CLINICAL PROFILE OF CHRONIC RHINO SINUSITIS AND POLYPOSIS- EXPERIENCED IN GOVERNMENT TERTIARY CARE HOSPITAL

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1 TJPRC: Journal of Otorhinolaryngology and Head & Neck Surgery (TJPRC: JOHNS) Vol. 5, Issue 1, June 2015, 1-16 TJPRC Pvt. Ltd. CLINICAL PROFILE OF CHRONIC RHINO SINUSITIS AND POLYPOSIS- EXPERIENCED IN GOVERNMENT TERTIARY CARE HOSPITAL SHIVAKUMAR K. L Department of ENT, Bangalore Medical College and Research Institute, Fort Road, Bangalore, Karnataka, India ABSTRACT The Maximum number of patients having CRS were seen in the age group between years (27.2%) and those who had polyposis were in the age group years (53.5%). Male and female ratio were almost equal in CRS group (30:29) and it was statistically significant (p<0.001). Whereas in polyposis group males outnumbered females (29:14), (p>0.001). The incidence rate was more in urban population, the most commonest nasal symptom was nasal obstruction were found to be hundred percent patients by nasal discharge complication. The present study revealed that the severity of symptoms and the nasal endoscopy scores were negatively correlated in CRS with polyposis (P>0.001) and it was showed to be statistically non significant. The diagnostic nasal endoscopy is considered as an added advantage over the counterpart of anterior rhinoscopy for detecting and confirming the sino-nasal pathologies. A total 52.54% of patients were positively responded to the medical line of treatment in short course of antibiotics, topical steroid spray, nasal saline irrigations, antihistamines and nasal decongestants(p<0.0001). The mean duration of medical trail was three month and it was statistically significant p<0.001 with course of treatment. In case of CRS group, the maximum improvement was observed in one month with fewer head ache, facial pain symptom, nasal discharge and nasal obstructions. In the account of polyposis group, the maximum improvement was days, the results revealed that, the nasal obstruction (100%), nasal discharge (84.6%) and head ache / facial pain (84.6%). The incidence of minor complications was 19.4%, the most common was synechae and it was managed by release under endoscopic guidance under local anesthesia. The improvement was observed in individual symptoms and total symptoms as compared with overall satisfaction claimed by the patients. FESS is an essential tool for the management of refractory and severe forms of CRS. KEYWORDS: CRS Group, Polyposis, FESS, Nasal Endoscopy INTRODUCTION Chronic rhino sinusitis is one of the commonly (16.3%) encountered problems in otorhinolaryngological practice. 1 A study by the National Institute of Allergy and Infectious Diseases (NIAID) recently concluded that 134 million Indians suffer from Chronic RhinoSinusitis (CRS), which is more than double the number of diabetic patients in India. It is a prevalent medical disorder that has both great personal and economic impact. Beside the enormous economic burden of CRS, there is also significant patient morbidity in terms of quality of life and decreased overall productivity caused by CRS as measured by various studies. 2,3 Nasal Polyposis is considered as a subgroup of CRS with an incidence of 4% in general population 4 and 25-30% in patients suffering from CRS. Nasal polyposis are common presentation in patients of CRS and are considered to be associated with more severe forms of disease with poor treatment outcome. Liou et al 5 examined causes and contributive

