Chronic rhinosinusitis

CHRONIC CHRONIC CHRONIC CHRONIC CHRONIC CHRONIC CHRONIC CHRONIC RHINOSINUSITISRHINOSINUSITISRHINOSINUSITISRHINOSINUSITISRHINOSINUSITISRHINOSINUSITISRHINOSINUSITISRHINOSINUSITIS

CHULEEPORN KONGMEESOOK ,MDCHULEEPORN KONGMEESOOK ,MD

OutlineOutline

•• DefinitionsDefinitions

•• ClassificationClassification

•• DiagnosisDiagnosis

•• TreatmentTreatment•• TreatmentTreatment

EpidemiologyEpidemiology

�� Prevalence estimated Prevalence estimated 1212..55% % -- 1515..55% in % in

US and US and 1010..99% in Europe% in Europe

In children In children 99..33% acute % acute rhinosinusitisrhinosinusitis ,,�� In children In children 99..33% acute % acute rhinosinusitisrhinosinusitis ,,

1919% chronic % chronic rhinosinusitisrhinosinusitis

PiromchaiPiromchai et al International et al International Journal of Journal of General Medicine General Medicine 2013;6:4532013;6:453--6464OrapanOrapan et al Asian Pac J Allergy et al Asian Pac J Allergy ImmunolImmunol 2012;30:1462012;30:146--5151

Definitions Definitions

•• RhinosinusitisRhinosinusitis : Inflammation of nose and : Inflammation of nose and paranasalparanasal sinusessinuses

•• Acute Acute rhinosinusitisrhinosinusitis (<(<4 4 weeks ) : weeks ) :

PPurulent nasal drainage, nasal urulent nasal drainage, nasal PPurulent nasal drainage, nasal urulent nasal drainage, nasal obstruction, facial painobstruction, facial pain--pressurepressure--fullness, or bothfullness, or both

Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20102010;;125125:S:S103103--1515

Definitions Definitions

•• SubacuteSubacute rhinosinusitisrhinosinusitis ((44--8 8 weeks )weeks )

•• CRSCRS ((88--12 12 weeks ,medical Rx ) : weeks ,medical Rx ) :

IInflammatory condition involve nflammatory condition involve paranasalparanasal sinuses and nasal passages sinuses and nasal passages paranasalparanasal sinuses and nasal passages sinuses and nasal passages


Symptoms of CRSSymptoms of CRS

4 4 major symptoms (major symptoms (≥≥ 2 2 , to, to make make DxDx ))

•• anterior, posterior, or both anterior, posterior, or both mucopurulentmucopurulentdrainagedrainage

•• nasal obstruction or blockage nasal obstruction or blockage •• nasal obstruction or blockage nasal obstruction or blockage

•• facial pain, pressure, and/or fullness facial pain, pressure, and/or fullness

•• decreased sense of smelldecreased sense of smell


Middleton's Middleton's allergy:principlesallergy:principles and practice 8th editionand practice 8th edition

Definitions of Definitions of rhinosinusitisrhinosinusitisbased on disease classificationbased on disease classification

CRSsNPCRSsNP CRScNPCRScNP AFRSAFRS

Symptoms present for >12 weeksSymptoms present for >12 weeks

Requires >Requires >2 2 of following symptomsof following symptomsAnterior or posterior Anterior or posterior mucopurulentmucopurulent drainagedrainageNasal congestionNasal congestionFacial pain/pressureFacial pain/pressure

Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 2010;125:S1032010;125:S103--1515

Facial pain/pressureFacial pain/pressureDecreased sense of smellDecreased sense of smell

Objective documentationObjective documentationRhinoscopicRhinoscopic examination ORexamination ORRadiograph (sinus CT scan preferred)Radiograph (sinus CT scan preferred)

Bilateral nasal polyps Bilateral nasal polyps in middle in middle meatusmeatus

AFRS criteriaAFRS criteriaPositive fungal stain Positive fungal stain

or culture of allergic or culture of allergic mucinmucin ANDANDIgEIgE--mediated fungal mediated fungal

allergyallergy

Classification Classification (Subtypes of CRS)(Subtypes of CRS)

CRSsNPCRSsNP ((6060%)%)

