CANADIAN GUIDELINES FOR

RHINOSINUSITIS:
PRACTICAL
TOOLS FOR THE BUSY
CLINICIAN
YOVY TRIJAYANTI
MONICA DAMAYANI SUSILO
RAPHAEL CHRISTIE

INTRODUCTION
RHINOSINUSITIS IS INFLAMMATION OF THE SINUS AND NASAL PASSAGES
OFTEN OCCUR SIMULTANEOUSLY DUE TO THEIR CLOSE LOCATION AND
SHARED RESPIRATORY EPITHELIUM
PREVALENCE ACUTE RHINOSINUSITIS INCREASED (11% (2006) 13%(2009))
UNITED STATES
COST OF TREATMENT 6 BILLION DOLLARS IN UNITED STATES
ANATOMY OF THE SINUS
Osteomeatal Complex
RHINOSINUSITIS EPIDEMIOLOGY
AFFECTS 14% OF THE
U.S. ADULTS
(NATIONAL CENSUS
DATA)
THE AMERICAN
ACADEMY OF
OTOLARYNGOLOGY
(AAO) REPORTS A
DIRECT HEALTH
CARE COSTS OF $3.4
BILLION / YEAR
TOP TEN DIAGNOSIS
ASSOCIATED WITH
LOSS OF
PRODUCTIVITY
18 TO 22 MILLION US
PHYSICIAN OFFICE
VISITS ANNUALLY


12
59
20
26
0
10
20
30
40
50
60
D
a
y
s

(
i
n

m
i
l
l
i
o
n
s
)
Lost Work Restricted
Activity
In Bed Health Care
Visits
PREDISPOSING FACTORS IN CHRONIC
RHINOSINUSITIS (CRS)
HOST FACTORS
SYSTEMIC
ALLERGIC RHINITIS
IMMUNODEFICIENCY
IGG SUBCLASSES
IGA
GENETIC/CONGENIT
AL
CYSTIC
FIBROSIS,
CILIARY
DYSKINESIA
LOCAL
ANATOMIC
OBSTRUCTION
GASTROESOPHAGE
AL REFLUX
ENVIROMENTAL
FACTORS
MICROORGANISMS
VIRAL ILLNESS
(CHILDREN IN
DAYCARE)
POLLUTANTS
CIGARETTE SMOKE
MEDICATIONS
RHINITIS
MEDICAMENTOSA
Acute Bacterial Rhinosinusitis
(ABRS)
Chronic Rhinosinusitis (CRS)
Role of antibiotics
Ancillary therapy, testing, and
prevention
ABRS DIAGNOSIS
AT LEAST 2 OF MAJOR SYMPTOMS (PODS) MUST PRESENT, ONE OF WHICH
MUST BE O (OBSTRUCTION) OR D(DISCHARGE)
DURATION OF SYMPTOMPS >7 DAYS WITHOUT IMPROVEMENT
ABSENCE OF DIAGNOSTIC TEST ABRS DIAGNOSIS RELIES ON CLINICAL
SYMPTOMS COUPLED BY DURATION



Facial Pain/pressure/fullness
P
Nasal Obstruction
O
Nasal purulence/discolored
postnasal Discharge D
Smell disorder
(hyposmia/anosmia)
S
PODS
Low
Severity
Easily
tolerated
symptom
Moderate
Severity
Steady
symptoms
tolerable
Severe
Severity
Symptoms
are difficult
to tolerate
or interfere
with sleep
and daily
acitivity
SYMPTOM SEVERITY
BASED BY THE
DEGREE TO WHICH
SYMPTOM IMPAIR
THE PATIENT

ABRS TREATMENT
Severity
Mild
ICNS
If no response within 72
hours, consider antibiotics
Moderate
ICNS
If no response within 72
hours, consider antibiotics
Severe
ICNS
1
st
line
Amoxicillin. TMP/SMX or
macrolide for B-lactam allergy
2
nd
line
Amoxicillin/clavulanic acid
combination or fluoroquinolone
for risk resistance, risk of
complication or 1
st
line failure
ABRS TREATMENT
CRS DIAGNOSIS
FIRST
2 COPDS
1 OBJECTIVE FINDING (ENDOSCOPY / CT-SCAN)
DURATION OF SYMPTOMS 8 12 WEEKS

SECOND
DETERMINE CRS WITH NASAL POLYPS OR CRS WITHOUT NASAL POLYPS
Facial
Congestion/fullness
C
Facial Pain/pressure
P
Nasal Obstruction
O
Purulent nasal Drainage
D
Smell disorder
(hyposmia/anosmia)
S
CPODS
ROLE OF ANTIBIOTICS
ANTIBIOTICS RESISTANCE INCREASED BETWEEN 1988-2005, SOME RATES
HAVE STABILIZED IN THE 5-YEAR PERIOD BETWEEN 2000-2005
CIPROFLOXACIN, TMP/SMX RESISTANCE
ERYTROMYCIN, PENICILLIN AND TETRACYCLINE RESISTANCE RATE CONTINUE
TO INCREASE
RESISTANCE DEPENDS ON REGIONAL DIFFERENCES
ANCILLARY THERAPY, TESTING AND
PREVENTION
1. SALINE IRRIGATION 5-10 YEARS HAD BEEN RECOGNIZED IN THE
MANAGEMENT OF SINONASAL DISEASE ( CRS; ARS; ALLERGIC, ACUTE AND
CHRONIC RHINOSINUSITIS)
2. ALLERGY TESTING OVER HALF OF PATIENT WITH RECURRENT ARS OR
WITH CRS TESTED POSITIVE FOR ALLERGIES
ALLERGY TREATMENT NOT KNOWN HELPS MINIMIZE SYMPTOMS, BUT KNOWLEDGE
AND AVOIDANCE REMAINS A PRUDENT APPROACH
3. PREVENTION IMPORTANCE OF HAND WASHING TO REDUCE VIRAL
TRANSMISSION AND PREVENT DEVELOPMENT OF ABRS AND ACUTE
EXACERBATION OF CRS

Mild and moderate
severity
CRSsNP
ICNS
Antibiotics
(2
nd
line)
Short course
oral steroid
Saline
irrigation
4 weeks refer to
surgical
evaluation
CRSwNP
ICNS
Short course
oral steroid
Antibiotic
Allergy testing
2-4 months refer to surgeon
*Severe symptoms of
CRS
require immediate
referral
CRS
TREATMENT
CONCLUSION
THE GUIDELINES ARE A MUCH-NEEDED USER-FRIENDLY TOOL FOR BUSY PHYSICIANS
WHO WANT TO QUICKLY GRASP THE APPROPRIATE METHODS OF DIAGNOSIS AND
MANAGEMENT OF ABRS AND CRS
1. EVIDENCE BASED STRATEGY
2. MULTIDISCIPLINARY GROUP OF EXPERTS
3. MNEMONIC DEVICES TO AID IN DIAGNOSIS &SUCCINCT ALGORITHMS
PHYSICIANS WHO DESIRE TO UNDERSTAND THE CURRENT STATE OF THE
PATHOLOGIES AND TREATMENT APPROACHES FOR ABRS AND CRS WILL BENEFIT FROM
THESE GUIDELINES AND AS AN EXTENSION, THEIR PATIENTS WILL BENEFIT AS WELL