2 2 Shivakumar K. L factors to asthma severity in 149 asthmatic patients at an asthma specialty clinic and found that CRS was associated with more severe asthma. Nasal saline irrigation reduces postnasal drainage, removes secretions, rinses away allergens and irritants, and improves mucociliary clearance. 6 Topical aqueous steroid nasal sprays are helpful in all types of CRS and are the cornerstone of maintenance treatment Intranasal glucocorticoids include budesonide, ciclesonide, fluticasone furoate, fluticasone propionate and mometasone furoate. Its efficacy in CRS is supported by a high level of evidence (grade A) from randomized trials, as reviewed in detail elsewhere Consensus recommendations acknowledged that antibiotic treatment for CRS is controversial because of a lack of evidence from well-conducted clinical trials. The most appropriate patients with CRS for antibiotic treatment are those with persistent purulent drainage and documented infection with pathogenic organisms, such as Staphylococcus aureus, methicillin-resistant S aureus, or gram-negative bacilli, such as Pseudomonas aeruginosa, klebsiella oxytoca, Stenotrophomonas maltophilia, or other pathogens These pathogens can be associated with either acute or chronic infection. A brief course of oral glucocorticoids has been studied primarily as a treatment for NP (ie, a medical polypectomy ). In most cases treatment results in significant clinical improvement and transient improvement in sense of smell. Patients refractory to medical management are potential candidates for surgical management. The advent of the nasal endoscope and CT scans have revolutionized the understanding and surgical management of CRS and CRS with polyposis. In the early twentieth century Mosher said that intranasal ethmoidectomy is one of the most dangerous and blindest of all surgeries. This view changed dramatically with the advent of the endoscopes. Throughout the history of numerous attempts have been made to illuminate and examine the inside of the various hollow cavities located within the body. 15 In 1907, Hirschmann used a modified cystoscope to examine the middle meatus and study sinus ostia. 16 The most significant development in nasal endoscopy was noticed during 1950 s when Hopkins developed solid rod lens with proximal cold light source. In the latter part of twentieth century, sinonasal endoscopy has been established as an important component in our diagnostic and therapeutic armamentarium. 17 The pioneering work of Professor Walter Messerklinger of Graz, Austria on sinus mucosa and mucociliary transport has brought light into the understanding the pathophysiology of sinus disease. This can be summarized in most PNS infections spread from nose to sinus. Recurrent sinusitis is secondary to insufficient outflow or obstruction of the natural sinus ostia into the nasal cavity. Sites of obstruction or partial stenosis are the ethmoid infundibulum at the entrance to the maxillary and frontal sinus. 17,18 This work of Messerklinger has been appreciated and accepted. The earlier concept that frontal and maxillary sinuses are the culprits for chronicity of the disease is no longer accepted. This point was again confirmed by the introduction of computed tomography (CT) scan. Modern endoscopic sinus surgery is arbitrarily divided into Messerklinger and Wigand approaches. The Messerklinger approach (1985) is ideal for patients with anterior ethmoid diseases with or without maxillary on frontal sinus disease. Here the approach is from anterior to posterior. It can be extended to the posterior ethmoids, sphenoid and frontal sinus, if necessary. The Wigand approach (1978) is in contrast ideal for patients with pan sinusitis who may not respond to limited surgery. This approach is from posterior to anterior and routinely involves clearance of all the sinuses. Both techniques are based on the assumption that the sinus mucosa is reversibly diseased and will return to normal once an adequate drainage has been established. FESS in the last two decades has become popular for sinusitis. However it is important to look at your results and complications. present study was conducted to analyse the demographics, clinical features and treatment outcomes for two group of CRS with or without

3 Clinical Profile of Chronic Rhino Sinusitis and Polyposis-Experienced 3 in Government Tertiary Care Hospital polyposis and to know the effectiveness of FESS for reducing the symptoms and endoscopic features of CRS. MATERIALS AND METHODS Total 59 patients of prospective study was conducted in the Department of ENT, BMCRI during Chronic rhino sinusitis with and without nasal polyposis attending ENT OPD were consider for the study. Inclusion Criteria Patients above 10 years of age diagnosed as CRS according to the American Academy of Otorhinolaryngology and Head Neck Surgery, 2007 criteria. 25 Exclusion Criteria Patients with Known case of chronic diseases like cystic fibrosis, primary ciliary dyskinesia, immune deficiencies. all types of fungal rhinosinusitis/odontogenic cause chronic granulomatous diseases of nose. not complying to study protocol or lost on follow up. paranasal tumours. medical or surgical treatment influencing the study. unfit for surgery. Pregnancy. Study Protocol Permission was taken from the Institutional Ethics Committee. Total of 102 subjects of which 59 patients with CRS and 43 patients with CRS with polyposis were enrolled in the study. A complete assessment and examination was carried out as follows: History: A detailed history including chief complaints, associated complaints, their onset, duration, severity and progression of symptoms was taken. An account of relevant past history was also documented. Most of authors namely Bhattacharyya 60 have used the Likert Scale from 0 (symptom absent) to 5 (very severe) in grading of the symptom severity as mentioned below. We also scored severity of symptoms as per the Likert Scale and coded :- Absent-0, Very mild-1, Mild-2, Moderate-3, Severe-4 and Very severe-5. Thus each patient had severity score for each symptom and Total Symptom Severity Score (TSSS) was calculated by adding the severity score of each symptom. Total six symptoms were taken into account associated with CRS ie, nasal obstruction, nasal discharge, headache / facial pain, post nasal discharge, sneezing and hyposmia/anosmia. Thus the TSSS ranged from 0 to 30.

