RHINOSINUSITIS. Classified in to acute ( ARS) and chronic ( CRS) forms, with infecting organisms playing a different role in each

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1 RHINOSINUSITIS The condition manifested by an inflammatory response involving the following: mucous membranes of the nasal cavity and paranasal sinuses, fluids within these cavities, and/or underlying bone. Classified in to acute ( ARS) and chronic ( CRS) forms, with infecting organisms playing a different role in each Acute rhinosinusitis Chronic rhinosinusitis without nasal polyposis Chronic rhinosinusitis with nasal polyposis Chronic allergic fungal rhinosinusitis Acute rhinosinusitis Defined as rhinosinusitis lasting up to 4/52 usually infectious First 7-14/7 predominantly viral aetiology ( human rhinovirus, adenovirus, influenza and parainfluenza and RSV ) Increased and more viscous secretions Nasal epithelium may be damaged by virus Mucosal defences impaired, permitting bacterial invasion into sinonasal mucosa Mucociliary clearance disrupted by up-regulating mucus production or damaging cilia directly Mucosal oedema resulting in obstructed sinus drainage Bacteria thought to predominate/ perpetuate after 7-14/7 commonly S.pneumoniae, H. influenza and M. catarrhalis. Risk factors for the development of sinusitis Episodic or inflammatory ostiomeatal obstruction Upper respiratory tract infection Allergic rhinitis Chronic rhinosinusitis associated with asthma and/or aspirin sensitivity (Samter) Chronic rhinitis from other causes Rhinitis medicamentosa Barotrauma Anatomical variations (significance varies in individual patients) Deviated nasal septum Concha bullosa (enlarged aerated middle turbinates) Bony spurs Immunodeficiency disorders Antibody deficiencies Isolated IgA deficiency IgG subclass deficiency+/- IgA deficiency Other congenital or acquired hypogammaglobulinaemias Cellular and combined deficiencies Phagocytic disorders Complement disorders Mucociliary disorders Cystic fibrosis Dysmotile ciliary syndromes

2 CHRONIC RHINOSINUSITIS Lifetime prevalence = 12% Aetiology Much of CRS is inflammatory Infection more likely due to coagulase negative staphylococci, S. aureus, and gram negative rods and anaerobes Biofilms have a role as a source of ongoing inflammation Biofilms are communicating organizations of microorganisms surrounded by a glycocalyx that forms on the surface of damaged biological surfaces such as the paranasal sinus mucosa Organisms living within a biofilm are relatively impervious to host defences and antimicrobials Mechanical debridement may be the only way to resolve a biofilm. This may explain why some patients with negative cultures and imaging and /or refractory to other treatment can respond well to surgery and irrigation Classification Mild: Intermittent low intensity symptoms Moderate: Frequent symptoms or at an intensity which bothers patient Severe: Continuous symptoms &/or symptoms interfering with daily activities Factors associated with chronic rhinosinusitis Major Nasal obstruction/blockage Minor Headache

3 Nasal discharge/purulence Discoloured post nasal drainage Hyposmia/anosmia Facial pain/pressure Purulence in nasal cavity on exam Fever Halitosis Dental pain Fatigue Ear pain/pressure/fullness Cough NB: Facial pain alone is not suggestive of CRS in absence of other nasal symptoms or signs Differential diagnosis of facial pain Vascular and neurological pain can cause autonomic symptoms such as nasal congestion and rhinorrhoea Other causes include : midfacial segment pain / tension headache atypical migraine cluster headache paroxysmal hemicrania atypical facial pain trigeminal neuralgia myofascial pain TMJ pain Diagnosis of CRS in adults 1. Continuous symptoms > 12 weeks The diagnosis of CRS based on simple presence or absence of symptoms may be inaccurate. There is a complex interaction between various symptom characteristics associated with CRS. The most reliable predictor for true CRS is significant dysosmia, even in the absence of polyps. 2. Clinical examination with at least one of the following signs of inflammation present such as: Purulent nasal discharge, polyps or polypoid mucosal swelling on examination Oedema or erythema of middle meatus / ethmoid bulla on endoscopy Localised or generalised erythema, oedema or granulation tissue Radiological evidence CT scan, if above CRS criteria met, demonstrating isolated or diffuse mucosal thickening, air fluid levels, bone changes There is no role for plain sinus radiograph in CRS CT is the gold standard. Role of CT scan in CRS 1. Diagnosis or screening tool 2. Staging tool : providing information on severity of disease and outcomes assessment 3. Anatomical roadmap for endoscopic sinus surgery BUT the radiographic level of disease may correlate poorly with individual symptom severity in patients with CRS. However this is also the case in other areas of medicine, for example in low back pain symptoms and MRI findings, and knee osteoarthritis symptoms and plain X-ray signs. CT demonstrates clinically reliable accuracy in the diagnosis of CRS, allowing differentiation between diseased and non diseased patients.

