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Training Module CPG Management of Rhinosinusitis in Adolescents & Adults
Training Module CPG Management of Rhinosinusitis in Adolescents & Adults
LEARNING OBJECTIVES
• To learn on how to diagnose rhinosinusitis
• To learn on risk factors of rhinosisnusitis
• To learn appropriate physical examinations in
diagnosing RS
• To learn common physical findings in RS
• To learn type of reliable imaging & when to do it in
managing RS
• To learn main pathogens in acute vs chronic
bacterial RS
• To learn indication for culture & sensitivity (C&S) in
RS diagnosis
• To learn reliable methods in obtaining specimen for
C&S in RS diagnosis
5
INTRODUCTION
• Rhinosinusitis (RS) is a common health problem
characterised by mucosal inflammation of the
paranasal sinuses.
INTRODUCTION-2
• Clinical presentation of RS includes:
• nasal obstruction or rhinorrhea
• headache
• decreased sense of smell
• postnasal drip
• facial pressure or pain
• fever
• sore throat & cough
7
INTRODUCTION-3
• RS poses a major health problem, & affects the
quality of life, productivity & finances of its sufferers.
EPIDEMIOLOGY
• Acute Rhinosinusitis (ARS) & Chronic Rhinosinusitis
(CRS) are common diseases worldwide
• ARS prevalence rate ranges from 6 - 15%.1
• CRS prevalence rate is between 5 - 15% in Europe,
United States of America & Brazil1; & ranges from
2.7 - 8% in Asia.2
PREDISPOSING/RISK FACTORS
• Active smokers with concurrent allergic
inflammation have an increased susceptibility to
ARS compared to non-smokers.1
• Current & past exposure to second hand smoke
carries a higher risk of CRS compared with no
exposure.4
PREDISPOSING/RISK FACTORS-2
• Other significant risk or associated factors for CRS
are:
• positive family history4
• asthma5 especially with the presence of CRS with
nasal polyps6
• allergies, chronic bronchitis & emphysema4
• ARS6
• chronic rhinitis6
• gastroesophageal reflux disease6
• sleep apnoea6
• adenotonsillitis6
DEFINITION
• ARS
• worsening of symptoms after 5 days or symptoms
persist after 10 days & less than 12 weeks1
• CRS
• symptoms persisting for >12 weeks8
• Common cold (acute viral RS)
• symptoms <5 days
DEFINITION OF ARS
13
DEFINITION-2
• In ARS:1
• The duration is <12 weeks with complete resolution of
symptoms.
• In CRS:1
• The duration is ≥12 weeks without complete resolution
of symptoms.
14
DIAGNOSIS
• The diagnosis of RS is usually based on clinical
symptoms & supported by diagnostic imaging or
nasal endoscopy.1
CLINICAL DIAGNOSIS
16
DIAGNOSIS
• Nasal endoscopy or computed tomography scan is
one the requirement to diagnose RS.
• Past medical history of CRS is therefore sufficient to
make a diagnosis in RS in PHC.
17
DIAGNOSIS-2
• Viral vs Bacterial
• Majority of ARS cases are viral in origin.1
• Only 0.5 - 2.0% are complicated by bacterial infections
• Clinically it is difficult to differentiate whether RS is
bacterial or viral in origin.
• This may lead to unnecessary antibiotic use for
patients & increase the incidence of antibiotic
resistance.
