Chronic Rhinosinusitis: What do we really know?

Jeanette L. Arnold, C-FNP

University of Mississippi Medical Center

Allergy, Immunology & Rheumatology

JLArnold@umc.edu

Consultant for AAFA-

I have no further disclosures.

Chronic Rhinosinusitis- Objectives:

• Discuss diagnostic criteria for acute and chronic rhinosinusitis

• Compare and contrast CRS with acute rhinosinusitis including nasal polyposis and inflammatory mediators

• Review recent updates on management of CRS

Diagnosis: What IS Rhinosinusitis? Rhinosinusitis is:

• An ‘inflammatory process’ involving the nasal mucosa, mucus membranes of the paranasal sinuses and/or underlying bone.

• Classified as acute, subacute, recurrent or chronic based on characteristics including duration and response to therapy

UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com;Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47.

Schematic from UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com.Sinus CT courtesy of Dr. Scott Stringer, UMC Otolaryngology

UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com

Acute Sinusitis• Lasts less than 4 weeks

• Usually is of viral origin (98% likelihood for acute infectious rhinitis)

• Usually self limiting in immunocompetent persons with normal anatomy and physiology

• Routine nasophyarngeal cultures not helpful

Puhakka T, et al. Sinusitis in the common cold. JACI. 1998; 102 (3): 403-8. Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47. The diagnosis and mangagment of rhinitis: A practice parameter update. JACI 2008; 122: S5.

Subacute Sinusitis

• Protracted episodes lasting 4-12 weeks

• Incomplete resolution of acute episode

• Components of both acute and chronic sinusitis

Recurrent Sinusitis• Defined as 3 episodes of sinusitis in 6 months• Or 4 episodes in 12 months.

Chronic Rhinosinusitis

• Lasts longer than 12 weeks

• May be associated with anatomical dysfunction,

• Inflammatory process or

• Autoimmune conditionJoint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47.

Chronic Rhinosinusitis:

• Possible sequelae can include-– Loss of taste and smell– Development of mucin plugs– Soft tissue displacement– Facial dysmorphism– Bony erosion

• Exacerbation of co-morbidities

Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47.

Signs & Symptoms include:

– Nasal congestion– Facial/dental pain– Cough– Anosmia– Headache/body

aches– Post nasal drip– Purulent discharge

Adapted from The Diagnosis and Management of Rhinitis:

An Updated Practice Parameter. JACI, August 2008; 122, 2.

Sinusitis in the Common Cold

– Cross sectional study of 197 young adults with sinus symptoms:

• 39% had radiographic evidence of sinusitis on day 7• Symptoms were identical for positive and negative films• Viral infection detected in 81.6% with positive films• No bacterial Ab detected• CRP, Sed rate & WBC low • All patients clinically recovered within 21 days w/o ABIC

Puhakka T, et al. Sinusitis in the common cold. JACI. 1998; 102 (3): 403-8.

UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com

Non-infectious Sinusitis: Allergic and Nonallergic Rhinitis

• IgE mechanisms• Other causes include:

– hormonal changes– SE of medications– Chemical irritants– Exercise– Weather and temperature changes– GERD

• S/S alone do not differentiateMeltzer, E., Nathan, R., et al., Physician perceptions of the treatment and management

of allergic and nonallergic rhinitis. Allergy & Asthma Proceedings.Jan-Feb 2009: 30 (1): 75-83.

• Rondon, C., Doña, I., et.al. JACI. Evolution of patients with nonallergic rhinitis supports conversion to allergic rhinitis. May 2009 (Vol. 123, Issue 5, Pages 1098-1102).– Roughly ¼ converted from NAR to AR within 3-7 years– Roughly ¼ developed new co-morbidities w/most common being

asthma

• Jacobs, R., Lieberman, P., et. al. Weather/temperature-sensitive vasomotor rhinitis may be refractory to intranasal corticosteroid treatment Allergy Asthma Proc., March-April 2009 (Vol.30, Num. 2, Pages 120-127)– Fluticasone INC – Unexpectedly, found that there was no improvement in any

measure of efficacy.

Meta-Analysis

• Reviewed 1100 articles and 168 abstracts in five languages. Found 49 studies that were done well enough to include in their review.

• Used sinus puncture or CT scan as a reference standard.

• “Clinical Exam is not a reliable method for diagnosis of acute maxillary sinusitis.”

Varonen J Clin Epid53(9);940-8. 2000 Sept.

Scan Interpretation

• 80% of CT scans are abnormal in viral rhinosinusitis if obtained within seven days of the onset of illness.

• 45-50% of asymptomatic individuals will have findings of mucosal edema on MRI scanning.

• Films don’t take into account the normal edema phase of the normal nasal cycle

Gwaltney JM, Philips CO, et al. NEJM 1994:330:25-30; Collins JK Vital Health Statistics 1997; Gordis Rhinology 1997; Patel J. Laryng Otol 1996. Gordis Rhinology 1997.

