Adult Rhinosinusitis Guidelines

Adult Rhinosinusitis
Pittaya Polwiang, MD
Virat Kirtsreesakul, MD
Department of Otolaryngology, Faculty of Medicine
Prince of Songkhla University
6th , 8th December 2017

Reference guidelines
• Orlandi RR, Kingdom TT, Hwang PH, et al. International Consensus Statement on
Rhinosinusitis. Int Forum Allergy Rhinol. 2016 (ICAR 2016)
• Rosenfeld RM, Acute Sinusitis in Adults. N Engl J Med 2016 (NEJM 2016)
• Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical practice guideline
(update): adult sinusitis. Otolaryngol Head Neck Surg 2015 (AAO 2015)
• Fokkens WJ, Lund VJ, Mullol J, et al. EPOS 2012: European position paper on
rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists.
Rhinology. 2012. (EPOS 2012)
• Chow AW, Benninger MS, Brook I, et al. IDSA clinical practice guideline for acute
bacterial rhinosinusitis in children and adults. Clin Infect Dis. 2012. (IDSA 2012)

Deﬁnitions and Diagnostic Criteria
EPOS 2012

IDSA 2012
• 2 Major
• 1 Major+2 Minor

AAO 2015
Reduction or loss of smell not include

AAO 2015

ICAR 2016

Consensus meeting, Brussels, Belgium.1998

Epidemiology of ARS
• 6-15% of the population
• 2-5 episode/year
• Women : men (1.9-fold)
• The primary cause of ARS are
viruses with 0.5-2.0% developing
ABRS
EPOS 2012

Pathophysiology: Evidence of Contributing
Factors
• Anatomic Variants:
• Weak evidence
Aggregate Grade of Evidence: C
ICAR 2016

• Allergy:
• Observational studies provide a modest level of evidence supporting a
relationship between AR and ARS
• Some evidence: AR increases the likelihood of orbital complications but no
evidence that AR prolongs the duration of ARS.
Factors
ICAR 2016

• Allergy:
Factors
ICAR 2016

• Viruses:
• Viral rhinosinusitis is thought to precede acute bacterial RS (ABRS)
• Bacterial infection is more likely with duration of symptoms greater than 10
days, largely based on the probability of conﬁrming a bacterial infection by
sinus aspiration
• Odontogenic Infections:
• Absence of a well-designed and published investigation ,low-level evidence.
Factors
ICAR 2016

Management
AAO 2015
Aggregate evidence quality: Grade B

Signs and symptoms of spontaneous rhinovirus infections
AAO 2015

Clinical presentations patients with ABRS
1. Persistent symptoms or signs >/=10 days without any evidence of
clinical improvement (strong, low-moderate)
2. Severe symptoms or signs of high fever (>/=39C [102F]) and
purulent nasal discharge or facial pain at least 3–4 days at the
beginning of illness (strong, low-moderate)
3. Worsening symptoms or signs characterized by the new onset of
fever, headache, or increase in nasal discharge following a typical
viral URI that lasted 5–6 days and were initially improving (‘‘double-
sickening’’) (strong, low-moderate)
IDSA 2012

Acute bacterial rhinosinusitis
EPOS 2012
Acute viral sinusitis/common cold
Acute post-viral rhinosinusitis
Double sickening

AAO 2015Severe symptom not include

Clinical examination
• Anterior rhinoscopy
• Nasal inflammation, mucosal oedema and purulent nasal discharge
• Temperature
• The presence of a fever of >38°C indicates the presence of a more severe
illness and the possible need for more active treatment
• Inspection and palpation of sinuses
• Swelling and tenderness, which are commonly interpreted as indicating more
severe disease and the need for antibiotics
• Nasal endoscopy
• Not generally available in routine primary care settings, and not required in
the clinical diagnosis of ARS
EPOS 2012

Investigation
Imaging
• Aggregate evidence quality: Grade B
• Exceptions: Suspicion of complicated ARS or alternative diagnosis based on
severe headache, proptosis, cranial nerve palsies, facial swelling, or other clinical
finding
AAO 2015

Investigation
Reider JM. Do imaging studies aid diagnosis of acute sinusitis? J Fam Pract.2003

• C-Reactive Protein (CRP)
• Haematological biomarker
• Raised in bacterial infection
• Low or normal CR
• A low likelihood of positive bacterial infection
• Unlikely to need or benefit from antibiotics
• Raised CRP is predictive of positive bacterial culture on sinus
puncture or lavage or changes in CT scans
Investigation
EPOS 2012