•• Facial pain, pressure, and/or fullness Facial pain, pressure, and/or fullness

•• Organisms : Organisms : S.pneumoniaeS.pneumoniae, , H.influenzaeH.influenzae, , M.catarrhalisM.catarrhalis, , S.aureusS.aureus, , H.influenzaeH.influenzae, , M.catarrhalisM.catarrhalis, , S.aureusS.aureus, , S.coagulaseS.coagulase--negative negative

•• Glandular hyperplasia and Glandular hyperplasia and submucosalsubmucosalfibrosis fibrosis



CRScNPCRScNP ((2020--3333%)%)

•• HyposmiaHyposmia//anosmiaanosmia

•• Nasal polyps are typically bilateralNasal polyps are typically bilateral

•• Associated with AERDAssociated with AERD•• Associated with AERDAssociated with AERD

•• Polyp tissue predominance of Polyp tissue predominance of eosinophilseosinophils, high levels of histamine, , high levels of histamine, and Thand Th2 2 cytokinescytokines

Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--1515


AFRSAFRS

��Presence of allergic Presence of allergic mucinmucin (thick mucus (thick mucus from light tan to brown to dark green,from light tan to brown to dark green,degranulateddegranulated EEosos))degranulateddegranulated EEosos))

��Fungal Fungal hyphaehyphae in in mucinmucin

��Evidence of Evidence of IgEIgE--mediated fungal allergymediated fungal allergy



AFRS AFRS

•• Sinus surgery usually requiredSinus surgery usually required

•• Usually have nasal polyps and Usually have nasal polyps and immunocompetentimmunocompetentimmunocompetentimmunocompetent

•• PathophysiologyPathophysiology :chronic, allergic :chronic, allergic inflammation directed against colonizing inflammation directed against colonizing fungifungi

Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--15 15

PathophysiologyPathophysiology

•• Basement membrane thickening, goblet Basement membrane thickening, goblet cell hyperplasia, cell hyperplasia, subepithelialsubepithelial edema, edema, mononuclear cell infiltration in mononuclear cell infiltration in CRSsNPCRSsNP

•• 31 31 untreated untreated CRSsNPCRSsNP, <, <1010% Eos (overall % Eos (overall mean mean 22%)%)mean mean 22%)%)

•• 123 123 untreated nasal polyp, untreated nasal polyp, 108 108 showed showed >>1010% Eos (overall mean % Eos (overall mean 5050%)%)

•• Tissue Tissue eosinophiliaeosinophilia not hallmark of not hallmark of CRSsNPCRSsNP


Middleton's Middleton's allergy:principlesallergy:principles and practice and practice 88th editionth edition

PathophysiologyPathophysiology

•• Typical cytokine patternTypical cytokine pattern

��CRS : high IFNCRS : high IFN--γ, elevated TGFγ, elevated TGF--ββ

��CRSsNPCRSsNP : IL: IL--11β, TNFβ, TNF--α, ILα, IL--88

��CRSwNPCRSwNP : high IL: high IL--55, low TGF, low TGF--ββ��CRSwNPCRSwNP : high IL: high IL--55, low TGF, low TGF--ββ


ComorbiditiesComorbidities and associated and associated conditionsconditions

•• Allergic rhinitis Allergic rhinitis ( ( 6060% of CRS ,perennial )% of CRS ,perennial )

•• Immunodeficiency Immunodeficiency

( ( hypogammaglobulinemiahypogammaglobulinemia 1212% of adults with % of adults with CRSsNPCRSsNP ))

•• GERDGERD•• GERDGERD

•• Defect in Defect in mucociliarymucociliary clearance clearance ( cystic fibrosis ( cystic fibrosis

and primary and primary ciliaryciliary dyskinesiadyskinesia ))

•• Viral infection Viral infection (role of viral infection in CRS is (role of viral infection in CRS is

controversial )controversial )


ComorbiditiesComorbidities and associated and associated conditionsconditions

•• Systemic disease Systemic disease (presenting feature of WG or CSS, (presenting feature of WG or CSS,

sarcoidosissarcoidosis ))

