Chronic rhinosinusitis

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Chronic rhinosinusitis

Presented by Chuleeporn Kongmeesook, MD,

Jan 24, 2014

Published in: Health & Medicine
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Chronic rhinosinusitis

  1. 1. CHRONIC RHINOSINUSITIS CHULEEPORN KONGMEESOOK ,MD
  2. 2. Outline • • • • Definitions Classification Diagnosis Treatment
  3. 3. Epidemiology Prevalence estimated 12.5% - 15.5% in 12. 15. US and 10.9% in Europe 10. In children 9.3% acute rhinosinusitis , 19% 19% chronic rhinosinusitis Piromchai et al International Journal of General Medicine 2013;6:453-64 2013;6:453Orapan et al Asian Pac J Allergy Immunol 2012;30:146-51 2012;30:146-
  4. 4. Definitions • Rhinosinusitis : Inflammation of nose and paranasal sinuses • Acute rhinosinusitis (<4 weeks ) : (<4 Purulent nasal drainage, nasal obstruction, facial pain-pressurepain-pressurefullness, or both Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  5. 5. Definitions • Subacute rhinosinusitis (4-8 weeks ) • CRS (8-12 weeks ,medical Rx ) : Inflammatory condition involve paranasal sinuses and nasal passages Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  6. 6. Symptoms of CRS 4 major symptoms (≥ 2 , to make Dx ) (≥ • anterior, posterior, or both mucopurulent drainage • nasal obstruction or blockage • facial pain, pressure, and/or fullness • decreased sense of smell Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  7. 7. Middleton's allergy:principles and practice 8th edition
  8. 8. Definitions of rhinosinusitis based on disease classification CRSsNP CRScNP AFRS Symptoms present for >12 weeks Requires >2 of following symptoms >2 Anterior or posterior mucopurulent drainage Nasal congestion Facial pain/pressure Decreased sense of smell Objective documentation Rhinoscopic examination OR Radiograph (sinus CT scan preferred) Bilateral nasal polyps in middle meatus AFRS criteria Positive fungal stain or culture of allergic mucin AND IgEIgE-mediated fungal allergy Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  9. 9. Classification (Subtypes of CRS) CRSsNP (60%) 60%) • Facial pain, pressure, and/or fullness • Organisms : S.pneumoniae, S.pneumoniae, H.influenzae, M.catarrhalis, S.aureus, H.influenzae, M.catarrhalis, S.aureus, S.coagulaseS.coagulase-negative • Glandular hyperplasia and submucosal fibrosis Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  10. 10. Classification (Subtypes of CRS) CRScNP (20-33%) 20-33%) • Hyposmia/anosmia Hyposmia/ • Nasal polyps are typically bilateral • Associated with AERD • Polyp tissue predominance of eosinophils, eosinophils, high levels of histamine, and Th2 cytokines Th2 Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  11. 11. Classification (Subtypes of CRS) AFRS Presence of allergic mucin (thick mucus from light tan to brown to dark green, degranulated Eos) os) Fungal hyphae in mucin Evidence of IgE-mediated fungal allergy IgE- Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  12. 12. Classification (Subtypes of CRS) AFRS • Sinus surgery usually required • Usually have nasal polyps and immunocompetent • Pathophysiology :chronic, allergic inflammation directed against colonizing fungi Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  13. 13. Pathophysiology • Basement membrane thickening, goblet cell hyperplasia, subepithelial edema, mononuclear cell infiltration in CRSsNP • 31 untreated CRSsNP, <10% Eos (overall CRSsNP, <10% mean 2%) • 123 untreated nasal polyp, 108 showed >10% Eos (overall mean 50%) 10% 50%) • Tissue eosinophilia not hallmark of CRSsNP Middleton's allergy:principles and practice 8th edition
  14. 14. Middleton's allergy:principles and practice 8th edition
  15. 15. Pathophysiology • Typical cytokine pattern CRS : high IFN-γ, elevated TGF-β IFNTGFCRSsNP : IL-1β, TNF-α, IL-8 ILTNF- ILCRSwNP : high IL-5, low TGF-β ILTGF- Middleton's allergy:principles and practice 8th edition
  16. 16. Comorbidities and associated conditions • Allergic rhinitis ( 60% of CRS ,perennial ) 60% • Immunodeficiency ( hypogammaglobulinemia 12% of adults with CRSsNP ) 12% • GERD • Defect in mucociliary clearance ( cystic fibrosis and primary ciliary dyskinesia ) • Viral infection (role of viral infection in CRS is controversial ) Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  17. 17. Comorbidities and associated conditions • Systemic disease (presenting feature of WG or CSS, sarcoidosis ) • Anatomical abnormalities ( nasal septal deviation, concha bullosa deformity, paradoxical curvature of middle turbinate ) • AERD and Asthma (20% CRS have asthma ,2/3 of 20% ,2 asthmatic have evidence of CRS) CRS) Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  18. 18. Diagnosis Nasal endoscopy • discolored mucus or edema in middle meatus or sphenoethmoidal recess Sinus CT scanning • sinus ostial narrowing or obstruction • sinus mucosal thickening or opacification, airopacification, air-fluid levels Evaluated for allergy • CRS associated with AR adults (60%) (60%) and children (36-60% ) 36-60% Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  19. 19. Middleton's allergy:principles and practice 8th edition
  20. 20. Treatment Topical corticosteroid nasal sprays • Recommended for all forms of CRS • Beneficial effects on nasal and sinus pain Antihistamines • Helpful in allergic rhinitis Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  21. 21. Treatment Antibiotics • Used to treat infection if nasal purulence present (acute exacerbation) Antifungals • Indicate only in invasive forms of sinus mycosis or immunocompromised host Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  22. 22. Treatment : CRScNP • Oral corticosteroids (10-15 days) shrink 10nasal polyps • Topical corticosteroid nasal sprays recommended to prevent recurrence of nasal polyps, although not always effective • Antileukotriene agents not FDA approved for treatment of nasal polyps • Sinus surgery in severe polyposis Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  23. 23. Treatment : AERD • Might benefit from aspirin desensitization and daily aspirin therapy Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  24. 24. Treatment : AFRD • Sinus surgery establish diagnosis, remove inspissated mucus and restore sinus patency • After surgery nasal polyps, oral corticosteroids 0.5 mg/kg/day with gradual tapering dose to control symptoms • Topical corticosteroid nasal sprays to control inflammation and prevent recurrence of nasal polyps Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  25. 25. Indications for sinus surgery • Persistence of CRS symptoms despite medical therapy • Correction of anatomic deformities • Debulking of advanced nasal polyposis Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15 2010;125:S103-
  26. 26. Conclusion Piromchai et al International Journal of General Medicine 2013;6:453-64 2013;6:453-
  27. 27. Piromchai et al International Journal of General Medicine 2013;6:453-64 2013; 453-
  28. 28. THANK YOU

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