• Erythrocyte Sedimentation Rate (ESR) and plasma viscosity
• Markers of inflammation
• ESR levels correlated with CT changes in ARS
• ESR >10 is predictive of sinus fluid levels or sinus opacity on CT
scan
• Raised ESR is predictive of positive bacterial culture on sinus
puncture or lavage
Investigation
EPOS 2012

Investigation
• The gold standard for the diagnosis of ABRS is the recovery of
bacteria in high density (>/= 104 colony-forming units/ml ) from the
cavity of a paranasal sinus
• Sinus aspiration
• Endoscopically guided cultures of the middle meatus (accuracy 81-
87%)
• May be indicated in more severe, recurrent or complicated
presentations
IDSA 2012

Microbiology
• Viruses
• Rhinoviruses (50%) and
coronaviruses
• Influenza viruses,
parainfluenza viruses,
adenovirus, RSV, enterovirus
EPOS 2012
IDSA 2012

• Aggregate evidence quality: Grade A
Initial therapy
AAO 2015

• ARS resolves without antibiotic treatment in most cases
• Symptomatic treatment and reassurance is the preferred initial
management strategy for patients with mild symptoms
• Antibiotic therapy should be reserved for patients with severe ARS,
especially with the presence of high fever or severe (unilateral) facial
pain
• Clinicians should weigh the moderate benefits of antibiotic treatment
against the potential for adverse effects
EPOS 2012
Initial therapy

• It is recommended that empiric antimicrobial therapy be initiated as
soon as the clinical diagnosis of ABRS (strong, moderate)
• Should shorten the duration of illness, provide earlier symptomatic
relief, restore quality of life, and prevent recurrence or suppurative
complications
Initial therapy
IDSA 2012

• The high spontaneous resolution rate in these placebo-controlled
RCTs is most certainly due to less stringent patient selection and the
inclusion of patients who had viral rather than true ABRS
• Watchful waiting is only reasonable if one is uncertain about the
diagnosis of ABRS owing to mild symptoms but cannot be
recommended when more stringent clinical criteria for the diagnosis
of ABRS are applied
Initial therapy
IDSA 2012

High spontaneous resolution rate : improving cure
rates at 7 to 15 days from 86% with placebo to 91%
with antibiotics
For potentially complicated infection or when
resistant organisms are suspected
ICAR 2016
Initial therapy

First-line antibiotic
• Aggregate evidence quality: Grade A
AAO 2015

• No significant differences have been found in clinical outcomes for
ABRS among different antibiotic agents
• Amoxicillin: safety, efficacy, low cost, and narrow microbiologic
spectrum
• Amoxicillin-clavulanate for high risk of being infected by an organism
resistant to amoxicillin
AAO 2015

AAO 2015

• Amoxicillin-clavulanate rather than amoxicillin alone is recommended
as empiric antimicrobial therapy for ABRS in adults (weak, low)
• National surveillance data in the United States indicate that during
2005–2007, the prevalence rate of b-lactamase–producing H.
inﬂuenzae was 27%–43%
• In one Scandinavian study, 49% of patients with antimicrobial
treatment failure had positive cultures for b-lactamase–producing H.
inﬂuenzae by sinus puncture
IDSA 2012

High spontaneous resolution rate : improving cure
rates at 7 to 15 days from 86% with placebo to 91%
with antibiotics
For potentially complicated infection or when
resistant organisms are suspected
ICAR 2016

IDSA 2012
Antibiotic for ABRS
S. pneumoniae 4 days
H. Influenzae 3 days
M. Catarrhalis 2 days

Antibiotic for ABRS if Pt allergic to penicillin
NEJM 2016

• 3=Aggregate evidence quality: Grade A
AAO 2015
• 2=Aggregate evidence quality: Grade B,C
Management

• Analgesics, such as NSAIDs or acetaminophen, are usually sufficient
to relieve facial pain associated with ABRS
• 4 RCTs of topical intranasal steroid vs placebo or no intervention as
monotherapy for ABRS, found that steroids increased the rate of
symptom improvement from 66% to 73% after 15 to 21 days
• Systemic steroids for ABRS found no benefit over placebo when oral
steroids were used as monotherapy
• Nasal saline irrigation, alone or in conjunction with other adjunctive
measures, may improve quality of life, decrease symptoms, and
decrease medication use for ABR
AAO 2015
Management