The problem with radiography is…

• Edema phase of the normal nasal cycle (unilateral nasal congestion q 1-4 hours)

• Common cold• Allergic/vasomotor rhinitis• Interpretation varies

Collins JK Vital Health Statistics 1997;Gordis Rhinology 1997; Patel J. Laryng Otol 1996

Evaluate for:

• Allergies- consider skin testing or IgE assay

• Asthma- consider PFT (pre and post)

• Anatomical obstruction- including nasal polyposis – sinus CT +/- rhinoscopy– mucosal thickening is significant at >6mm in

an adult and >4 mm in a child– focus on OMC

Chronic sinusitis

• Chronic infectious sinusitis – usually secondary to primary

immunodeficiencies, cystic fibrosis, or anatomic defects.

• Non-infectious chronic sinusitis– thought to be inflammatory disease:

“hyperplastic” or “eosinophilic” sinusitis

Pathogenesis:Infectious and inflammatory components are likely to

be involved-

Neither one alone explains the disease.

• Infection is often present and may obscure the underlying inflammatory process.

• Colonization is hard to differentiate from infection.

• Allergy is often present and may alter the inflammatory response to infection or other stimuli.

Chronic rhinosinusitis

(CRS)

Key distinction: What is the evidence for distinct pathogenesis?What is the evidence for distinct pathogenesis?

CRS without NP CRS with NP

Clinical Pathologic Differences

CRS without NP CRS with NP

Asthma Lower Higher

ASA sensitivity Lower Higher

Inflammatory Infilt Mostly PMN’s Mostly EOS

Mucus MCP Mildly increased Very High

Local IgE prod. Little/unclear Lot

Adapted from Rhyoo 1999, Nonoyama 2000, Demoly 1997, Bachert 1998, Rudack 1998Adapted from Rhyoo 1999, Nonoyama 2000, Demoly 1997, Bachert 1998, Rudack 1998

Consider:

• GERD

• Aspirin hypersensitivity

• CF, esp. in children with nasal polyps

• Fungal sinusitis

• Primary immunodeficiency – (IgG subclasses not initial labs)

• Motility disorder

• Autoimmune conditionJoint Task Force on Practice Parameters, The diagnosis and management of sinusitis:

A practice parameter update. JACI 2005; 116: S13-47

Link between AR and Asthma is strong

• Neurologic and inflammatory “crosstalk” between conditions

• 78% of patients with asthma have AR

• 38% of pt. with AR have concomitant asthma

• 3-4 fold higher incidence as asthma in AR than in non allergic children

Meltzer, E., Blaiss, M., et al. Burden of allergic rhinitis: Results from the Pediatric

Allergies in America survey. JACI. Sept. 2009: 124:3: S43-S70.

Summary:Treatment Options:

• Viral: conservative therapies designed to promote drainage with comfort measures and tincture of time including but not limited to:– INC, saline nasal lavage

• AR: Avoidance of allergens, patient education, INC/pharmacotherapy, anti-infectious tx and immunotherapy if appropriate

Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis:

A practice parameter update. JACI 2005; 116: S13-47.

Bacterial Sinusitis• Broad spectrum ABIC for 14-21 days

• Maintain drainage

• No benefit for mucolytics or antihistamines in bacterial sinusitis (??)

• No good data RE use of decongestants

• Some recent studies suggest INC helpful

• Saline mechanically helpful; no clear data to indicate which method is most helpful

Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis:

A practice parameter update. JACI 2005; 116: S13-47

Above all else, do no harm.

• Do intranasal solutions negatively effect nasal physiology?– Infused ofloxacin, betadine, hydrogen peroxide,

amphotericin B, itraconazole, clotrimazole over nasal respiratory cells

– Noted a strong dose dependant decrease in ciliary beat frequency.

Gosepath J, et al Am J Rhinol 16(1):25-31 2002

• Literature review commentary vs. meta-analysis– Long term (@ least 12 wks.) macrolide ABIC- use

supported, esp. in pt. with low or normal IgE– 1% baby shampoo nasal saline irrigation- no

controlled trials or randomized studies– Citric acid zwitterionic irrigations destroyed the sinus

cilia (85% were denuded)– Topical amphotericin B- ineffective– Mupirocin irrigations- more successful than

vancomycin or ciprofloxin– Manuka honey irrigations- in vitro study looks

interesting

Recalcitrant CRS: investigation and managementWoodbury, Kristin; Ferguson, Berrylin J. Woodbury, Kristin; Ferguson, Berrylin J.

Curr Opin in Otolaryngol Head Neck Surg. 2011 Feb: 19 (1): 1-5

Take home points:

• Rhinitis of less than 7-10 day duration typically is less likely to benefit from oral antibiotics

• Look for presence of nasal polyps to direct management

• Look for fungus on surgical pathology to direct care

• Keep those doggies draining (OMC)

JAI-NET: technique for yoga cleansing of the sinuses