18
DIAGNOSIS-3
• Acute bacterial RS is suggested when there are at
least 3 symptoms/signs of:
• discoloured discharge (with unilateral
predominance) & purulent secretion in the nasal
cavity
• severe local pain (with unilateral predominance)
• fever (>38ºC)
• elevated erythrocyte sedimentation rate/C-reactive
protein
• deterioration of symptoms & signs
19
EXAMINATION, IMAGING
& LABORATORY
INVESTIGATION
20
OUTLINE
• History
• Physical examination
• Imaging (CT Scan)
• Laboratory Tests
• Recommendations-3
21
PHYSICAL EXAMINATION
• Anterior rhinoscopy1
• In ARS, it should be performed at primary care
• Mucosal oedema, nasal inflammation, purulent nasal
discharge, polyps & anatomical abnormalities
EXAMINATION IN ARS
EXAMINATION IN ARS-2
23
EXAMINATION IN ARS-3
24
25
EXAMINATION IN ARS
26
PHYSICAL EXAMINATION-2
• Nasal endoscopy
• Rigid & flexible nasal endoscope (Fig. 2 & 3)
• Should be performed at ORL centre
• In the diagnosis of ABRS, the sensitivity & specificity
of flexible nasal endoscopy in reference of sinus
radiograph are 97.7% (95% CI 72.41 to 92.97) &
67.3% (95% CI 54.56 to 80.06) respectively.14
PHYSICAL EXAMINATION-3
• Nasal endoscopy
• The diagnostic values of nasal endoscopy in CRS
compared with CT scan as a gold standard are:
• sensitivity & specificity of 29 to 38% & 93 to 95%
respectively9
• accuracy of positive symptoms at 69.1%4
• PPV ranging from 0.56 to 0.89 & NPV ranging from 0.30
to 0.7615, 16
TYPES OF ENDOSCOPE
NASAL ENDOSCOPY
29
30
FINDINGS IN
ENDOSCOPY
ARS
31
Mucop
us
Middle
turbinate
Nasal
polyp
34
35
IMAGING
• Plain radiography has no role in the routine
management of rhinosinusitis.18
• CT scan is the gold standard for radiographic
evaluation of the paranasal sinuses.19
• Had been used in many studies as a reference in
diagnosing bacterial rhinosinusitis20, 21
• Can quantify the extent of inflammatory disease
based on opacification of the paranasal sinuses
IMAGING-2
• Indications for CT scan in RS are:18
• failed medical therapy
• planned for surgery
• atypical or severe disease i.e. unilateral symptoms,
blood-stained discharge, displacement of the eye &
severe pain
37
38
LABORATORY INVESTIGATION
• Laboratory culture & antibiotic susceptibility (C&S)
tests aim to document bacterial infection &
resistance pattern in bacterial RS.
• Important to ensure:
• appropriate indications
• sampling methods
39
RHINOSINUSITIS
BACTERIOLOGY
40
CHRONIC RS
• Bacteriology-different from ABRS
• Main pathogens:
• Staphylococcus aureus 8%
• Enterobacteriaceae
• Pseudomonas spp
42
ENDOSCOPICALLY-DIRECTED MIDDLE
MEATAL CULTURE (EDMMC)
• Less invasive compared with MST
• EDMMC is as accurate as MST (based on 2 meta-
analyses):
• Pooled accuracy calculated per culture & per isolate is
comparable at 73%, (95% CI 50 to 88) & 82% (95% CI 65
to 92) respectively in acute & chronic RS.24
• An accuracy of 87.0% (95% CI 81.3 to 92.8) is obtained
when detecting main pathogenic bacteria
(Streptococcus pneumoniae, Haemophilus influenzae
& Moraxella catarrhalis) in ABRS. However, the
accuracy reduced in the detection of all bacteria
(76.3%, 95% CI 69.1 to 83.6).25
OBTAINING SPECIMEN
FOR C&S
48
23. Desrosiers M, et al. J Otolaryngol - Head Neck Surg BioMed Central Ltd;
2011;40(SUPPL. 2):99–
142
EDMCC VS SINUS CT SCAN IN
49
DIAGNOSIS OF BACTERIAL RS
• EDMMC has comparable performance with sinus
CT scan as gold standard in the diagnosis of
bacterial RS (sensitivity of 92.8%, specificity of 80.0%
& accuracy of 90.2%).21
MEDICAL THERAPY
• The aims of pharmacotherapy:
• to alleviate symptoms
• to prevent complications
Cochrane meta-analyses:
◦ 2009 - a reduced risk of treatment failure in antibiotics
comparing to placebo by 34% within 7 to 15 days (RR=0.66,
95% CI 0.44 to 0.98)26
◦ 2012 - a favourable overall treatment effect of antibiotics
against placebo (OR=1.25, 95% CI 1.02 to 1.53; NNT=18).27
ANTIBIOTICS IN ARS-2
Adverse effects - mostly gastrointestinal27
Antimicrobial resistance due to overuse of
antibiotics1
Streptococcus pneumoniae, Haemophilus
influenza29, 30, 31
ANTIBIOTICS IN ARS-3
There is no significant difference in efficacy
between different antibiotics in ARS.1
ANTIBIOTICS IN CRS
• Insufficient strong evidence to support the routine
use of antibiotics in CRS.