4 4 Shivakumar K. L EXAMINATION A detailed general physical examination was done in all patients. A detailed ENT examination was done which included Ear, Nose, oral cavity and throat and Nick examination b. Routine haematological and urine analysis was carried out. All subjects underwent rigid nasal endoscopy after written informed consent. To identify any anatomical site of nasal obstruction. To know condition of inferior and middle turbinate, meati and OMC. To identify type and source of nasal discharge or polyp. To look for any associated sinus pathology. Identify any anatomical variation or abnormality. Procedure Was carried out as a daycare procedure. Xylocaine sensitivity test was done in all cases prior to the procedure. In cases where clinical examination revealed severe congestion of nasal cavity topical decongestant drops of Xylometazoline were instilled in nose a day prior and on the day of procedure. Written and informed consent was obtained from patient / guardian in their mother tongue. Local anaesthesia with nasal patty of 4% Xylocaine + 1:1000 adrenaline was used. All procedures were carried out under guidance with 4mm 0 degree rigid endoscopes, 30 degree endoscopes were used whenever it was required. The findings of nasal endoscopy were recorded in the proforma and photo documentation was made in selected patients. Amoxiclav 625 mg twice daily) for 3 weeks, topical steroids (fluticasone furoate/fluticasone propionate-200microgram/puff, 2 puffs in each nostril twice daily), saline nasal drops, oral antihistamine-decongestant for 3 months. Follow up nasal endoscopy was done at 1, 3 and 6 months. We also asked the patient about his overall assessment and satisfaction and we graded overall assessment. In grading of overall assessment and satisfaction we followed the same pattern as mentioned by Lund VJ. 46 Overall Assessment / Satisfaction -2 All symptoms worsened -1 Few symptoms worsened, rest unchanged 0 No change in any of the symptoms

5 Clinical Profile of Chronic Rhino Sinusitis and Polyposis-Experienced 5 in Government Tertiary Care Hospital +1 Few symptoms better, rest unchanged +2 All symptoms better. In subjects were the symptom scores and endoscopy scores were the same or have worsened at 1 month, the treatment was continued upto total 3 months adding a course of systemic steroid (oral methyl prednisolone 48 mg in divided doses daily tapering for a total duration of 2 months).7. At 3 months, the subjects with same or worsened symptom and endoscopy scores were labelled refractory to medical therapy and FESS was planned in them. Those subjects which showed improvement in both symptom and endoscopy scores at 1 and 3 months were maintained on topical steroid therapy. Patients under the CRS with polyposis group were given broad spectrum antibiotics (Ciprofloxacin 500mg twice daily or Amoxiclav 625 mg twice daily) for 3 weeks, topical steroids (fluticasone furoate/fluticasone propionate- 20microgram/puff, 2 puffs in each nostril twice daily), saline nasal drops, antihistamine-decongestant and course of systemic steroid (oral methyl prednisolone 48 mg in divided doses daily tapering for a total duration of 1 month) and FESS was planned in them. CT-Paranasal sinus scan was done in all the patients planned for FESS. In each patient, the combined axial, coronal & sagittal sections of CT scan of the paranasal sinuses was obtained and staged using the Lund Mackey CT scoring system. 30 This system is based on the appearance of each paranasal sinus on the CT scan. Table 1 Sinus Systems (0-2) Right Left Maxillary Anterior ethmoids Posterior ethmoids Sphenoid Frontal Ostiomeatal complex Total no Opacification/no occlusion Partial opacification/partial occlusion Complete opacification/complete occlusion Thus a total score of 0 to 24 is possible, and each side can be considered separately (0-12). Final diagnostic evidence of CRS was defined by the gold standard of a Lund MacKay score greater than or equal to 4. It also helped as a road map to endoscopic sinus surgery. FESS was done in all the patients with CRS refractory to medical therapy and in patients of CRS with polyposis. The Messerklinger technique was used in all the patients ie, from anterior to posterior approach but the extent of surgery was decided on the basis of preoperative CT scan and the intraoperative findings and was thus tailored to the individual.

