Rhinosinusitis John Ramey, MD Joseph Russell, MD
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What is Rhinosinusitis? Symptomatic inflammation of the paranasal sinuses and nasal cavity
Case 1 A 28 year-old female presents to clinic for evaluation of discolored nasal drainage and sinus pressure. Symptoms started 2 weeks ago after exposure to a known sick contact. What is the diagnosis and treatment?
Sinus Overview There are 4 sinus cavities: Frontal (a) Maxillary (b) Ethmoid (anterior (c) & posterior) Sphenoid (d) c d a b The paranasal sinuses function to filter, humidify, and warm the air
Clinical Sign and Symptoms of Sinus & Nasal Inflammation Fever Headache Facial Pain Anosmia/Hyposmia Purulent Rhinorrhea Post-nasal Drip Nasal Congestion Clear Rhinorrhea Itching/Red Eyes Nasal Crease Seasonal Symptoms Sneezing Sinusitis Rhinitis
Rhinosinusitis can be classified into two broad subtypes based upon the duration of clinical symptoms Rhinosinusitis Acute Rhinosinusitis < 4 weeks in duration Chronic Rhinosinusitis > 12 weeks in duration
Acute Rhinosinusitis (ARS) Duration of symptoms: < 4 weeks Clinical symptoms typically include: Purulent nasal drainage Fever Facial pressure/pain Cough Nasal obstruction Teeth Pain Diagnosis is made by clinical history
Rhinosinusitis Acute Rhinosinusitis Chronic Rhinosinusitis Viral Bacterial
Viral Acute Rhinosinusitis: - Majority of all ARS cases - Symptoms resolve in 10 days or less Bacterial Acute Rhinosinusitis: - 0.5-2% of all ARS cases - Symptoms fail to improve within 10 days or more beyond the onset of URI -or- - Symptoms worsen within 10 days after an initial improvement (double worsening)
Common Pathogens in ARS Common viruses in ARS include Rhinovirus and Coronavirus
Treatment of ARS Viral Acute Rhinosinusitis: - Fluids, decongestants, nasal rinses - Nasal and/or oral corticosteroids - Antibiotics are NOT indicated Bacterial Acute Rhinosinusitis: - Fluids, decongestants, nasal rinses - Nasal and/or oral corticosteroids - Antibiotics for 5-7 days in adults and 10-14 days in children
Indication Initial therapy Antibiotics for Acute Beta lactam allergy Type 1 hypersensitivity Non-type 1 hypersensitivity Rhinosinusitis Children Adults Antibiotics Amoxicillin-clavulanate Levofloxacin Clindamycin and cefixime or cefpodoxime Indication Initial therapy Beta lactam allergy Antibiotics Amoxicillin-clavulanate Doxycycline Levofloxacin Moxifloxacin
Recurrent Acute Rhinosinusitis Duration of symptoms: 3+ episodes of acute bacterial rhinosinusitis in 1 year period Clinical symptoms are similar to ARS except patients are asymptomatic between episodes of acute infections Diagnosis is made by clinical history and treatment of flares is the same as for bacterial ARS
Complications of ARS Orbital, intracranial or osseous infections Cellulitis, abscess or osteomyelitis Clinical presentation is nonspecific Periorbital erythema or edema Vision changes High fever Headache Diagnosis: CT scan or MRI Treatment: Antibiotics and Surgical drainage
Case 2 28 year-old female presents to clinic for evaluation of 4 months of persistent sinus pressure and facial pain. She also notes intermittent discolored drainage and poor sense of smell. A sinus CT scan reveals the following:
What is the diagnosis?
Chronic Rhinosinusitis (CRS) Duration of Symptoms: > 12 weeks Clinical Symptoms: Anterior or posterior nasal drainage Nasal congestion Facial pressure/pain Hyposmia Diagnosis is made by clinical history and by evidence of sinonasal inflammation on sinus CT scan and/ or nasal endoscopy
Chronic rhinosinusitis can be further divided into two subgroups based upon the presence or absence of nasal polyps Chronic Rhinosinusitis Without Polyps (CRSsNP) With Polyps (CRSwNP)
CRS without Nasal Polyps (CRSsNP) ~60-65% of all CRS cases More often associated with facial pain and pressure Potential pathogenesis includes bacterial infections
Treatment Options for CRSsNP Nasal steroids: Grade 1 evidence for benefit Allergy testing and possible immunotherapy Oral steroids: No good evidence for benefit Nasal steroid washes Nasal saline irrigation: May help as an adjunctive treatment Antibiotics: No placebo controlled study for short courses of antibiotics Long term antibiotics: Limited evidence that macrolides are beneficial Surgery: For medical management failures
Case 3 32 year-old male presents with a 3-year history of recurrent episodes of sinus pressure, purulent nasal discharge, and pain in his maxillary teeth. Additionally he notes progressively worsening constant nasal obstruction (R > L), and his sense of smell is poor.