ANTIBIOTICS
56
CORTICOSTEROIDS
• Intranasal (INS) & oral
• It reduces the inflammation & oedema of the nasal
mucous membrane rendering resolution of RS
symptoms.
57
CORTICOSTEROIDS-2
Improve patency of
ostiomeatal complex
by reduction in
mucosal swelling
Immunomodulator
Stabilise mast cells
Block formation of
inflammatory
mediators
Inhibit chemotaxis of
inflammatory cells
INS CORTICOSTEROIDS 58
ARS:
◦ 2 good meta-analyses showed that INS significantly
improved symptoms of ARS compared with placebo in 14
- 21 days. However, the effects were small.
◦ Higher doses of mometasone furoate led to better
improvement of symptoms. The side effects were mild to
moderate.34, 35
CRS:
◦ 2 meta-analyses found that INS given between 16 & 52
weeks duration was more efficacious than placebo.
Reduction in polyp size with a mean difference of 0.43 (95% CI
0.25 to 0.61)36
Improvement of symptoms, SMD= - 0.37 (95% CI - 0.60 to -
0.13)37
No difference in side effect between the INS group &
placebo37
◦ However, there was no difference in endoscopic score
between the 2 groups (SMD= -0.37, 95% CI -0.84 to 0.11)37
34. Zalmanovici Trestioreanu A, et al. Cochrane Database Syst Rev. 2013;(12):CD005149
35. Hayward G, et al. Ann Fam Med. 2012;10(3):241–9
36. Joe SA, et al. Otolaryngol - Head Neck Surg. 2008;139(3):340–7
37. Snidvongs K, et al. Cochrane Database Syst Rev. 2011;(8):CD009274
59
INS CORTICOSTEROIDS-2
Common adverse effects
◦ Nasal irritation, mucosal bleeding & crusting
ADMINISTRATION
61
CORTICOSTEROIDS
64
SALINE IRRIGATION
• Facilitates mechanical removal
• mucus
• infective agents
• inflammatory mediators
• Decreases crusting
• Increases mucociliary clearance (MCC)
SALINE IRRIGATION-2
Cochrane systematic review:41
◦ saline irrigation was efficacious as a treatment
adjunct for managing the symptoms of CRS
(SMD=1.42, 95% CI 1.01 to 1.84).
◦ no difference in the efficacy between isotonic &
hypertonic saline irrigation (p= 0.14).
SALINE IRRIGATION-3
• Adverse events are minor:41
• nasal burning
• irritation
• nausea
RECOMMENDATION ON SALINE
67
IRRIGATION
68
ANTI-HISTAMINE
There is an increase prevalence of allergic rhinitis
(AR) in patients with CRS, although the role of
allergy in the development of CRS remains
unclear.23
Antihistamine controls sinusitis symptoms in AR.
Current data yields insufficient evidence to
recommend antihistamines for treatment of CRS in
non-allergic rhinitis patients.1, 23, 42
23. Desrosiers M, et al. J Otolaryngol - Head Neck Surg BioMed Central Ltd;
2011;40(SUPPL. 2):99–142
42. Braun JJ, et al. Allergy. 1997;52(6):650–5
69
ANTI-HISTAMINE-2
• First generation
• chlorphenarimine, diphenhydramine
• Second generation
• loratadine, terfenadine, cetrizine
• Third generation
• fexofenadine, desloratadine, levocetrizine
• The newer generations are less sedative
70
RECOMMENDATION ON
ANTI-HISTAMINE
71
OTHER MEDICATIONS
• There is insufficient recent evidence on the
following treatment in rhinosinusitis:
• analgesics
• decongestants
• mucolytics
• antiviral agents
OTHER MEDICATIONS -
72
ANALGESICS
• Provide symptomatic relief in both viral & bacterial
infections of the upper respiratory passages in RS23
OTHER MEDICATIONS - 73
DECONGESTANTS
MCC improves significantly with oxymetazoline
after 20 minutes.44
Topical or systemic decongestants may offer
additional symptomatic relief in VRS, however their
ability to prevent ABRS is unproven.19
In local context, decongestants is prescribed in
ARS.
