CHRONIC

RHINOSINUSITIS
 CLINICAL DEFINITION OF
RHINOSINUSTIS IN ADULT
(EPOS2012)

⦿ Defined as inflammation of the nose and the paranasal sinuses .

Acute
▪ < 12 weeks
▪ complete resolution of symptoms.

Chronic
⦿ ≥12 weeks symptoms
⦿ without complete resolution of symptoms.
⦿ Chronic rhinosinusitis may also be subject to exacerbations
 RHINOSINUSITIS
Two or more SYMPTOMS:
🞂 Nasal
blockage/obstruction/congestion
or
🞂 Anterior nasal
discharge/posterior nasal drip
± facial pain/pressure

± reduction or loss of smell/

cough (children)
 RHINOSINUSITIS
and either
ENDOSCOPIC SIGNS OF:
Nasal polyps
and/or
Mucopurulent discharge
primarily from middle meatus
and/or
Oedema/mucosal obstruction
primarily in middle meatus
 RHINOSINUSITIS

and/or

CT SCAN OF PARANASAL
SINUSES:

Mucosal changes within the

ostiomeatal complex and/or
sinuses
SEVERITY
⦿ Severity of symptoms (VAS, main symptoms or symptoms
score)

*Adult VAS >5 affects the patient

QoL
⦿ Other significant risk or associated factors for CRS are:
• positive family history
• asthma
• allergies, chronic bronchitis and emphysema
• Smoking
• chronic rhinitis
• gastroesophageal reflux disease
• sleep apnoea
• adenotonsillitis
BACTERIOLOGY IN CRS

◦ The main pathogens

●Staphylococcus aureus
●Pseudomonas aeruginosa
●Enterobacteriaceae spp

◦ Less common pathogens

●Beta-hemolytic streptococci
 SYMPTOMS ASSOCIATED
WITH RHINOSINUSITIS
MAJOR MINOR
SYMPTOMS: SYMPTOMS:
Facial pain/pressure Headache
Facial Halitosis
congestion/fullness Fatigue
Nasal Dental Pain
obstruction/blockage Cough
Nasal discharge/PND Otalgia/fullness
Hyposmia/Anosmia
Fever
AAO-Rhinosinusitis task force 1997
General management strategies for CRS:
◼ Identify and address contributing or predisposing factors

◼ Oral or topical steroids with or without antibiotics :

⦿ Antibiotic therapy should be broader spectrum than for ABRS
Empirical therapy should target enteric gram-negative organisms, S. aureus, and anaerobes in addition to the most
common encapsulated organisms associated with an ABRS (S. pneumoniae, H. influenzae, M. catarrhalis)

⦿ Use antibiotics with broad-spectrum coverage (eg, amoxicillin–clavulanic acid inhibitors, fluoroquinolones such as
moxifloxacin)

⦿ Antibiotic therapy duration tends to be slightly longer than that for ABRS

In the absence of complication or severe illness, the initial treatment is medical:

⦿ CRSsNP: nasal or oral corticosteroid and oral antibiotics
⦿ CRSwNP: topical INCSs and short courses of oral steroids
Simultaneous oral antibiotics indicated only in the presence of symptoms suggesting infection.
Canadian Clinical Practice Guidelines for Acute and Chronic
Rhinosinusitis 2011
HOW DO WE MANAGE THE PATIENT

🞂 History
◦ Symptoms suggestive of CRS
◦ Severity
◦ Underlying diseases or co-morbidities

🞂 Examination
◦ Nasal endoscopy
◦ Biopsy and bacteriology (if necessary)

🞂 Computed tomography (CT) scan of

paranasal sinuses, orbit (if necessary)
INDICATION FOR CT SCAN IN
CRS

◦ An immunocompromised host

◦ Presence of complications (intra-

orbital/intracranial)

◦ If surgery is being considered

MANAGEMENT
🞂 Nasal airway assessment (if necessary)
◦ Nasal inspiratory peak flow
◦ Rhinomanometry
◦ Acoustic rhinometry

🞂 Sniffin’ stick olfactory test (if necessary)

🞂 Skin prick test (history of allergy positive)

🞂 Lab assessment (if necessary)

◦ CRP, FBC, ESR,RP, LFT, TFT, IgG subclass, IgE, IgG to
Aspergillus, HIV, ACE and ANCA
 MANAGEMENT OF CHRONIC
RHINOSINUSITIS WITHOUT NASAL
POLYPOSIS (CRSsNP)

◦ Intranasal corticosteroids spray 2 puffs BD

◦ Normal saline nasal irrigation 2 times OD

◦ Consider oral antibiotics (in bacterial

infection)
◦ Surgery - failed optimum medical therapy,
6 months
- recurrent infections
 MANAGEMENT OF CHRONIC
RHINOSINUSITIS WITH NASAL
POLYPOSIS (CRSwNP)

◦ Long term intranasal corticosteroids spray

●2 puffs BD
◦ Normal saline nasal irrigation
●200 ml BD
◦ Short term oral corticosteroids
●15-25 mg daily for 2 weeks (3 courses per
year)
 MANAGEMENT OF CHRONIC
RHINOSINUSITIS WITH NASAL
POLYPOSIS (CRSwNP)
◦ Consider low dose long term treatment of
Clarithromycin
●500mg daily for 2 weeks followed by 250 mg
daily for 4-6 weeks (2-3 courses/year)
●500 mg for 3 days/week for 3 months (2
courses/year)

◦ Surgery
●if failed optimum medical therapy, 3-6
months
◦ Normal saline irrigation 2-3 times per day
 ROLE OF MACROLIDES IN CRSwNP

🞂 Macrolide therapy

◦ Long-term low-dose is effective in treating CRS with

neurophilic nasal polyps

◦ Effects on the ability to modulate the neurophilic

immune response, direct activity on bacteria and
anti-biofilm properties.

Wallwork B, Coman W. Chronic rhinosinusitis and eosinophils: do macrolides have an effect? Curr Opin Otolaryngol Head Neck
Surg. 2004; 12(1): 14-17
Cervin A, Wallwork B. Macrolide therapy of chronic rhinosinusitis. Rhinology. 2007; 45(4):259-67
Harvey RJ, Wallwork BD, Lund VJ. Anti-inflammatory effects of macrolides: applications in chronic rhinosinusitis. Immunol
Allergy Clin North Am. 2009; 29(4):689-703
SALINE IRRIGATION
⦿ Increase mucociliary flow rates
⦿ Brief vasoconstrictive effect
⦿ Mechanically rinse
⦿ Adding baking soda
– Alkaline medium leads to thinning of mucus
– An acidic medium creates a more viscous (gel) mucus
CONTROL OF DISEASE
⦿ The goal of treatment is to achieve and maintain clinical
control
⦿ Define as a disease state in which the patient does not
have symptoms or the symptoms are not bothersome,
combine with healthy or almost healthy mucosa and only
the need for local medication.
EPOS2012
 ENDOSCOPIC SINUS SURGERY

⦿ Indicated for patients who fail maximal medical therapy

⦿ Goal:
◼ Clear diseased mucosa
◼ Relieve obstruction

⦿ Restore ventilation
COMPLICATIONS OF CHRONIC
RHINOSINUSITIS

⦿ Complications associated with CRSwNP and CRSsNP are less

dramatic and rarer than those that can occur in ARS but may be
difficult to manage
The following may be included:
⦿ Mucocoele formation
⦿ Osteitis
⦿ Bone erosion and expansion
⦿ Metaplastic bone formation
⦿ Optic neuropathy
THANK YOU