6 6 Shivakumar K. L Functional Endoscopic Surgery Anesthesia Hypotensive general anesthesia was used in all patients as it had an advantage of controlled ventilation, reduced bleeding and pain. The sites of infiltration of the local anesthesia agent (2% lignocaine with adrenaline 1:20,000) are uncinate process, bulla ethmoidalis and root head and posterior end of the middle turbinate. In cases of nasal polyps, they too are infiltrated. It is important to wait for 10 minutes after infiltration before surgery is commenced. Instruments of FESS 0,30 and 70 degree nasal endoscopes with guard Cold light source and fiber optic cable Suction tips straight and curved Long curved needle 26 G with 5 ml syringe Antifog solution (ultrastop / savlon) Freer s elevator Sickle knife Ball probe Blakesley forceps straight, 45 and 90 degree Ostrum s reverse cutting forceps Table 2: Correction between the Management and Nasal Endoscopy Score (NES) in Chronic Rhinosinusitis Patients (n=59) Nasal Endoscopy Score(NES): CRS Medical (31) No (%) Surgical(28) No (%) 0-2 3(9.7) 0(0) (83.8) 7(25) 5-6 2(6.5) 6(21.4) 7-8 0(0) 14(50) (0) 1(3.6) (0) 0(0) Of 31 patients managed medically, 100% had NES score in the range of 6 and of 28 patients managed by FESS 53.5% patients (15) were in the range of >6, thus proving that patients with more severe disease evident by endoscopy had to undergo FESS eventually. The observations were statistically significant. (p<0.0001, Fisher s exact t test)

7 Clinical Profile of Chronic Rhino Sinusitis and Polyposis-Experienced 7 in Government Tertiary Care Hospital Table 3: Distribution of Patients According to the Extent of FESS in Patients of Chronic Rhinosinusitis and Chronic Rhinosinusitis with Polyposis Surgery Chronic Rhinosinusitis(28) No (%) Chronic Rhinosinusitis with Polyposis(43) No (%) Uncinectomy+Osteomeatal complex widening 3(10.8) 4(9.4) Uncinectomy+Osteomeatal complex widening+ 19(67.8) 30(69.7) Fronoethmoidectomy Uncinectomy+Osteomeatal complex widening+ 6(21.4) 9(20.9) Fronoethmosphenoidectomy Total 28(100) 43(100) 19(67.9%) CRS patients out of 28 operated for FESS underwent uncinectomy with osteomeatal complex widening and fronoethmoidectomy. Whereas 30(69.8%) out of 43 patients of the CRS with polyposis group underwent the same procedure. Septoplasty was done in 23 patients (32.4%) and turbinoplasty was done in 16 patinets (22.5%). Table 4: Distribution of Patients according to the Complications of FESS Complication of FESS Chronic Rhinosinusitis(28) No (%) Chronic Rhinosinusitis with Polyposis(43) No (%) Total (71) No (%) Hemorrhage 1(3.6) 1(2.3) 2(2.8) Orbital cellulitis 1(3.6) 2(4.7) 3(4.2) Synechae 2(7.2) 4(9.3) 6(8.5) Surgical emphysema 1(3.6) 1(2.3) 2(2.8) Meningitis 1(3.6) 0(0) 1(1.4) The most common complication was synechae formation (8.5%) and the least common was meningitis (1 patient-1.4%). Pre operatively, 10 patients (35.7%) were having moderate to severe (scores 3, 4, 5) headache and post operatively at 1 month follow up, 2 patinets (7.1 %) were having mild to severe headache. Thus, there was 80% improvement in head ache symptom after surgery, which was consistent at 6 months follow up after surgery. The observations were statistically significant. (p= i.e <0.05, Fisher s exact t test) Figure 1: Recording Unit and SAAS WOLF Endoscopes

8 8 Shivakumar K. L Figure 2: Pre Endoscopic Nasal Packing with Cottonoids Figure 3: Diagnostic Nasal Packing Endoscopy and Excised Choanal Polyp Specimen

9 Clinical Profile of Chronic Rhino Sinusitis and Polyposis-Experienced 9 in Government Tertiary Care Hospital Figure 4: Polyp Actual Score Images Table 5: Distribution of Chronic Rhinosinusitis Patients According to the Pre-Operative and Post Operative Symptom Severity Score for Post Nasal Discharge Symptom Post Operative (Follow Up) Pre-Operative Severity 1 Month 3 Months 6 Months No(%) Score No(%) No(%) No(%) 0 13(46.4) 20(71.4) 20(71.4) 20(71.4) 1 0(0) 3(10.7) 3(10.7) 3(10.7) 2 2(7.2) 1(3.6) 1(3.6) 1(3.6) 3 8(28.6) 1(3.6) 1(3.6) 1(3.6) 4 5(17.8) 3(10.7) 3(10.7) 3(10.7) 5 0(0) 0(0) 0(0) 0(0) Pre operatively, 15 patients (53.6%) were having moderate to severe (scores 3, 4, 5) post nasal discharge and post operatively at 1 month follow up, only 4 patinets (14.2%) were having moderate to severe post nasal discharge. Thus, there was 73.3% improvement in post nasal discharge symptom after surgery, which was consistent at 6 months follow up after surgery. The observations were statistically significant. (p=0.0041i.e<0.05, Fisher s exact t test)

