CHRONIC RHINOSINUSITIS IN ADULTS SCOPE OF THE PRACTICE GUIDELINE This clinical practice guideline is for use by the Philippine Society of Otolaryngology-Head and Neck Surgery. It covers the diagnosis and management of chronic rhinosinusitis in adults. OBJECTIVES The objectives of the guideline are (1) to state the criteria of diagnosis of chronic rhinosinusitis in adults; (2) to evaluate present diagnostic techniques; and (3) to provide treatment options. LITERATURE SEARCH This guideline is based on the 1997 Clinical Practice Guideline of the Philippine Society of Otolaryngology Head and Neck Surgery and revised according to new evidence. The National Library of Medicine s Pubmed Database and Cochrane Reviews Database were searched for literature using the medical subject headings: sinusitis, sensitivity and specificity or likelihood functions or Meta-analysis for diagnosis; "meta-analysis" or clinical trials for therapy. Individual subject headings are used for each kind of therapy (antiinfectives, decongestants, saline irrigation, etc.) and diagnostics (x-rays, CT-scan, etc). Literature relevant to chronic rhinosinusitis were used. Meta-Analysis 2 Review/Guidelines 2 Clinical Trial (RCT and CT) steroids and Antibiotics (33)* RCT (other medical therapy) (8)* CT (other medical therapy) (1)* Descriptive Studies 5 *Literatures were covered by latest published reviews. DEFINITION RHINOSINUSITIS is a group of disorders generally characterized by inflammation of the mucosa of the nose and paranasal sinuses. CHRONIC RHINOSINUSITIS (CRS) is defined as inflammation of the nasal cavity and paranasal sinuses and/or the underlying bone that has been present for at least 12 weeks characterized by the presence of (1) nasal congestion, obstruction or blockage with (2) facial pain or pressure, (3) discolored discharge (anterior or posterior nasal drip), or (4) hyposmia or anosmia. Presence of nasal polyps will be considered a subgroup of chronic rhinosinusitis due to the different behavior of nasal mucosa of patients with concomitant nasal polyposis. 8 NASAL POLYPOSIS is defined as presence of bilateral, smooth, semi-translucent, pearly white to pinkish, pedunculated masses arising from the mucosa surrounding the ostiomeatal complex. PREVALENCE There is no precise local and foreign information regarding prevalence of chronic rhinosinusitis because of lack of accurate epidemiologic data and a uniformly accepted definition. 8 Foreign data states that rhinosinusitis affects approximately 30 million per year being 1 of 5 usual complaints during consult with primary physician. Inadequate treatment of rhinosinusitis is often the main cause in its recurrence/persistence. 17 For chronic cases of sinus trouble of symptoms more than 3 months, a survey in US showed a prevalence of 15.5% of the total population. 8 Socio-economic cost of chronic rhinosinusitis was estimated with direct costs amounting to between 200 to 2,000 euros per patient per year (American and European Data) and indirect costs 1,500 US Dollars per patient per year. 8 41
RECOMMENDATIONS ON THE DIAGNOSIS OF CHRONIC RHINOSINUSITIS 1. The diagnosis of chronic rhinosinusitis may be made on the presence of two or more symptoms of 1.1 nasal blockage/congestion 1.2 discharge (anterior or posterior nasal discharge) 1.3 facial pain/pressure 1.4 hyposmia or anosmia 1.5 combined with EITHER physical findings based on anterior rhinoscopy* and/or endoscopy (polyps, mucopurulent discharge from the middle meatus and edema/mucosal obstruction of the middle meatus) OR CT scan findings (mucosal changes within the ostiomeatal complex and/or sinuses). 2. Anterior rhinoscopy remains the first step in examining a patient. Nasal endoscopy may be performed with or without decongestion. Endoscopy can detect small polyps. The classification of nasal polyps, based on size and extent, is used as a guide in its management. A modification of the Mackay classification will be used. Grade 0 Grade 1 Grade 2 Grade 3 absence of polyps polyps do not prolapse beyond the most anterior part of the middle turbinate. Nasal endoscopy may be required for visualization polyps extend below the middle turbinate and are visible with a nasal speculum polyps are massive and occlude the entire nasal cavity. Positive endoscopic findings correlate well with CT scan while negative endoscopic findings correlates only in 71% of patients with negative CT results. 