• Intranasal corticosteroids are recommended for the treatment of
ARS, both in moderate (monotherapy) and severe (with oral
antibiotics) disease (level of evidence Ia)
• Oral steroids as adjunctive therapy to oral antibiotics are effective
for short-term relief of symptoms (headache, facial pain, nasal
decongestion and) in ARS (level of evidence Ia)
• Nasal douching with saline solution has limited effect in adults with
ARS (level of evidence Ia)
EPOS 2012
Management

EPOS 2012
All Significant effect
Management

• Intranasal saline irrigations with either physiologic or hypertonic
saline are recommended as an adjunctive treatment in adults with
ABRS (weak, low-moderate)
• The mechanism is unclear
➔enhancing mucociliary function
➔decreasing mucosal edema
➔mechanically clearing inspissated mucus
➔decreasing inﬂammatory mediators
IDSA 2012
Management

Antibiotic for ABRS with initial treatment failure
NEJM 2016

Recurrent Acute Rhinosinusitis
ICAR 2016

Warning sign of complications in ARS
EPOS 2012

Summary
No Yes
No Yes NoYes
NEJM 2016

Summary
Yes
YesNo
No
NEJM 2016

Epidemiology
• CRS without NP
• 5-15% of total population in the United States
• Female/male ratio of 6:4
• CRS with NP
• 4.2% of total population in the United States
• High prevalence (6.7%) in the asthmatic patients.
• 36-96% of ASA sensitivity have CRSwNP
EPOS 2012

The Burden of CRS
• Direct cost of 770-1220 US$ per patient-year for CRS
• RS-related work productivity cost that approaches US$4 billion in the
USA annually
• CRS quality of life is worse than congestive heart failure, chronic
obstructive pulmonary disorder, and Parkinson’s disease
• Extrasinus manifestations such as fatigue, poor sleep quality, bodily
pain, and depression
ICAR 2016

Pathophysiology of CRS without NP

Pathophysiology of CRS with NP

Inflammatory and remodeling parameters
Koen Van Crombruggen et al. J Allergy Clin Immunol 2011

Evidence of Contributing Factors of CRS

Evidence of Contributing Factors of CRS without
NP
• Allergy:
• Swelling of the nasal mucosa in AR at the site of the sinus ostia may
compromise ventilation and even obstruct sinus ostia, leading to mucus
retention and infection
• 54% of CRS had positive skin prick tests
• Among CRS patients undergoing sinus surgery, positive skin prick tests 50%-
84%
• Evidence for allergy as a contributing factor in CRSsNP is level D
• Allergy testing is considered an option in CRSsNP due to the small amount of
potential harm and the possibility of identifying inﬂammatory triggers
Aggregate Grade of Evidence: D
ICAR 2016EPOS 2012

• Bioﬁlms:
• Protective extracellular matrix ➔ resist to ATB action, phagocytosis and
complement binding
• There is insufﬁcient clinical evidence to determine a role.
NP
ICAR 2016

• Osteitis:
• Associated with refractory CRS but no cause-and-effect relationship has been
demonstrated
• Reflux:
• Significant evidence demonstrating a coexistent relationship between reflux
and CRS, although causation cannot be clearly demonstrated.
• It is not entirely clear with the evidence currently available whether
extraesophageal reflux of gastric acid directly injures the sinonasal mucosa, whether
reflux events cause vagally-mediated neuroinflammatory changes, or if it is a
combination of both of these factors.
Aggregate Grade of Evidence: B
NP
ICAR 2016

• Vitamin D Deﬁciency:
• Two statements can be made about Vitamin D in CRSsNP:
1. CRSsNP is not associated with systemic vitamin D deﬁciencies
2. Smoke exposure in CRSsNP patients can lower systemic and local vitamin D
levels
• Fungus:
• Current evidence casts doubt on fungus as a primary etiologic factor in CRS
• Fungus may play a role in some subtypes of CRS, such as allergic fungal
rhinosinusitis.
NP
ICAR 2016

• Anatomic Variation:
• The evidence may contribute to CRSsNP, although some of the data are
conﬂicting and many studies do not differentiate between CRSsNP, CRSwNP,
and ARS
• Septal Deviation:
• Most studies are low-level and show an apparent limited effect.
• Superantigens:
• There is insufﬁcient clinical evidence to determine a role
NP
ICAR 2016