10 10 Shivakumar K. L Table 6: Distribution of Chronic Rhinosinusitis Patients According to the Pre-Operative and Post Operative Symptom Severity Score for Sneezing Symptom Post Operative (Follow Up) Pre-Operative Severity 1 Month 3 Months 6 Months No(%) Score No(%) No(%) No(%) 0 5(17.8) 6(21.4) 6(21.4) 6(21.4) 1 0(0) 8(28.5) 8(28.5) 8(28.5) 2 1(3.5) 1(3.6) 1(3.6) 1(3.6) 3 18(64.3) 10(35.8) 10(35.8) 10(35.8) 4 4(14.4) 3(10.7) 3(10.7) 3(10.7) 5 0(0) 0(0) 0(0) 0(0) Pre operatively, 22 patients (78.5%) were having mild to severe (scores 3, 4, 5) sneezing and post operatively at 1 month follow up, 13 patinets (46.4%) were having mild to severe sneezing. Thus, there was only 40.9% improvement in sneezing symptom after surgery, which was consistent at 6 months follow up after surgery. The observations were statistically significant. (p=0.0261i.e<0.05, Fisher s exact t test) Table 7: Distribution of Chronic Rhinosinusitis Patients According to the Pre-Operative and Post Operative Total Symptom Severity Score (N=28) Total Symptom Pre- Post Operative (Follow Up) Severity Score (TSSS): Crs Operative No(%) 1 Month No(%) 3 Months No(%) 6 Months No(%) 0-5 0(0) 12(42.8) 12(42.8) 12(42.8) (17.8) 11(39.3) 11(39.3) 11(39.3) (53.6) 4(14.4) 4(14.4) 4(14.4) (28.6) 1(3.5) 1(3.5) 1(3.5) (0) 0(0) 0(0) 0(0) (0) 0(0) 0(0) 0(0) Preoperatively, patients with TSSS >10 was 23/28 (82.1%) and post operatively the number of patients with TSSS >10 was reduced to 5/28 (17.9%) at 1 month follow which was consistent at 6 months follow up also. Thus the improvement rate in all symptoms post FESS is 78.3%. The observations were statistically significant. (p<0.0001, Fisher s exact t test) DISCUSSIONS Family practioners, general physicians, paediatricians, and otorhinolaryngologists see large numbers of patients with symptoms of facial pain, nasal obstruction and nasal discharge is obviously a nuisance that causes absence from school, work and social functions. However it may exacerbate more serious illnesses such as asthma or chronic obstructive pulmonary disease, necessitating the use of long term daily steroids or increase in other pulmonary and cardiovascular medications. 39 Surgical intervention in CRS typically is performed when patients remain refractive to medical therapy. Current trans-nasal approaches popularly known as FESS aim to remove bony sinus partitions and debulk polypoid mucosa, thereby allowing restoration of mucociliary clearance through the natural drainage pathways. This approach significantly reduces morbidity and provides satisfactory results when combined with appropriate medical therapy. However it has been clearly indicated that resolution of patient s symptoms does not equal resolution of disease. So deciding on the best outcome to measure after treatment of CRS is difficult. Because the disease itself is defined by signs and symptoms (and not physical findings), it is logical to use the presence and severity of sinonasal symptoms as the primary outcome measure for sinusitis. We therefore based our case proforma on several major and minor clinical criteria

