive of acute rhinosinusitis, but may also be seen in chronic rhinosinusitis (A plain sinus x-ray without the equivocal signs listed in a, b, or c is not considered diagnostic. Aside from an air-fluid level, plain sinus radiographs have low sensitivity and specificity) ii) Computed Tomography (CT) scandemonstrating isolated or diffuse mucosal thickening, bone changes and air-fluid level. {Figure 3} This is the gold standard investigation for CRS. iii) Magnetic Resonance Imaging (MRI) is not recommended as an alternative to CT for routine diagnosis of CRS because of its excessively high sensitivity and lack of specificity3. Other investigations: A number of other tests that may be important to individual studies and protocols include the following: Allergy testing: There is good evidence that the incidence of CRS is increased in the allergic patient. Therefore allergy testing by Skin prick test or Specific IgE or RAST may be measured in many studies. Validated outcomes instruments to measure the quality of life and patient perception of disability. Rhinomanometry and acoustic rhinometry to objectively measure nasal patency and resistance Mucociliary clearance testing including saccharine methods or radioisotopes Olfactory evaluations with validated threshold and suprathreshold testing Nasal cytology Directed laboratory evaluation to detect underlying associated systemic disease such as measurement of serum eosinophilia, IgE levels, and genetic testing. Nasal Endoscopy: Most commonly used endoscopes are 4.0mm, 30 degree rigid scope and/or 0 degree scope. In adults with narrow nasal passages or in children, a 2.7mm, 30 degree rigid endoscope or a flexible nasopharyngoscope may be better tolerated. 30 and 45 degree scopes provide direct line of sight and angled visualization. An organized nasal endoscopy in 3 passes is the usual method adopted. The first pass is along the floor of the nose. Inferior meatus, Eustachian tube orifices, Torus tubarius, adenoid pad and entire nasopharynx can be visualized. Secretions originating from the OMC will typically drain below the Eustachian tube orifice, while those originating from the posterior ethmoids or sphenoid sinuses will pass above the torus tubarius.

Fig. 2: Nasal endoscopic appearance of polyp in the right middle meatus

b. Oedema or erythema of the middle meatus or ethmoid bulla as identified by nasal endoscopy. c. Generalized or localized erythema, edema, or granulation tissue. If it does not involve the middle meatus or ethmoid bulla, radiologic imaging is required to confirm a diagnosis (Other chronic rhinologic conditions such as allergic rhinitis can have such findings, and therefore they may not be associated with rhinosinusitis. It is recommended that a diagnosis of rhinosinusitis requires radiologic confirmation under these circumstances)8. Investigations: Imaging modalities for confirming the diagnosis: i) Plain sinus radiographCaldwells and Waters views revealing: a) Mucous membrane thickening of > 5 mm b) Complete opacification of one or more sinuses

Fig. 3: Coronal study of Computed tomography of paranasal sinus showing opacification and diffuse mucosal thickening of maxillary and ethmoid sinuses, right > left
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For the second pass, the endoscope is reinserted between the middle and inferior turbinates, and advanced in a posterior direction. The inferior portion of the middle turbinate, middle meatus, the fontanelles and accessory ostia are examined. Sphenoethmoidal recess, superior turbinate and natural sphenoid os may also be visualized. Third pass view is by lateral rotation of the endoscope beneath the posterior aspect of middle turbinate to gain access to the deeper areas of the middle meatus, bulla ethmoidalis, hiatus semilunaris and infundibular entrance. As the scope is withdrawn, further excellent view of the uncinate process is obtained. Once diagnosed, attempts to further define the severity of CRS include methods to assess patient symptoms. Here again, various study groups have come up with different evaluation systems. Rhinosinusitis Task Force Major and Minor symptom criteria9 20 item Sinonasal Outcome Test 10 (SNOT20) Chronic Sinusitis Survey9 (CSS) Rhinosinusitis Symptom Inventory (RSI)10 Visual Analogue Score (VAS) Questionnaire11 An approximate algorithm in a CRS case could be as follows:
Diagnostic Nasal Endoscopy (DNE)

Sinus system Maxillary Anterior ethmoidal Posterior ethmoidal Sphenoidal Frontal Ostiomeatal complex Total points for each side

Right Left 0,1and 2 0,1and 2 0,1and 2 0,1and 2 0,1and 2 0,1and 2 0,1and 2 0,1and 2 0,1and 2 0,1and 2 0, and 2 0, and 2 0-12 0-12

