CHRONIC RHINOSINUSTIS

Presentation, Diagnosis and

management

BY Dr Aritro Bhattacharji
 Rhinosinusitis
• Inflammation of nose and pns – 2 or more
• One –nasal blockage/obstruction/congestion
or nasal discharge +/- facial pain/pressure,+/-
reduction or loss of smell and either-
• Endoscopic signs
• Or Ct evidence
DURATION
 Chronic rhinosinusitis
• It is a heterogenous group

• multiple aetiologies, rather than a single disease process.

• In some cases manifestation of systemic disease

• treatment in these groups is usually directed at systemic

• disease management, where possible. CRS may also occur
• as a direct result of focal abnormalities; a foreign body,
 Chronic Rhinosinusitis
• CRS-with polyps (CRSwNPs) and without
polyps
• (CRSsNPs).
• The reason for subcategorization -
Pathphysiology
• CRSwNPs characterized by an intense
oedematous stroma in sinonasal epithelium
Factors Ciliary impairment
Allergy
Asthma
Aspirin sensitivity
Immunocompromised state
Genetic factor
Pregnancy and endocrinestate
Local hostfactor
Biofilm
Environmental factor
Iatrogenic factor
H.pylori and laryngopharyngealreflux
Osteitis
Definition
 Types
Polypoidal chronic rhinosinusitis
• ‘nasal polyposis’ - pathological endpoint
• of sinonasal disease,
• Most common manifestation of polyps

• LOCALIZED NASAL POLYPOSIS

• benign -antro-choanal polyp
• inverted papilloma
• or sinonasal malignancy
• DIFFUSE NASAL POLYPOSIS
• bacterial (super-antigen
response), fungal
• sensitization, and atopy
• Severe B/l nasal polyposis -
AERD , AFRS
 NON-POLYPOIDAL CHRONIC
RHINOSINUSITIS (CRSsNPS)
• Localized CRSsNP (isolated
sinus disease and
odontogenic disease)
• Anatomical variation
• allergic or viral
exacerbation,
• leading to obstruction of
the sinus ostia, with
• secondary bacterial
infection.
• DIFFUSE NON-POLYPOIDAL
CRSsNP
• histologically characterized by
fibrosis, goblet
• cell hyperplasia,BM thickening,
• subepithelial oedema and
mononuclear cell infiltration
Systemic causes
 Chronic Rhinusinustis
Symptoms can vary from :

Local Regional Systematic

Nasal obstruction and Sore throat Malaise

congestion

Nasal discharge: Anterior/ cough Fever

Posterior

Facial pain/fullness Ear fullness Anorexia

Headache Dental pain Fatigue

Smell dysfunction Halitosis
 Pathophysio

typical cytokine pattern of CRS

● proinflammatory and neutrophil-associated
cytokines, ( IL-1β, TNF-α, IL-8), resulting in increased
neutrophil activation

CRS show Th1-Cytokines (IFN-γ) and elevated

TGF-β , may lead to increased fibrosis, hallmark
of CRSsNP
Investigations
Endoscopy:
Mucosal edema, discharge,
polyps, crusting
Assess anatomy
Also to take culture

CT scan :
preferred test- correlates
with extent of the disease
But,cannot distinguish
between infection and
inflammation.
useful in assessing severity
of the disease or response
to treatment.
Medical Management
Intranasal corticosteroids is considered as the first and the main
line of treatment in CRS. It can reduce obstructive symptoms
,decrease in the size of polyps and prevent postoperative polyp
recurrence.

Techniques of administration are

- Cross Handed Technique

- Mecca Position/ Mygind position

Another method of delivery is : Nebulised

steroids with nasal saline irrigation.
Systemic steroids are typically
administered as a part of resume of
maximal medical therapy before
considering a patient for surgery for
use in:

● perioperative period to reduce

inflammation.
● to augment optimal healing
postoperatively.
● during acute exacerbation of
CRS
● in management of
comorbidities such as asthma or
other allergic inflammatory
conditions.
Antibiotics
at least three weeks of culture directed or broad spectrum
antibiotics should be given before considering surgery.
- Amoxicillin phenols and a combination therapy of clindamycin
class trimethoprim and sulfamethoxazole.