11 Clinical Profile of Chronic Rhino Sinusitis and Polyposis-Experienced 11 in Government Tertiary Care Hospital set forth by the American Academy of Otorhinolaryngology and Head Neck Surgery, 2007 criteria 25 and Likert Scale 60 from 0 (symptom absent) to 5 (very severe). The present study was conducted in the Department of ENT, of a tertiary care hospital during the period of Dec 2011 Sep The study population included 59 patients of CRS and 43 patients of CRS with polyposis after fulfilling inclusion and exclusion criteria. It is focused on the demographic profile, clinical profile of patients with CRS and CRS with polyposis and improvement in the symptom profile of patients after FESS. According to Nayak et al 49, ages of the patients were varying between 12 to 57 years and the average age was 34.5 years. While in the study by Francis TK Ling 62 age of the patients were varying between 18 years and 80 years and the average age was 49.4 years. In general, Nasal Polyposis occurs in all races 7 and becomes more common with age. The average age of onset is approximately 42 years and are uncommon under the age of In the present study the age of the CRS patients were varying between 16 years and 67 years and the average age was 35.9 years. Thus our age prevalence is comparable with others. The age of CRS with polyposis patients were varying from 11 years and 64 years and the average age was 34.7 years. Common age group of presentation in CRS patients in the present was between age group (27.2%) and in CRS with polyposis was between age group (51.2%). Francis T. K. Ling 62 found the male to female ratio almost similar (1.1:1). Bajaj and Mudhol et al found the male incidence higher 1.66:1, 2.75:1 respectively. In the present study, we have observed a higher incidence in males; this may be because males are exposed more to environment pollutions and infections. Generally Nasal Polyposis are twice as prevalent in men although the proportion of those with polyps and asthma is twice that in women than men. 7 In the present study the male: female ratio in the polyposis group was 2.07:1. There have been relatively few studies examining the relationship between air pollutants and CRS incidence or prevalence. Bhattacharyya 3 performed a cross-sectional analysis to examine the relationship between the prevalence of hay fever and sinusitis and US-wide air quality measurements during the period Using the National Health Interview Survey and pollutant level data from the US Environmental Protection Agency, a direct relationship was found between the prevalence of both hay fever and sinusitis and pollutant levels of carbon monoxide, nitrous dioxide, sulfur dioxide, and particulate matter. The role of environmental factors in the development of Nasal Polyposis is unclear. No difference in the prevalence of Nasal Polyposis has been found in the patient s habitat or pollution at work 7. One study found that a significantly smaller proportion of the population with polyps were smokers compared to an unselected population (15% vs. 35%) 65 whilst another found an association between the use of a woodstove as a primary source of heating and the development of Nasal Polyposis. 66 The present study, the prevalence of CRS and CRS with polyposis were more in urban areas ie 91.5% and 58.1% respectively, the reason being may be urban population being more exposed to air pollutants and also they have more access to health facilities. Nasal Symptoms The following authors: Bajaj MRCS 64, Francis T K Ling 62, Brain L Mathew et al 67, Nasser A Fageeh 68 and Sevendstrup F69 all found nasal obstruction was the commonest presenting complaint. Table 7

12 12 Shivakumar K. L Authors Nasal Nasal Obstruction Discharge Brain L Methew et al (1991) 67 96% - Nayak et al(1991) % 92% N A Fagee et al(1996) 68 76% - Jakobsen J et al (2000) 69 61% - Y Bajaj et al(2007) % 35.7% Francis T K Ling et al (2007) % - Mudhol et al(2011) % 90% Present study 100% 91.5% (CRS) 90.7%(CRS with polyposis) In the present study, the commonest symptom was nasal obstruction followed by nasal discharge. In the present study, history of asthma was present in 14/102 patients ie in 13.7% of patients. Medical Management Table 8 Study (Reference) Drug Number Time/Dose Effect on Symptoms 875/125 mg for 14 Clinical cure: Amoxi-clav vs Namyslowski et al, days; 500 mg for Amoxiclav-95% Cefcefuroxime axetil 14 days 88% Subramanian et al, 2002 Mc Nally et al,1997 Legent et al,1994 Present study Antibiotics; corticosteroids Oral antibiotics+topical steroids +adjunctive therapy Ciprofloxacin vs Amoxi-clav Ciprofloxacin and Amoxiclav weeks weeks days 59 1g daily for 4 weeks; 875/ 125 mg for 4 weeks Yes, improvement after 6 weeks Yes, subjectively after 4 weeks Nasal discharge disappeared: cipro- 60% Am-cl-56% Clinical cure in 52.5% To date five RCT s have investigated the use of topical steroids in CRS. Two of these trials involved intrasinus instillation. The other three involved topical treatment. Four of the five trails demonstrated significant improvement in symptoms with no evidence of increased infection The studies treatment duration ranged from 3 weeks to 20 weeks. Table 9 Study Drug Number Time Lund, etal 2004 Lavigne, 2002 Parikh, 2001 Topical budesonide Intrasinus budesonide Fluticasone propionate weeks 3 weeks 16 weeks Effect on Symptoms Significant improvement Significant improvement Not significant