• Innate Immunity:
• In patients with CRSsNP, the data demonstrate that key innate immune
mediators are differentially expressed. The current evidence is relatively
sparse
• Microbiome Disturbance:
• Epithelial Barrier Disturbance:
• Ciliary Derangements:
• There is insufﬁcient clinical evidence to determine a substantial role
NP
ICAR 2016

• Immunodeﬁciency:
• Review of the literature demonstrates a potentially underappreciated role,
especially in refractory cases
• Primary immunodeﬁciency should be considered in patients with refractory
CRS
• Genetic Factors:
• Our understanding of the role of genetics in the pathogenesis of CRSsNP is in
its infancy
• Intriguing concepts continue to emerge that anticipate further exciting
developments
NP
ICAR 2016

Evidence of Contributing Factors of CRS with NP
• Allergy:
• Conflicting data prevents definitive conclusion about the association between
atopy and nasal polyposis
• Bioﬁlms:
• Fungus, Osteitis, Reﬂux :
• Combined with CRSsNP above
ICAR 2016

• Vitamin D Deﬁciency:
• Available evidence indicates that vitamin D deﬁciency is common in CRSwNP
and correlates with severity of mucosal and bone disease in CRSwNP
• Microbiome Disturbance:
ICAR 2016

• Superantigens:
• Based on a wealth of in vitro
and some clinical data,
superantigens appear to
have a signiﬁcant role in the
pathogenesis of CRSwNP.
• Superantigens -> stimulate
T-cell (less specific than
normal Ag) -> nonspecific
and polyclonal activation of
T-cell with massive
cytokine release
ICAR 2016 EPOS 2012

• Anatomic Variation:
• Independently evaluate this group of patients suggest minimal inﬂuence on
pathophysiology and instead favor a systemic inﬂammatory process leading
to sinonasal disease.
• Septal Deviation:
• Combined with CRSsNP above.
ICAR 2016

• Innate Immunity:
• Conflicting data suggesting either an up or down regulation of expression of
antimicrobial proteins, antimicrobial peptides and pattern recognition
receptors in CRSwNP.
• Epithelial Barrier Disturbance:
• Insufficient clinical evidence to determine a role
• Ciliary Derangements:
• Insufficient clinical evidence to determine a substantial role
ICAR 2016

• Immunodeficiency:
• Some experts have recommended testing for immunodeficiency in refractory
CRSwNP patients. Immunodeficiency testing is an option
• Aspirin Exacerbated Respiratory Disease:
• Aspirin is a trigger of CRSwNP in select patients
ICAR 2016

CRS : Diagnosis
• Using Symptoms Alone
• Aggregate Grade of Evidence: B
• High rate of false-positive diagnoses -> delay the establishment of correct
underlying diagnoses and potential for inappropriate interventions
• Harm over benefit, if used as the sole clinical method for CRS diagnosis, as
there is a significant risk of misdiagnosis
• Recommend against using a “symptoms-alone” strategy to make the
diagnosis
ICAR 2016

CRS : Diagnosis
• With Nasal Endoscopy
• Higher PPV and specificity compared to using symptoms alone, allowing for the
avoidance of CT utilization costs and potential radiation exposure of imaging
• If the clinician still suspects CRS, a negative endoscopy exam will still require a CT
scan due to the potential for a false-negative endoscopy.
• Mild discomfort
• Endoscopy is recommended in conjunction with a history and physical examination
ICAR 2016

CRS : Diagnosis
• With Diagnostic Imaging
• More sensitive than nasal endoscopy
• Radiation exposure
• Benefits-Harm Assessment: dependent on the pre-test likelihood of disease, access
to CT scan, and findings of physical exam and endoscopy
• CT scanning is recommended for all patients meeting symptom-based criteria for
CRS with a lack of objective clinical findings or for preoperative planning
• Option for confirming CRS instead of nasal endoscopy.
ICAR 2016

CRS : Diagnosis
AAO 2015
Endoscope
Nasal
speculum

Evidence-Based Rhinosinusitis Management
Recommendations

CRS without NP
EPOS 2012
Meta-analysis
comparing INCS
to placebo

Management of CRS
Aggregate evidence quality: Grade A
AAO 2015
• Benefit: Symptomatic relief, promoting awareness of effective over-the-counter interventions,
discouraging improper and ineffective usage, and avoiding adverse events from systemic
therapies
• Risks, harms, costs: Intranasal discomfort, burning, stinging; epistaxis; direct costs of saline or
steroid