19 Endoscopy and CT scan are necessary procedures prior to surgical management. 3. CT scan may be used to confirm the diagnosis of chronic rhinosinusitis. CT scan demonstrates good sensitivity and above average specificity in diagnosing sinusitis in general. 5 Multi-slice CT and High resolution CT show advantage over conventional CT in demonstrating chronic rhinosinusitis. 3,12 There are only few recent studies to show good correlation between CT scan and severity of symptoms of chronic rhinosinusitis. CT scan studies however, are very important in the evaluation of disease. 1,9,11,20 It is recommended in failed medical and/or surgical therapy, and in presence of complications or malignancies. CT scan is routinely used in patients undergoing endoscopic sinus surgery. 42
4. Sinus radiograph series may be used to suggest the presence of chronic rhinosinusitis. There is only a limited role for plain x-rays in the management of chronic rhinosinusitis. Although rapid, economical and non-invasive, it has limited evaluation of the paranasal sinuses and the lower third of the nasal cavity. It has high specificity but 50% sensitivity in diagnosing CRS. Water s projection may suggest but can not rule out the presence of sinusitis. 22 5. Maxillary aspirate culture and sensitivity is not routinely used. Occasionally, endoscopic guided middle meatus cultures may be done as alternative to maxillary sinus puncture for obtaining cultures in patients with chronic rhinosinusitis. Indications of which can be for research and establishment of present local bacteriology and resistance or in patients who are immunocompromised or with severe infections. 2,4 6. Tests to assess nasal airway patency can be done for research purposes. No Recommendation Rhinomanometry and rhinometry can be useful in confirming that improvement in nasal congestion is the result of reduction in inflammation in the middle meatus rather than mechanical obstruction. RECOMMENDATIONS ON THE TREATMENT OF CHRONIC RHINOSINUSITIS 1. Chronic rhinosinusitis of infectious origin should be treated with antibiotics. 2. The duration of antibiotic therapy may be for a minimum of two weeks. It may be extended to four weeks when necessary. The data supporting the use of antibiotics in this condition are limited and lacking in terms of randomized placebo controlled clinical trials. Based on available evidence, CRS is treated with a four week course of oral antibiotics with evaluation every two weeks. Therapy can be extended to 12 weeks after which further work-ups and surgical management can be done. However, the panel, taking into consideration the cost of antibiotics, opted for a shorter duration of treatment. If there is no response to therapy after two weeks, another antibiotic may be used. 43
3. The choice of antibiotics for CRS depends on the local culture-resistance studies and clinical response. A monotherapy or a combination of antibiotics may be used. Ideal antibiotic should cover Beta-lactamase producing bacteria, Gram (+) specifically Staphylococcus aureus and Streptococcus Pneumonia, and Gram (-) organisms as well as anaerobic organisms. The benefit of long-term, low-dose macrolide treatment seems to be that it is, in selected cases, effective when steroids fail. The exact mechanism of action is not known, but it probably involves down-regulation of the local host immune response as well as downgrading of the virulence of the colonizing bacteria. Placebo-controlled studies should be performed to establish the efficacy of macrolides if this treatment is to be acceptable as evidence-based medicine. Studies comparing antibiotics do not show significant difference between Ciprofloxacin, Amoxicillin-clavulanate and Cefuroxime axetil. 