Scoring: For all sinus systems, except the ostiomeatal complex: 0 - no abnormalities, 1- partial opacification, 2- total opacification For the ostiomeatal complex: 0 - not occluded, 2 - occluded Treatment modalities Medical therapy12. Absolute medications Allergen or irritant avoidance, 3-weeks course of culture-directed or broad spectrum antibiotics and 8-weeks course of topical nasal steroid spray Supportive Treatment Systemic decongestants, Antihistamines and tapering systemic corticosteroids Role and relevance of endoscopic sinus surgery In those patients who have failed medical management, functional endoscopic sinus surgery (FESS) has been demonstrated and is generally accepted to provide improved relief of symptoms and better quality of life. Although there is some controversy as to the best or most appropriate surgical technique for treating patients with CRS with polyposis (CRSwP) most surgeons will recommend that these patients undergo polypectomy, complete ethmoidectomy, and middle meatal antrostomy, with or without frontal sinusotomy or sphenoidotomy. Surgical anatomy Of all the paranasal sinuses, the ethmoid sinus is the most complex and is aptly referred to as a labyrinth. The ethmoids attain adult size by the twelfth year. However, when infection spreads from the ostiomeatal area to involve the maxillary and frontal sinuses, it is the symptoms and the roentgenographic changes in these latter sinuses that predominate. Thus the surgeon may attempt to correct the secondary pathologic changes while overlooking the underlying problem in the ostiomeatal complex. The introduction of Functional Endoscopic Sinus Surgery by Messerklinger and Wigand radically changed the way Otolaryngologists treat sinusitis14. The purpose of functional endoscopic sinus surgery is to re-establish ventilation and mucociliary clearance of the sinuses. This is achieved by removing disease from key areas of the anterior ethmoid and middle meatus. Middle
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Positive Findings

Normal Findings

Allergic

Discharge

Polyps

Anti-allergic treatment

Culture & sensitivity directed antimicrobials

Protocol treatment (Including oral steroids)

Consider CT PNS

Role and relevance of CT PNS study To confirm the diagnosis of rhinosinusitis To assess the severity of cases refractory to medical therapy prior to surgery To provide the anatomic precision needed to guide endoscopic sinus surgery To assess response to surgical intervention {Figure 4 a, b}

Lund-Mackay staging system, proposed in 1993, is considered as the most widely accepted staging system in CRS (Table 2).

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turbinate is preserved and sphenoethmoidectomy is done. The technique allows for excellent visualization, whilst causing minimal bleeding and low morbidity15. In 1978 Messerklinger introduced the concept of functional endoscopic sinus surgery based on endoscopic observation and documentation of anatomy and pathology in the middle meatal area and sinus mucociliary clearance in normal and diseased mucosa16. In 1980 Stammberger published a series of papers on FESS. The principle of the technique is limited resection of inflammatory tissue or anatomic defects that interfere with normal mucociliary clearance and result in localized persistent inflammation. Routinely carried out steps in FESS for CRS w/wo Polyps would include: Uncinectomy: removal of the comma-shaped piece of bone at the anterior edge of the middle meatus Infundibulotomy: entering the narrow space just anterior to the ethmoid air cells Ethmoidectomy: exentration of the diseased anterior, middle and posterior ethmoid air cells Sphenoidotomy: opening into the sphenoid sinus to clear disease within and widening the natural ostium Midde meatal antrostomy: widening the natural ostium of the maxillary antrum and clearing disease within Frontal recess and sinus clearance: careful identification and clearance of the frontal sinus ostium area to ensure drainage of the sinus into the nose {Figure 5 a, b}

Chronic Rhinosinusitis An Overview

techniques for biofilm detection on the sinus mucosal specimens of CRS patients19. For better understanding of the anatomy of paranasal sinuses, Tolsdorff et al demonstrated a virtual reality simulator for endonasal sinus surgery based on a volume model. This is a fully operational simulator for sinus surgery based on standard PC hardware20. Balloon sinuplasty is a new surgical technique to manage CRS, being done as an office procedure at many Centres.