4 CT scan of patient with persistent nasal congestion, purulent nasal discharge and facial pain. CT shows subtotal opacification of maxillary antra, with bilaterally occluded ostiomeatal complexes. There is patchy opacification of ethmoid sinuses bilaterally. MRI scan of same patient, who had rapid loss of vision in left eye in addition to other symptoms. This shows the same extensive obstructive inflammatory disease and was used to investigate compromise of the optic nerve/canal and other intra-orbital abnormalities. MRI not recommended for routine diagnosis of CRS due to its overly high sensitivity and low specificity and greater cost. However it is indicated in a small number of situations, especially when soft tissue definition is required. It is used preferentially when imaging aggressive lesions, differentiating neoplasm from entrapped secretions, and when looking for peri-neural spread. Treatment of CRS without Polyps Patients with chronic sinusitis usually benefit from a steroid nasal spray. Many will also benefit from nasal saline irrigations. The "recipe" for the irrigations and patient instructions are attached. A prolonged course of appropriate antibiotics ( 3-4/52) and oral prednisone should be used for moderate to severe symptoms

5 Patients with symptoms suggestive of allergies should be evaluated with skin sensitivity +/- RAST testing. They may benefit from antihistamine use, sodium cromoglycate nasal spray, and possibly immunotherapy. Patients with severe, recurrent, or unusual infections may be immunocompromised and benefit from an immune-deficiency workup. Occasionally patients, particularly in the younger age groups, may first be diagnosed with cystic fibrosis as a result of paranasal sinus manifestations. When cystic fibrosis is suspected, a sweat-chloride test and genetic analysis can be performed. Surgery should not be considered in patients with chronic sinusitis until they have failed a prolonged course of appropriate antibiotics (3-4/52 course) and oral steroids, and have been shown to have radiologically significant disease. In these circumstances, the patient must feel that their symptoms are sufficiently bothersome to warrant surgery. A full and frank discussion of the risks, benefits, and alternatives to operative intervention is carried out. Treatment of CRS with polyposis Trial of topical INSS for patients with mild symptoms or small nasal polyps ( from middle meatus but not reaching IT) Short course oral corticosteroids for patients failing INSS trial, or with moderate severe symptoms, or more extensive polyps No role for concomitant antibiotics unless infection is thought to be present ( pain, purulent discharge) Consider role of allergy significantly higher incidence in patients with nasal polyps than in general population. Important to identify and avoid environmental allergens and consider immunotherapy Consider Samter s triad especially in patients with recurrent polyposis adult onset asthma, aspirin sensitivity and nasal polyposis refer for immunotherapy Treatment of Fungal Sinusitis Treatment of fungal sinusitis depends on accurate diagnosis of the type of fungal sinusitis. The four varieties of fungal sinusitis : 1. Acute fulminant invasive 2. Chronic indolent 3. Fungal ball 4. Allergic fungal sinusitis Each has different prognoses and treatments. Fulminant invasive fungal sinusitis is almost always seen in the context of an immunocompromised patient Prognosis often reflects the cause, degree, and reversibility of the immunocompromise Treatment: 1. Surgery with resection to normally bleeding tissue 2. Antifungal drug 3. Granulocyte colony-stimulating factor and hyperbaric oxygen are occasionally used. Chronic indolent fungal sinusitis is extremely uncommon Fungal balls can be simply treated by evacuation of the fungus and aeration of the sinus. Allergic fungal sinusitis is a complex, incompletely understood disease. Initial treatment involves surgical removal of the fungus and use of systemic steroids

6 Duration of treatment, dosing, and assessment of response to the systemic steroids, as well as the role of oral antifungal agents postoperatively, is all controversial. Immunotherapy may be of help in the postoperative period. All patients are placed on nasal saline irrigations and topical steroid sprays. In summary In patients treated for CRS without polyps, failure of a trial of 6/52 of intranasal steroids and 3-4/52 of oral antibiotics should prompt imaging confirmation with CT scanning. This should prevent unnecessary intervention in the form of extended medical treatment and surgery if the scans are negative.

7 Symptoms suggestive of CHRONIC RHINOSINUSITIS Mild Moderate & severe INSS 6-8/52 Antibiotics: 21/7 Prednisone 21/7 Allergy tests INSS 6-8/52 Saline irrigation Allergy tests Response Poor Good Response Good Poor Maintenance Therapy: INSS > 6/12 Saline rinse Allergen avoidance CT scan, Sinuses Abnormal Normal Alternate diagnosis?? Refer for ESS ESS = endoscopic sinus surgery INSS = intranasal steroid spray

8 Treatment of CRS with polyposis INSS x 6-8/52 Oral steroids +/- Antibiotics Good response Poor or no response Obtain CT scan ESS Continue maintenance therapy Good response Poor or no response