19. Rosenfeld RM, et al. Otolaryngol - Head Neck Surg (United States)
2015;152:S1–39
44. Inanli S, et al. Laryngoscope. 2002;112(2):320–
OTHER MEDICATIONS -
74
DECONGESTANTS-2
OTHER MEDICATIONS - 75
MUCOLYTICS
• There is no evidence to support the use of
mucolytics in RS.1
• Commonly available mucolytic are bromhexine
and guaifenesin - has not proven to be effective in
reducing symptoms of sinusitis.
OTHER MEDICATIONS - ANTIVIRAL 76
AGENTS
• There is no evidence of antiviral agents used
effectively in treating patients with RS.
SUMMARY OF TREATMENT
77
RELEVANCE
78
MEDICATION DOSAGE,
INDICATIONS & SPECIAL
PRECAUTIONS IN RS
MEDICATION DOSAGE,
INDICATIONS & SPECIAL
79
PRECAUTIONS IN RS
80
ACUTE RHINOSINUSITIS
81
Early Urgent
CHRONIC RHINOSINUSITIS
Early Urgent
COMPLICATION
• Acute
• Dental abscess
• Orbital Abscess, Optic neuropathy
• Bony erosion
• Intracranial
• Chronic
• Mucocoele formation
• Osteitis
• Metaplstic bone formation
• Descending infections – OM, pharyngitis, tonsillitis,
pneumonia
85
MODE OF SPREAD
• Bony dehiscence – lamina propria, floor of orbit,
intraorbital canal
• PNS development – frontal sinus absent at birth,
ethmoid and maxillary
• Thrombophlebitis
• Dental – first and 2nd premolar
• Lymphatic channels – subperiosteal abscess formation
• Subarachnoid space via perineurla space of olfactory
nerve
CT SCAN OF ARSS WITH ORBITAL
86
COMPLICATION
87
CASE 1
• A 21-year-old female presents to Klinik Kesihatan
with right painful periorbital swelling for 2 days. It is
associated with right foul smelling nasal discharge
& fever for 1 week. She has history of allergic rhinitis.
MANAGEMENT AT THIS
POINT?
A.Start oral antibiotic & give appointment
within 1 week to review the progress of
the symptoms.
B. Refer urgently to ENT
specialist/secondary or tertiary center
with ENT service.
C.Do paranasal sinus radiography to see
the air fluid level in the sinuses.
D.Start nasal decongestant & intranasal
steroid spray.
89
ANSWER 1
***At this stage. the diagnosis is ARS with orbital
complication
CHANDLER’S
CLASSIFICATION
INDICATIONS OF REFERRAL FOR 91
ARS
CASE I (CONT.)
• The patient is referred to ENT specialist within 24
hours. She complains of increasing pain of the right
eye.
MANAGEMENT
OPTION AT THIS POINT?
A. Culture & sensitivity of the nasal discharge
B. Admission & urgent referral to Ophthalmology team
C. Early referral to Ophthalmology team
D. Surgical intervention
95
ANSWER 2
A. C&S is one of the investigation & no urgency.
SCENARIO 1
• The patient agrees for admission & urgent referral
to Ophthalmology Clinic.
ANSWER 3
Acute rhinosinusitis with pre-septal
cellulitis
Q4. WHAT IS THE SUBSEQUENT
98
MANAGEMENT?
A. Broad spectrum IV antibiotic
B. Computed tomography scan of paranasal
sinuses & orbit
C. Broad spectrum IV antibiotic which cross blood
brain barrier
D. Systemic decongestant
99
ANSWER 4
A. Broad spectrum IV antibiotic is not adequate
because the infection in the orbit could spread
to the brain through orbital apex.