13 Clinical Profile of Chronic Rhino Sinusitis and Polyposis-Experienced 13 in Government Tertiary Care Hospital Cuenant, 1986 Sykes, 1986 Present study Tixocortol irrigation Dexamethasone +tramazoline Ciprofloxacin and Amoxiclav days 4 weeks 12 weeks Significant improvement Significant improvement Significant improvement Thus the primary treatment in CRS is medical treatment using the above modalities in conjunction with saline nasal irrigation, antihistamines, anti-leukotrines, etc. The primary aim is to reduce the congestion and oedema so as to allow ventilation and drainage of the sinuses. Present study we managed 31/59 patients by medical management ie 52.5% and maximum medical therapy was given for 3 months after which FESS was done in those refractory to medical therapy. FESS. 47.5% of the patient with CRS and 100% of the patients with CRS with polyposis were managed surgically by Improvement in Nasal Obstruction after FESS Table 10 Authors Preoperative (%) Improvement Rate (%) Brain L Methew et al (1991) Nayak et al(1991) N A Fagee et al(1996) Jakobsen J et al (2000) Y Bajaj et al(2007) Francis T K Ling et al (2007) Mudhol et al(2011) Present study % at 1 month and same at 6 months(crs) ; 100% at 1 month and 93% at 6 months (CRS with polyposis) Francis K Ling et al, 62 found improvement in nasal obstruction in 92% of their patients postoperatively. In the present study we observed an improvement in nasal obstruction in 74.1% in CRS patients at 1 month follow up visit after FESS and was consistent at 6 months follow up. In patients with CRS with polyposis 100% of patients had improvement in nasal obstruction at 1 month follow up visit after FESS which decreased to 93% at 6 months follow up. Improvement in Rhinorrhoea In the present study we found moderate to severe rhinorrhoea, in 25/28 CRS patients (89.3%) and post operatively at 1 month follow up, 6 patients (21.4%) were having moderate to severe nasal discharge. Thus, there was 76% improvement in nasal discharge symptom after surgery, which was consistent at 6 months follow up after surgery. In CRS with polyposis group, pre operatively, 39 patients (90.7%) were having moderate to severe nasal discharge and post operatively at 1 month follow up, 6 patients (15.4%) were having moderate to severe nasal discharge. Thus there was 84.6% improvement in nasal discharge symptom after surgery. At 6 months follow up after surgery, 11 patients (25.6%) had moderate to severe nasal discharge, thereby decreasing the improvement rate to 71.8%. Improvement in Headache

14 14 Shivakumar K. L Table 11 Authors Preoperative (%) Improvement Rate (%) N A Fagee et al(1996) Bhattacharyya etal(2004) 60 - Largest effect size improved Byan Khademi et al(2007) Y Bajaj et al(2007) Mudhol et al(2011) Our study 39.3(CRS) 81.8% at 1 month and same at 6 months(crs) ; 84.6% at 1 month and 69.2% at 6 months (CRS with polyposis) In the present study, pre operatively, 11/28 CRS patients (39.3%) were having mild severe headache and post operatively at 1 month follow up, 2 patients(7.1%) were having mild to severe headache. Thus, there was 81.8% improvement in head ache symptom after surgery, which was consistent at 6 months follow up after surgery. Pre operatively, 13/43 CRS with polyposis patients (30.2%) were having moderate to severe head ache and post operatively at 1 month follow up, 2 patients(4.7%) were having moderate to severe headache. Thus, there was 84.6% improvement in headache symptom after surgery. At 6 months follow up after surgery, 4 patients (9.4%) had moderate to severe headache, there by decreasing the improvement rate to 69.2%. Improvement in Postnasal Discharge In the present study, 15/28 CRS patients (53.6%) were having mild to severe post nasal discharge and post operatively at 1 month follow up, 5 patients (17.9%) were having mild to severe post nasal discharge. Thus, there was 66.7% improvement in post nasal discharge symptom after surgery and 19/43 CRS with polyposis patients (44.2%) were having moderate to severe postnasal discharge and post operatively at 1 month follow up, only 6 patients (14%) were having moderate to severe postnasal discharge. Thus, there was 68.4% improvement in postnasal discharge symptom after surgery. At 6 months follow up after surgery, 8 patients (18.6%) had moderate to severe post nasal discharge, thereby decreasing the improvement rate to 57.9%. Improvement in Hyposmia Y Bajaj etal (2007) 64 and Nasser a Fageeh(1996) 68 et al found hyposmia was the second commonest, and third commonest symptom in their pre-operative patients respectively. Hyposmia was found in 56.5%, 66%, 66%, 83.5% by the following authors Nasser A Fageeh 68 Bijan Khademi 73,Damm M et al(2002) 74 and Y Bajaj(2007) 64 respectively. Nasser A Fageeh et al 68 found least improvement of hyposmia in their patients post operatively. In this study also we did not find much improvement in this symptom post operatively. Pre operatively, 29/43 CRS with polyposis patients (67.4%) were having mild severe hyposmia and post operatively at 1 month follow up, 23 patients(53.5%) were having mild to severe hyposmia. Thus, there was only 20.7% improvement in hyposmia symptom after surgery which was consistent at 6 months follow up. Overall Improvement after FESS