CRS without NP
Isotonic/hypertonic similar subjective outcomes and high-volume (>200
ml) saline irrigation superior to low-volume nasal saline spray techniques
Irrigation, atomization devices, through tubes in the maxillary
sinus(MAST tubes), or through catheters (eg, YAMIK)
ICAR 2016

Atomization devices
Improvement in health-related (HR)-QoL

YAMIK sinus catheter
No beneﬁt seen Patient discomfort,
epistaxis

CRS without NP
For patients with complications or extrasinus manifestations of
CRS, benefits of Treatment may outweigh the cost and risk of
adverse events
ICAR 2016

CRS with NP
mainly after sinus surgery
recommended for CRSwNP before or after sinus surgery
High-volume (>200 mL) nasal saline irrigations are recommended
as an adjunct to other medical therapies
ICAR 2016

CRS with NP
may be beneﬁcial insetting following ESS to
decrease recurrence of polyps
ICAR 2016

CRS with NP
For patients with complications or extrasinus manifestations of
CRS, benefits of Treatment may outweigh the cost and risk of
adverse events
ICAR 2016

CRS with NP
Montelukast may be beneﬁcial in patients
who are intolerant or unresponsive to INCS
Should be considered in AERD patients after
surgical removal of NPs to prevent recurrence
ICAR 2016

Surgery for Chronic Rhinosinusitis
• Endoscopic. sinus surgery (ESS) is the standard surgical treatment for
CRS that has failed more conservative treatments.
• “Appropriate” medical therapy (AMT) is used in order to suggest
striking a balance between proceeding to surgery before appropriate
nonsurgical options have been tried and delaying too long so that
outcomes are negatively impacted
ICAR 2016

Surgery for Chronic Rhinosinusitis
• Length of Appropriate Medical Therapy Prior to ESS
• No direct studies on this topic
• Multiple RCTs evaluating the beneﬁts of INCS in CRS.
• Treatment duration is less than or equal to 3 weeks show no beneﬁt over
placebo.
• 4 weeks or more consistently favor INCS.
• Aggregate Grade of Evidence: D
• Policy Level: Recommendation
• Intervention: A trial of 3 to 4 weeks of AMT should be considered as
the minimum.
ICAR 2016

Preoperative Management
• Topical Steroids :
• Aggregate Grade of Evidence: C
• Benefit: Objective improvement in surgical field, objective decrease in
intraoperative bleeding, and objective decrease in operation time seen with
INCS. Subjective improvement in surgical difficulty
• Harm: Possible side effects of topical are known
• Policy level: Recommendation for INCS
• Antibiotics:
• Because of a paucity of evidence, no recommendation regarding
preoperative antibiotics can be made.
ICAR 2016

• Oral Corticosteroids :
• Benefit: Objective improvement in surgical field, decrease in intraoperative
bleeding, and decrease in operation time. Subjective improvement in surgical
difficulty.
• Harm: No specific reports about side effect as preoperative treatment
• Value Judgment: Improvement in surgical field is important. There is no
evidence-based agreement on dosage and duration. In case of oral
corticosteroids, medium dose (30-40 mg) for 4-7 days is the most commonly
prescribed regimen.
• Policy Level: Recommendation for CRSwNP. No recommendation for CRSsNP.
Preoperative Management
ICAR 2016

Surgical Techniques
ICAR 2016
Minimally invasive sinus
technique (MIST) and balloon
dilation of the sinuses

Postoperative Management
ICAR 2016

Summary EPOS
Therapy Adult ARS Children ARS CRS without polyp CRS without polyp
Pre-op Post-op Pre-op Post-op
INCS A(Ia) A(Ia) A(Ia) A(Ia) A(Ia) A(Ia)
ATB (Short term) A(Ia) in ABRS A(Ia) in ABRS B(II) B(II) C(Ib) A(Ib)
ATB (Long term) - - C(Ib) C(Ib) C(III) C(Ib)
Oral steroid A(Ia) in ABRS - C(IV) C(IV) A(Ia) A(Ia)
Saline irrigation A(Ia) D(Iv) A(Ia) A(Ia) D(Ib) D
Oral
antihistamine
B(Ib) D(Iv) D - D -
Decongestant D D(Iv) D - D -
Mucolytic D A-(Ib-) C(III) - D -

Summary
confirmed
Not confirmed
ICAR 2016

Yes
Summary
No
No
Yes
ICAR 2016

Adult Rhinosinusitis Guidelines

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