SCENARIO 2
• The patient’s symptoms are worsening despite 24
hours of medical therapy.
• Right eye movement is restricted.
• Her visual acuity is deteriorating from 6/12 to 6/24.
Q5. WHAT SHOULD BE THE 101
MANAGEMENT AT THIS
POINT?
A. Increase the antibiotic dosage.
B. Do computed tomography of paranasal sinuses
& orbit.
C. Increase the frequency of nasal douching.
D. Increase the intranasal corticosteroids dosage.
102
ANSWER 5
A. No
B. CT scan to look for intraorbital abscess
C. No
D. No
103
SCENARIO 2 (CONT.)
• CT scan of paranasal sinuses & orbit:
• Opaque of right maxillary & ethmoid sinuses
• Abscess formation in medial subperiosteal region of
the orbit
SCENARIO 2 (CONT.)
• Patient agrees for emergency surgery.
• Endoscopic sinus surgery & right orbital
decompression is performed.
• Post-surgery, vision improves & intraocular pressure
is normal.
• The patient discharged home on day 4 post-
surgery.
105
106
SURGICAL
INTERVENTION
SURGICAL INDICATIONS IN ARS
107
SURGICAL INDICATIONS IN CRS
108
109
No clinical
improvement
after 24-48
hrs of IV
ARS antibiotics
Indicatio Orbital or
intracranial
n of complication
Surgery s
Fail optimal
CRS medical
therapy
110
FUNCTIONAL ENDOSCOPIC SINUS 111
SURGERY (FESS)
A Cochrane systematic
review & a Health
Technology Assessment
Uses showed that FESS is a
endosco safe surgical procedure
pe with minor complications
ranging from 1.1 to
Most 20.8%45, 49
common
surgical Minimally
treatmen invasive
t techniqu
e
Improvement of ventilation Restoration of nasal cavity &
paranasal sinuses physiological
function
Nasal
obstruction
Headach Loss of
e smell
FESS
Symptomatic
improvement
Postnasa Polyp
l drip size
113
CASE 1
• A 30-year-old female presents to klinik kesihatan
with complaints of low grade fever, nasal
congestion with clear nasal discharge, watery
eyes, mild persistent facial pain & muscle aches for
3 days.
DIAGNOSIS?
A. Acute viral rhinosinusitis
B. Acute bacterial rhinosinusitis
C. Chronic rhinosinusitis
D. Allergic rhinitis
115
ANSWER 1
• In ARS, the duration is <12 weeks.
• In CRS, the duration is >12 weeks with no resolution of
symptoms.
• Differentiation between AVRS or ABRS are based on
symptoms. ABRS is suggested when there are at least 3
symptoms or signs:
• discoloured discharge (with unilateral predominance)
& purulent secretion in the nasal cavity
• severe local pain (with unilateral predominance)
• fever (38oC)
• elevated ESR, C-reactive protein
• deterioration of symptoms & signs (double sickness)
• Allergic rhinitis is defined as the presence of nasal
obstruction/rhinorrhea, itchiness of nose & eyes, &
sneezing.
116
CASE 1 (CONT.)
• Patient describes mild right facial discomfort for
which analgesics provides minimal relief. She has
no toothache.
• She works as a storekeeper & her husband smokes
one pack of cigarettes a day.
• She is not on any other medications except
inhalers for her asthma.
• She was under ENT follow-up for her allergic rhinitis
& was found to have deviated nasal septum &
inferior turbinate hypertrophy.
ANSWER 2
• Passive smoker
• Dust exposure
• Bronchial asthma
• Allergic rhinitis
118
ANSWER 2
• Environmental pollutants or allergens (cigarette
smoke & dust) & allergic rhinitis can lead to
changes in mucociliary action or initiate
inflammation, thus leading to thickened mucous
secretions & establishing a proliferation of viruses
&/or bacteria.
• Asthma & RS often coexist, & may represent a
spectrum of the same disease entity (one airway
hypothesis).
*Anatomical variation e.g. deviated nasal
septum is not a risk factor for RS.