15 Clinical Profile of Chronic Rhino Sinusitis and Polyposis-Experienced 15 in Government Tertiary Care Hospital Jakobsen J and Svensdstrop F et al 69 observed that 45% were totally satisfied with the results and were symptom free and another 44% were feeling definitely better. Thus, 89% were satisfied after FESS at the end of one year. Similar studywasconducted by Nayak et al 49 out of 78 patients, 75.64% (59/78) patients had total relief, 15.38% (12/78) patients had partial relief, and 9% (7/78) patients have no relief (12/78) of their patients were lost for follow up. And 7.69% (6/78) patients with recurrence were taken up for revision. 79% of patients studied by Roth Y et al 52 reported good results. They observed minor complications in 17% of patients. According to Howard L Levine et al 47, 221 patients were available for long term follow up at 12 to 42 months (mean=17 months) with series success rate of 80.2% for relief of chronic sinusitis. Y Bajaj et al 64 found positive outcome in 81.9% at 3 months and 84.7% at 6 months. 85.1% of the patients operated by Nasser a Fageeh et al 68, had a favourable opinion about the procedure. They said that they would recommend it to others with similar problems. Hopkins et al 75 in their propspective analysis of 3128 patients undergoing endoscopic sinonasal surgery have observed a 7% risk of minor complications like synechae and mild bleeding. The patients with higher risk of complications are usually those having higher subjective and objective disease preoperatively. Nair et al 76 in their study reported an incidence of 11.2% minor complications. In the present study the most common complication was synechae formation (8.5%) and the least common was meningitis(1 patient-1.4%). Other complications were hemorrhage, orbital cellulitis and emphysema. CONCLUSIONS The improvement was observed in individual symptoms and total symptoms as compared with overall satisfaction claimed by the patients. FESS is an essential tool for the management of refractory and severe forms of CRS. Acknowledgement: Author acknowledge the Dean and HOD of ENT, BMCRI, Bangalore REFERENCES 1. Anand K. Adult chronic rhinosinusitis: Diagnosis and dilemmas. Otolaryngol Clin North Am Apr; 37(2):243-52, v. 2. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg Sep; 117(3 Pt 2):S Rosenfeld RM, Andes D, Bhattacharyya N, Cheung D, Eisenberg S, Ganiats TG, Gelzer A, Hamilos D, Haydon RC 3rd, Hudgins PA, Jones S, Krouse HJ, Lee LH, Mahoney MC, Marple BF, Mitchell CJ, Nathan R, Shiffman RN, Smith TL, Witsell DL. Clinical practice guideline. Otolaryngol Head Neck Surg.2007 Sep;137(3 Suppl):S Ragab S, Parikh A, Darby YC, Scadding GK. An open audit of monkelukast, a leukotriene receptor antagonist, in nasal polyposis associated with asthma. Clin Exp Allergy Sep;31(9): Liou A, Grubb JR, Schechtman KB, Hamilos DL. Causative and contributive factors to asthma severity and patterns of medication use in patients seeking specialized asthma care. Chest.2003 Nov;24(5): Hauptman G, Ryan MW. The effect of saline solutions on nasal patency and mucociliary clearance in rhinosinusitis patients. Otolaryngol Head Neck Surg Nov; 137(5): Scadding GK, Durham SR, Mirakian R, Jones NS, Drake-Lee AB, Ryan D, et al. BSACI guidelines for the management of rhinosinusitis and nasal polyposis. Clin Exp Allergy Feb;38(2):

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