Chronic rhinosinusitis

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Chronic Rhinosinusitis

Presented by Sasikarn Suesirisawad, MD

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  • Epithelial damage/host barrier dysfunction result colonization of S.aureus.Secretion of superantigenic toxin multiple cell type ได้แก่ epithelium cell, lymphocyte, Eo, fibroblast and mast cellNet effect help organism evade host immune responseEffect Th2 direction generate polyclonal IgE, promote Eo survival/mast cell degranulation and alteration ecosanoid metabolismLocal tissue effect: foster polyp formation
  • 1: Intrinsic host deficits in nasal epithelium results in reduced production of innate immune anti-microbial molecules.2: Local immune deficits permit colonization and overgrowth of microbial agents.3: Intrinsic patterns within microbial agents capable of activating epithelial cells through pre-programmed pathways. integrity of epithelialbarrierdisruptedsecondarytoepithelial activationallowingincreaseddirectstimulationof Tand B-cellsthroughantigenor epithelial mediatedpathways.4:Thesepro-inflammatoryfactorslead todysregulationof local inflammatorymicroenvironmentleading tolocal pseudofollicleformationandsite-specificimmunoglobulin production.Localantibodymediatedeffectsdegranulateeosinophils and basophils releasingcytotoxicand vasoactiveMediatorsintonasal mucosa..
  • grey-white color is due to relatively avascular nature of polyp tissue. Nasal polyps lack sensation and should be distinguished from swollen nasal turbinates, which are pink in color, similar in appearance to rest of nasal mucosa, and very sensitive to touch
  • goal of CRS txis to achieve and maintain clinicalcontrol. Control defined as disease state in which pts does not have symptoms or symptoms are notbothersome, if possible combined with healthy or almosthealthy mucosa and only need for local medication.
  • Macrolide effective in lower airway , not strong proof that same is true for CRSCRS with normal IgE do better that increase IgEBactrim doxycycline azithromycin similar effect
  • INS improve symp and pt report outcome in CRSwNPINS post surgery not greater effect that modern INS(althrough fewer S/E)
  • Chronic rhinosinusitis

    1. 1. Sasikarn Suesirisawad, MD
    2. 2.  Chronic Rhinosinusitis (with or without NP) in adults ≥ 2 symptoms one of which should be either nasal blockage/obstruction/congestion or nasal discharge(ant/post drip) or ± Facial pain/pressure ± reduction or loss of smellfor ≥12 weekswith validation by telephone or interview.Questions on allergic symptoms (sneezing, wateryrhinorrhea, nasal itching, and itchy watery eyes) should beincluded. EPOS 2012
    3. 3.  CRSwNP: bilateral, endoscopically visualised polyps in middle meatus. CRSsNP: no visible polyps in middle meatus, if necessary following decongestant. EPOS 2012
    4. 4.  Symptoms ≥ 12 weeks ≥ 2 symptoms one of which should be either nasal blockage/obstruction/congestion or nasal discharge (ant/post nasal drip): ± facial pain/pressure, ± reduction or loss of smell; Signs (if applicable)•nasal examination•oral examination: posteriordischarge; exclude dental infection. Additional diagnostic information• questions on allergy should be added and, if positive, allergy testingshould be performed. Not recommended: plain x-ray or CT-scan EPOS 2012
    5. 5.  Symptoms ≥ 12 weeks ≥ 2 symptoms one of which should be either nasal blockage/obstruction/congestion or nasal discharge (ant/post nasal drip): ± facial pain/pressure, ± reduction or loss of smell; Signs• ENT examination, endoscopy;• review primary care physician’s diagnosis and treatment;• questionnaire for allergy and if positive, allergy testing if it has not already been done. EPOS 2012
    6. 6.  ≥ 2 symptoms one of which should be either nasal blockage/obstruction/congestion or nasal discharge(ant/postnasal drip) or ± Facial pain/pressure ± Coughfor ≥12 weekswith validation by telephone or interview. Questions on allergic symptoms (sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes) should be included. EPOS 2012
    7. 7.  5-15% of general population both Europe and USA. Prevalence of MD-diagnosed CRS was 2-4% EPOS 2012
    8. 8.  Ciliary impairment Allergy Asthma Aspirin sensitivity Immunocompromised state Genetic factor Pregnancy and endocrine state Local host factor Biofilm Environmental factor Iatrogenic factor H.pylori and laryngopharyngeal reflux Osteitis
    9. 9.  Defect in barrier and/or innate immune response of sinonasal epithelium. Increase microbial colonization, accentuated barrier damage. Defect in STAT 3(CRSwNP) Inappropriated Th2 adaptive response Local autoantibody Biofilm EPOS 2012
    10. 10. EPOS 2012
    11. 11. Comparison of major cells and mediators in CRS vs NP. TGF-β, a keymediator inducing fibrosis, is increased in CRS, but decreased in NP. Middleton’s Allergy Principle & Practice, seventh edition
    12. 12. Mucosa in CRS: BM thickening, goblet cell hyperplasia, subepithelial edema, mononuclear cell infiltration with few eosinophils Middleton’s Allergy Principle & Practice, seventh edition
    13. 13. Numerous subepithelial eosinophils in luminal compartment of early-stage polyp. Middleton’s Allergy Principle & Practice, seventh edition
    14. 14. Eosinophils accumulated subepithelially and diffusely in tissue of mature polyp. Middleton’s Allergy Principle & Practice, seventh edition
    15. 15. Koen Van Crombruggen et al. J Allergy Clin Immunol 2011;128:728-32.
    16. 16. Spencer C et al. J Allergy Clin Immunol -
    17. 17. Endoscopic view of nasal polyps protruding from middle meatus. Middleton’s Allergy Principle & Practice, seventh edition
    18. 18.  Nasal polyposis Fungi on staining Eosinophilic mucin without fungin invasion into sinus tissue Type I hypersensitivity to fungi and Characteristic radio findings with soft tissue differential densities on CT scaning EPOS 2012
    19. 19. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707
    20. 20. CT scans nasal polyps. (A) Central disease, an early stage. (B) Nearly total ‘white-out,’ a late stage. Middleton’s Allergy Principle & Practice, seventh edition
    21. 21. CT scan of fungal infection of right maxillary sinus: heterogeneous opacification and calcification with increased attenuation. Middleton’s Allergy Principle & Practice, seventh edition
    22. 22. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707
    23. 23. EPOS 2012
    24. 24. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707
    25. 25. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707
    26. 26. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707
    27. 27. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

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