CRS with Nasal Polyps (CRSwNP) Nasal polyps are benign inflammatory outgrowths found within the nasal cavity ~33% all CRS cases More often associated with the nasal congestion and hyposmia Potential pathogenesis includes immune dysfunction and barrier dysregulation
Treatment Options for CRSwNP Nasal steroids: Grade 1 evidence that steroids improve symptoms and decrease polyp size Oral steroids: Limited evidence that steroids decrease polyp size and improve olfaction Oral antibiotics: Limited evidence that doxycycline is effective Nasal saline irrigation: Improves symptoms Surgery: For medical management failures
Chronic Rhinosinusitis Comorbidities Asthma 26-48% of CRSwNP patients have asthma More severe sinus disease is associated with increased asthma severity Allergic Rhinitis 51-86% of CRSwNP patients are sensitized to at least 1 aeroallergen Unclear if having allergic rhinitis predisposes to developing chronic rhinosinusitis Conflicting evidence if allergic rhinitis correlates with sinus disease severity
Chronic Rhinosinusitis Comorbidities Primary Immunodeficiency Antibody deficiencies are the most common immunodeficiency in CRS IgA, IgM, and/or IgG deficiency Low total levels of IgA, IgM, and/or IgG Prevalence is 23% among CRS patients Specific Antibody Deficiency Normal total IgG, IgA, and IgM levels but impaired response to immunization against polysaccharide antigen (e.g. Pneumovax ) Prevalence is 8-34% among CRS patients
Other Notable CRS Conditions Allergic Fungal Rhinosinusitis Aspirin Exacerbated Respiratory Disease / NSAID Exacerbated Respiratory Disease / Samter s Disease Cystic Fibrosis
Allergic Fungal Rhinosinusitis (AFRS) Non-invasive fungal disease commonly associated with Aspergillus species More prevalent in warmer climates (e.g. southern US) Secondary to an immune response directed toward the fungus, not direct damage from the fungus ~5-10% of all CRS cases
Allergic Fungal Rhinosinusitis (AFRS) Diagnostic Criteria: Clinical symptoms of CRS Allergic mucin - fungal hyphae + eosinophils - peanut butter like appearance Fungal sensitization determined by skin testing or by ImmunoCAP Characteristic findings of heterogeneous opacities with areas of hyper-attenuation on sinus CT scan Treatment: Surgery and Oral/Nasal Steroids
Aspirin Exacerbated Respiratory Disease (AERD) CRSwNP Asthma Intolerance to all COX-1 Inhibitors* *Patients with AERD predominantly develop upper and lower respiratory symptoms (e.g. nasal congestion, rhinorrhea, wheezing, cough) to COX- inhibitors such as NSAIDs
Aspirin Exacerbated Respiratory Disease ~8.7% of CRS patients estimated to have AERD As many as 15% of patients with CRSwNP and asthma may have undiagnosed AERD AERD patients have more significant sinonasal disease compared to patients with both CRSwNP and asthma or with just CRSwNP Aspirin desensitization followed by daily aspirin use is a treatment option for AERD
Cystic Fibrosis (CF) Consider in pediatric patients with CRS, especially those with nasal polyps 65% of adults and ~100% of children with CF have CRS CFTR gene mutation leads to impaired mucociliary clearance,chronic bacterial infections, and a chronic host inflammatory response
Rhinosinusitis Acute Rhinosinusitis Chronic Rhinosinusitis Viral Bacterial Without Polyps With Polyps Recurrent Acute Rhinosinusitis Allergic Fungal Rhinosinusitis Aspirin Exacerbated Respiratory Disease Cystic Fibrosis
Surgical Management Reserved for patients who have failed medical therapy Functional endoscopic sinus surgery (FESS) Balloon sinuplasty Minimally-invasive sinus surgery
Functional endoscopic sinus Current gold standard surgery Used for any disease process and extent Removal of mucosa and bone around all of the diseased sinuses, as well as polyps and fungal debris, if present Requires general anesthesia 5-7 days of down time
Balloon Sinuplasty First outcome studies published in 2007 Balloon is guided over a wire or probe into each affected sinus opening and inflated to dilate the sinus opening Used for recurrent acute sinusitis and CRSsNP; cannot be used to treat nasal polyps, AFS, or ethmoid sinus disease Frequently performed with local anesthesia in the office 1 day of down time
Minimally-invasive sinus surgery Latest innovation in surgical sinus treatment Balloon sinuplasty + selected techniques from standard FESS to treat all areas of sinus disease while also limiting tissue removal and maximizing preservation of normal mucosa Frequently performed with local anesthesia in the office 1-2 days of down time
Adjunctive surgical treatments Septoplasty For deviated nasal septum that causes obstruction or creates a contact point with lateral nasal wall causing headaches Inferior turbinate reduction For hypertrophied inferior turbinates that cause obstruction
What about children? Adenoidectomy alone success rate 47 to 61% Adenoidectomy + maxillary sinus balloon dilation or limited FESS success rate 80 to 88%
When to refer for ENT/Allergy evaluation 3 or more episodes of acute sinusitis per year One episode or string of closely related episodes of sinusitis lasting >12 weeks Nasal congestion persisting between episodes of sinusitis Decreased or declining sense of smell Nasal polyps Allergic component? Seasonal? Perennial? Pets? Recurrent infections such as pneumonia, otitis media, skin infections