CONCLUSiONS An improved understanding of the underlying disease process has led to an evolution in the treatment of CRS. Detailed recording of the clinical symptoms and physical findings, followed by diagnostic nasal endoscopy (DNE) and CT scan of PNS play a crucial role in the diagnosis, prognosis and follow-up of CRS patients. Medical therapy has begun to shift from antibiotics and decongestants to a combination of topical steroids, systemic steroids, decongestants, antihistamines and antibiotics. Surgical treatment of CRS, still a crucial component of the overall treatment plan, has shifted from radical to a more conservative, yet complete approach. Although important, surgery alone does not lead to a long term disease free state. A comprehensive management plan incorporating both medical and surgical care remains the most likely way to provide long term disease control for CRS. The exact combination continues to be debated. Nevertheless, use of long term topical steroids and regular followup of all patients seem to be the best option till date.
References
1) Murugappan Ramanathan, Jr, MD; Ernst W. Spannhake, PhD; Andrew P. Lane, MD. Chronic Rhinosinusitis with Nasal Polyps is Associated with Decreased Expression of Mucosal Interleukin 22 Receptor. Laryngoscope October 2007;117:1839-42

a) Pre-operative endoscopic view of sino-nasal polyposis

b) Post-operative endoscopic view of the same case, 2 months later

2) Hopkins et al.: Surgery Audit for Nasal Polyposis and CRS. Laryngoscope 2009:119:245965 3) Benninger et al Adult Chronic rhino sinusitis: Definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003; 129S:S1-S32. 4) Meltzer EO, Hamilos DL, and Hadley JA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. Otolaryngol Head Neck Surg 2004; 131(Suppl 6): S162. 5) Cryer J, Schipor I, Perloff JR, Palmer JN. Evidence of bacterial biofilms in human chronic sinusitis. ORL J Otorhinolaryngol Relat Spec 2004; 66:1558. 6) Report of the Rhinosinusitis Task Force Committee Meeting. Alexandria, Virginia, August 17, 1996. Otolaryngol Head Neck Surg 1997; 117(3 Pt 2):S1-68. 7) Lanza DC, Kennedy DW. Adult rhinusitis defined. OtolaryngolHead Neck Surg 1997; 117(3 Pt 2):S1-7.

Recent advances The role of various inflammatory mediators CD3, CD25, IFN-r, TGF-B, IL-1, MMP in the pathogenesis of CRS and thereby the role for targeted therapy is gaining attention17. Ramanathan et al demonstrate IL-22R1 mRNA and protein expression on nasal epithelial cells. Failure of medical and surgical therapy in CRSwNP is associated with significantly decreased expression of IL-22R118. Studies have shown the role of biofilm detection in characterization of CRS. BacLight/ confocal scanning laser microscope (CSLM) and fluorescence in situ hybridization (FISH) / CSLM are complementary
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8) A.K. Devaiah / Otolaryngol Clin N Am 37 (2004) 24352. 9) Bradely DT, Kountakis SE. Correlation between computed tomography scores and symptomatic improvement after Endoscopic sinus surgery. Laryngoscope 2005:115(3): 466-9 10) Basu S, Georgalas C, Kumar BN, Desai S. Correlation between symptoms and radiological findings in patients with Chronic Rhinosinusitis: an evaluation study using the Sino nasal Assessment Questionnaire and Lund-Mackay grading system. Eur Arch Otorhinolaryngeology. 2005: 262 (9): 751-4 11) Neil Bhattacharyya Clinical and symptom criteria for the accurate diagnosis Chronic Rhinosinusitis. Laryngoscope 2006 ;116 no7 part2,supplement no.110 12) Metson R, Gliklich RE. Stankiewicz JA. Et al. Comparison of sinus staging systems. Otolaryngol Head Neck Surg 1997;117:372-9 13) Timothy L, Smith. Objective testing and quality of life evaluation in candidates with Chronic Rhinosinusitis; Am J Rhinol 2003;17(6):351-6 14) Proctor DF; The nose, paranasal sinuses and pharynx, in Walters W (ed): Lewis- Walters practice of surgery. Boston, Little Brown and co;1982:1-37 15) Raju Polavaram, Anand K. Deviah, Osamu Sakai, Stanley M. Shapshay, Anatomic variants and pearls-Functional endoscopic sinus surgery; Otolaryngol Clin N Am;37(2004):221-42 16) Stammberger H, Micheal Hawke, Functional endoscopic sinus surgery:1-13 17) Messerklinger W.Endoscopy of the nose. Baltimore: Urban and Schwarzenberg; 1978. 18) Bachert etal.Important research questions in allergy and related diseases: Chronic Rhinosinusitis-A galen study;Allergy2009;64:520-33 19) Andrew Foreman, Deepti Singhal, Alkis J. Psaltis, Peter-John Wormald.Targeted Imaging Modality Selection for Bacterial Biofilms in Chronic Rhinosinusitis Laryngoscope 2010; 120:427-31 20) Boris Tolsdorff, Virtual Reality: A New Paranasal Sinus Surgery Simulator Laryngoscope 2010; 120:420-7