4. Antibiotic therapy can be combined with topical steroids in the management of CRS. 15 Double-blind data show a positive effect of the addition of local corticosteroid treatment to oral antibiotics in the treatment of acute exacerbation of chronic rhinosinusitis. There is some evidence for an effect of intranasal steroids on CRS particularly with intramaxillary instillation of steroids. No side effects were seen, including any increased signs of infection. For chronic rhinosinusitis, budesonide aqueous nasal spray improve symptoms of disease more in allergic than in non-allergic patients. 14 There is benefit for intrasinus administration of topical budesonide to allergic patients with chronic rhinosinusitis following surgery in the improvement of symptoms score as well as parameters for inflammation. 13 5. Topical antibiotic in the management of chronic rhinosinusitis is not routinely used at present. 21 6. Nasal saline douche can be used for symptomatic relief of symptoms of CRS during medical therapy and even after surgical management. 10,18 There is research-based evidence for adjunctive use of hypertonic or isotonic saline in the treatment of CRS. 7. There is limited role for decongestants in the management of chronic rhinosinusitis. 8. The role of mucolytics or expectorants in the management of CRS is still unclear. 44
9. For chronic rhinosinusitis, it should be initially managed maximally with medical therapy. Surgical therapy is an option for refractory cases. 16 There is limited data comparing medical management with that of surgical management of CRS. Maximal medical management may mean a 3 month course of antibiotics, nasal douche, topical steroids and other modalities. Sinus surgery is effective treatment for chronic sinusitis that is refractory to maximal medical therapy. 8 10. Other indications for sinus surgery are orbital complications and intracranial complications RECOMMENDATIONS ON THE TREATMENT OF CHRONIC RHINOSINUSITIS WITH NASAL POLYPOSIS 1. The management of CRS with Grade 1 and 2 nasal polyps is primarily medical. 6 2. Grade 1 nasal polyps are managed with intranasal corticosteroid for 4 to 6 weeks. If with positive response, it is continued on a maintenance basis. If there is no response, oral systemic steroids may be added. 3. Grade 2 nasal polyps are managed with short term systemic steroids and intranasal steroids. They may be given concurrently or sequentially. 3.1 Concurrent treatment- short term systemic steroids and intranasal steroids. 3.2 Sequential treatment- short term systemic steroids followed by intranasal steroids There are no studies to show advantage of concurrent over sequential steroid therapy. 4. Patients with grade 1 and grade 2 polyps not responding to medical therapy may warrant surgical therapy. 45
5. There is divergence in the management of Grade 3 polyps. They may be managed medically or surgically. There is scarcity of data for the long term treatment outcome for nasal polyposis. However, in CRS with nasal polyposis, topical steroids have been used to improve the sense of smell both in medically treated and postoperative patients. 8 A combined oral and topical short-term steroid is effective in reducing mucosal inflammation and symptoms in chronic polypoid rhinosinusitis. Indication for the short-term steroid can be as a preoperative therapy to decrease extent of surgical procedures, time and risks of surgery. (Its exact role on the outcomes of surgery is unclear.) 7 Antibiotics and steroid therapy can be used for pre-operative preparation. 6. Post-operative steroid therapy is recommended to prevent recurrence. 7. Adjunctive treatment can be given depending on patient s concomitant problems, e.g. antibiotics, nasal douche. 46
References 1. Arango P, Kountakis SE. Significance of computed tomography pathology in chronic rhinosinusitis. Laryngoscope. 2001. Oct; 111(10);1779-82. 2. Araujo E, et al. Microbiology of middle meatus in chronic rhinosinusitis. American Journal of Rhinology. 2003 Jan-Feb 7(1):9-15 3. Baumann et al. Preoperative Imaging of chronic sinusitis by multislice computed tomography. Eur Arch Otorhinolarygology. 2004 Oct; 26(9):497-501 4. Benninger MS, et al. Maxillary sinus puncture and culture in the diagnosis of acute rhinosinusitis: the case for pursuing alternative culture methods. Otolaryngology Head and Neck Surgery. 2002 Jul; 127(1):7-12. 5. Bhattacharyya N, Fried MP. The accuracy of computed tomography in the diagnosis of chronic rhinosinusitis. Laryngoscope 2003 Jan:113(1):125-9. 