119
CASE 1
• Mr. R, 17-year-old boy, chronic smoker, presents at
Klinik Kesihatan with 2-week history of fever, right-
sided nasal blockage, nasal discharge & facial
pain. Anterior rhinoscopy is normal.
QUESTION 1
• What is the best management option at this point?
A. Take a nasal swab for culture & sensitivity testing
B. Change treatment to broad spectrum antibiotics
C. Arrange for plain radiography of paranasal
sinuses
D. Refer for full ENT assessment
121
ANSWER 1
A. Nasal swab should not be performed in RS.
• Nasal swab cultures are of little predictive value in
diagnosing ABRS & CRS.
• When necessary, bacterial cultures in CRS should be
performed either via endoscopic culture of the
middle meatus or maxillary tap, but not by simple
nasal swab.
B. Proper C&S result is required before change/add
another antibiotics.
C. Plain radiograph MAY BE helpful only in ARS.
D. ORL referral should be done at this point for nasal
endoscopy & middle meatal swab for C&S.
122
CASE 1 (CONT.)
• Patient agrees for further assessment at ORL clinic.
ANSWER 2
• Right Acute Bacterial Rhinosinusitis (ABRS)
124
CASE 1 (CONT.)
• C&S taken endoscopically from the middle meatus
CASE 1 (CONT.)
• 2 weeks after discharge, patient presents again at
KK with fever & right-sided purulent nasal
discharge with orbital pain & diplopia.
• On examination:
• lethargic looking, febrile, right periorbital redness &
swelling
ANSWER 3
• Recurrent ABRS with orbital complication
127
QUESTION 4
• What is your next step of management?
128
ANSWER 4
• URGENT referral to ORL
• Need to exclude intraorbital/intracranial
complications (e.g. right orbital cellulitis, periorbital
abscess, orbital abscess, extradural abscess)
• Urgent CT scan of paranasal sinuses to confirm
diagnosis & for any subsequent surgical intervention
129
NES - PURULENT
DISCHARGE
130
CASE 2
• A 35-year-old male presents to klinik kesihatan with
bilateral nasal obstruction for 2 years. The
symptom has worsened for the past 6 months. He
also complains of hyposmia & postnasal discharge.
He has no history of allergy.
SCENARIO 1
• Patient is reviewed after 4 weeks. He claims the
symptoms have improved.
ANSWER 6
B. The intranasal corticosteroids & nasal saline
irrigation should be continued for at least 4
months & the evaluation should be done after
that if the medication can be reduced to
maintenance dose according to the symptoms.
133
SCENARIO 2
• Patient is reviewed after 4 weeks. However, he
claims that the symptoms worsen with the
medication given.
ANSWER 7
A. Referral to ENT should be made after fail a
course of optimal medical treatment.
Antihistamine should only be given to patients
that have allergic rhinitis symptoms.
MANAGEMENT OF CHRONIC RHINOSINUSITIS FOR
PRIMARY CARE & NON-ORL CENTRE 135
136
INDICATIONS OF
Early referral REFERRAL FOR
Urgent CRS
referral
• Failed a course of • Severe pain or
optimal medical swelling of the sinus
therapy areas (lower
• >3 sinus threshold for
infections/year immune-
• Suspected fungal compromised
infections, patients e.g.
granulomatous uncontrolled
disease or diabetes, end-stage
malignancy renal failure, HIV)
• Immunodeficiencies
*Early referral : within 2 weeks
**Urgent referral : within 24 hours
137
SCENARIO 2 (CONT.)
• Patient is reviewed by the ENT specialist.
• Nasal endoscopic examination reveals bilateral
nasal polyposis grade 2 with mucopurulent post-
nasal discharge.
ANSWER 8
B. The accepted duration for optimum medical
therapy is 16 - 52 weeks.
SCENARIO 3
• Patient is started on medical treatment & reviewed
after 4 months. The symptoms improve.
ANSWER 9
• Patient is to continue the medication until review.
SCENARIO 3 (CONT.)
• During review, patient complains of worsening
symptoms.
ANSWER 10
A. Functional endoscopic sinus surgery should be offered
in patients with CRS who fail optimal medical
treatment.
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