Doxycycline has been investigated for a potential anti-

inflammatory role. Immunomodulator antibiotic: a 20-day course
of doxy-cycline was shown to reduce levels of myeloperoxidase,
eosinophil cationic protein and matrix metalloproteinase-9 in
CRSwNP patients, and had a moderate, sustained effect on polyp
size.

Mucolytics :
Mechanical Drainage can be improved by mucolytics. Guifenesini
is most commonly used to thin mucolytics.
Nasal saline irrigation and saline nasal spray: It is a safe and effective treatment
modality which can be used with intranasal corticosteroids its improves mucociliary
clearance by flushing out the mucous trust and irritants and it also has effect in
removal of antigen biofilm for inflammatory mediators and has a protective role in
Sino nasal mucosa it also allows nasals local steroid spray to acts better

Decongestants are alpha-adrenergic agonist that induce the release of 9 epinephrine

from sympathetic nerves however topical decongestant should not be used for long

Leukotriene inhibitor like montelukast can cause reduction in significant fill count
patients with allergic rhinitis and asthma.
Immunomodulatory antibiotics
Long-term macrolide antibiotics are used for their
antiinflammatoryeffects

target markers including IL-8, IL-4,

IFNγ and TNFα,

have a predominant effect on neutrophil-

mediated inflammation

Novel immunoregulation
Direct targeting using monoclonal antibodies.

omalizumab (anti-IgE) reduce both symptom and polyp size,29

and mepolizumab (anti-IL-5) has a significant effect on
polyp size.
 SURGICAL OPTIONS
Indications for surgery
• topical steroids and nasal irrigation should be
• tried for at least 4 weeks
• If the diagnosis is clinically confirmed and
maximal medical therapy
• has not improved symptoms, a CT scan is then
indicated
• The CT findings- residual disease also
anatomical risk factors
 Allergic Fungal rhinosinusitis
Afrs -non invasive
Allergic and immune response to
extramucosal hyphae
type 1 hypersensitivity reaction to
fungal
antigens in which patients usually
present with unilateral
or bilateral nasal polyps.
Approx 80% of patients
with fungal sinusitis have nasal
polyp

Aspergillus,
Bipolaris, curvularis and alternaria
 Symptoms
• u/l or b/l polyposis
thick, sticky yellow/green mucus,
• double density sign on CT
• oral steroids.
• On nasoendoscopy, inspissatted
thick yellow or brown
• peanut-butter like mucus may
be seen among the polyps
Diagnosis
St Paul’s Sinus Center Diagnostic Criteria for
AFRS
Major criteria
• Immunocompetent patient

• Presence of nasal polyposis

• Characteristic CT findings

• Presence of allergic mucin

• Positive fungal cultures or the presence of

fungal hyphae
on fungal staining
 Histology
• Hallmark – allergic mucin
• Grossly- peanut butter and axle grease
• Micro-eosinophilic, charcot –leyden crystals
• Fungal culture-positive supporting evidence
• Investigation
• IMMUNOLOGIC TEST
• elevated IgE level- 50 and >1000 IU/ml.
• average 550 IU/mL
• IMAGING –CT and MRI
• CT without contrast is the imaging of choice
 Management
• Mainstay- Surgical
• Unlike classical CRS,
• the first line treatment in AFRS

• ESS -gold standard for restoring ventilation

• Removal of allergic mucin and fungal debris

eliminates the antigenic factor
• application of topical medication
• Medical treatment
• SYSTEMIC MEDICATIONS
• I. Corticosteroids
• Oral steroids are useful in the perioperative period
• AFRS improved more compared to CRSwNP

• II. Antifungals
• Oral- recalcitrant AFRS
• steroid sparing alternative
• Itraconazole-
• II. Antifungals
• AFRS-topical antifungals reduces the
immunological reaction of atopic host

• III. Immunotherapy
• Adjunctive
treatment
• MANUKA
HONEY
• Manuka
(Leptospermum
scoparium)
• active ingredient
is methylglyoxal
(MGO)