6. Clinical Practice Guidelines, PGH-ORL August 2003. 7. Damm M, et al. Effects of systemic steroid treatment in chronic polypoid rhinosinusitis evaluated with magnetic resonance imaging. Otolaryngology Head Neck Surgery. 1999 Apr; 120(4):517-23. 8. European Position on Rhinosinusitis and Nasal Polyposis, 2005. 9. Hwang PH, et al. Radiologic correlates of symptom based diagnostic criteria for chronic sinusitis. Otolaryngology Head and Neck Surgery 2003 Apr; 128(4):489-96. 10. Johannssen V, et al. Effect of postoperative endonasal mucous membrane care on nasal bacterial flora: prospective study of 2 irrigation methods with NaCl solution after paranasal sinus surgery. Laryngorhinootologie. 1996 Oct;75(10);580-3. 11. Krouse JH. Computed tomography stage, allergy testing, and quality of life in patients with sinusitis. Otolaryngology Head and Neck Surgery. 2000. Oct; 123(4):389-92. 12. Krupski et al. Diagnostic value of HRCT and 3 DCT in the assessment of chronic maxillary sinusitis. Ann Univ Mariae Curis Sklodowska (med) 2002; 57(2):309-16 13. Lavigno F, et al. Intrasinus administration of topical budesonide to allergic patients with chronic rhinosinusitis following surgery. Laryngoscope. 2002 May 112(5):858-64. 14. Lund VJ, et al. Efficacy and tolerability of budesonide aqueous nasal spray in chronic rhinosinusitis patients. Rhinology. 2004. Jun; 42(2):57-62. 15. Parikh A, et al. Topical corticosteroids in chronic rhinosinusitis: a randomized doubleblind, placebo-controlled trial using fluticasone propionate aqueous nasal spray. Rhinology. 2001 Jun; 39(2)75-9. 16. Ragab SM, et al. Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomized, controlled trial. Laryngoscope. 2004 May; 114(5):923-30. 17. Ruckenstien M. Comprehensive Review of Otolaryngology. 2004.pp 85-95. 18. Shoseyov D, et al. Treatment with hypertonic saline versus normal saline nasal wash of pediatric chronic sinusitis. J Allergy Clin Immunol. 1998 May; 101(5):602-5. 19. Stankiewicz JA. Nasal endoscopy and the definition and diagnosis of chronic rhinosinusitis. Otolarygology Head and Neck Surgery. 2002 Jun; 126(6):623-7. 20. Steward MG and Johnson RF. Chronic sinusitis versus CT scan findings. Curr OpinionOtolaryngology Head and Neck Surgery. 2004 Feb; 12(1): 27-9 21. Sykes DA, et al. Relative importance of antibiotic and improved clearance in topical treatment of chronic mucopurulent rhinosinusitis. A controlled study. Lancet. 1986 Aug 16;2(8503):359-60. 22. Timmenga N, et al. The value of Waters projection for assessing maxillary sinus inflammatory disease. Oral surg Oral Med Oral Pathol Oral Radiol Endod. 2002 Jan 93(1):103-9 47
Algorithm for Chronic Rhinosinusitis with and without Nasal Polyposis CRS: 2 or more Symptoms of -nasal blockage/congestion -anterior or posterior nasal discharge -facial pain or pressure -smell disturbance PE findings of - (+/-) nasal polyposis - mucopurulent discharge middle meatus - edema/mucosal obstruction of the middle meatus (+/-) CT scan - mucosal changes within the ostiomeatal complex Signs which warrant special diagnosis and management for possible complications of CRS or presence of neoplasm: - unilateral symptoms - bleeding - crusting - cacosmia - orbital symptoms - swelling of eyes/lids - eye redness - displaced globe - double vision - reduced vision With Nasal Polyposis Without Nasal Polyposis (see next page) Grade 1 & 2 nasal polyp sis - 1 week oral systemic steroids - topical steroids x 4-6 weeks (concurrent or sequential) - antibiotics - follow up after 2 weeks Grade 3 Nasal Polyposis - 1 week systemic steroids - 2 week antibiotic therapy - CT scan - Surgical Option - Antibiotic and Topical Steroids Improvement of Symptoms? N Y maintenance use of topical steroids (3 months) Option for continued antibiotic therapy OPTIONS: CT scan Surgical Option Shift antibiotic Topical Steroid therapy 48
(continued from previous page) CRS without Nasal Polyposis Antibiotic Therapy (+/-) Topical Steroid Nasal Douche Improvement of Symptoms? Y Continue Antibiotics N Shift Antibiotics Improvement of Symptoms? Y N CT Scan Surgical Option (+/-) Prolonged subsequent antibiotic therapy 49