•• Anatomical abnormalities Anatomical abnormalities ( nasal ( nasal septalseptal

deviation, deviation, conchaconcha bullosabullosa deformity, paradoxical curvature deformity, paradoxical curvature of middle turbinate )of middle turbinate )of middle turbinate )of middle turbinate )

•• AERD and Asthma AERD and Asthma ((2020% CRS have asthma ,% CRS have asthma ,22//3 3 of of

asthmatic have evidence of CRSasthmatic have evidence of CRS))


DiagnosisDiagnosis

��Nasal endoscopy Nasal endoscopy

•• discolored mucus or edema in middle discolored mucus or edema in middle meatusmeatus or or sphenoethmoidalsphenoethmoidal recess recess

��Sinus CT scanning Sinus CT scanning

•• sinus sinus ostialostial narrowing or obstructionnarrowing or obstruction•• sinus sinus ostialostial narrowing or obstructionnarrowing or obstruction

•• sinus mucosal thickening or sinus mucosal thickening or opacificationopacification, air, air--fluid levels fluid levels

��Evaluated for allergyEvaluated for allergy

•• CRS associated with AR adults (CRS associated with AR adults (6060%) %) and childrenand children ((3636--6060% )% )



TreatmentTreatment

��Topical corticosteroid nasal sprays Topical corticosteroid nasal sprays

•• Recommended for all forms of CRSRecommended for all forms of CRS

•• Beneficial effects on nasal and sinus Beneficial effects on nasal and sinus pain pain

��Antihistamines Antihistamines

•• Helpful in allergic rhinitis Helpful in allergic rhinitis


TreatmentTreatment

��Antibiotics Antibiotics

•• Used to treat infection if nasal purulence Used to treat infection if nasal purulence present (acute exacerbation)present (acute exacerbation)

��AntifungalsAntifungals��AntifungalsAntifungals

•• Indicate only in invasive forms of sinus Indicate only in invasive forms of sinus mycosis or mycosis or immunocompromisedimmunocompromised hosthost


Treatment : Treatment : CRScNPCRScNP

•• Oral corticosteroids Oral corticosteroids ((1010--15 15 days) shrink days) shrink nasal polypsnasal polyps

•• Topical corticosteroid nasal sprays Topical corticosteroid nasal sprays

recommended to prevent recurrence of recommended to prevent recurrence of nasal polyps, although not always effectivenasal polyps, although not always effectivenasal polyps, although not always effectivenasal polyps, although not always effective

•• AntileukotrieneAntileukotriene agents agents

not FDA approved for treatment of nasal not FDA approved for treatment of nasal polypspolyps

•• Sinus surgery Sinus surgery in severe in severe polyposispolyposis


Treatment : Treatment : AERDAERD

•• Might benefit from aspirin desensitization Might benefit from aspirin desensitization and daily aspirin therapyand daily aspirin therapy


Treatment : Treatment : AFRDAFRD

•• Sinus surgery Sinus surgery establish diagnosis, remove establish diagnosis, remove inspissatedinspissated mucus and restore sinus mucus and restore sinus patencypatency

•• After surgeryAfter surgery nasal polyps, nasal polyps, oral oral corticosteroidscorticosteroids 00..5 5 mg/kg/day with mg/kg/day with corticosteroidscorticosteroids 00..5 5 mg/kg/day with mg/kg/day with gradual tapering dose to control symptomsgradual tapering dose to control symptoms

•• Topical corticosteroid nasal sprays Topical corticosteroid nasal sprays to to control inflammation and prevent control inflammation and prevent recurrence of nasal polypsrecurrence of nasal polyps


Indications for sinus surgeryIndications for sinus surgery

•• Persistence of CRS symptoms despite Persistence of CRS symptoms despite medical therapymedical therapy

•• Correction of anatomic deformitiesCorrection of anatomic deformities

•• DebulkingDebulking of advanced nasal of advanced nasal polyposispolyposis•• DebulkingDebulking of advanced nasal of advanced nasal polyposispolyposis


ConclusionConclusion

PiromchaiPiromchai et al International et al International Journal of Journal of General Medicine General Medicine 2013;6:4532013;6:453--6464

PiromchaiPiromchai et al International et al International Journal of Journal of General Medicine General Medicine 20132013;;66::453453--6464

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Health & Medicine

Chronic rhinosinusitis