Chronic sinusitis

1. Chronic sinusitis

2. Incidence
• 15% of US population
• 8. billion dollar per year
• 11.5 million work days missed per year
• Worse QOL than other chronic disease

3. Case presentation
• 57 year old female presents with a chief complaint of chronic recurring
“sinus headaches”. Patient reports that over the past 5 years, she has
several episodes per week of headache with forehead/sinus pressure and
pain.
• On further questioning, she denies nasal purulence, difficulty smelling,
fevers/chills, tooth pain, changes in vision.
• Denies allergy symptoms no sneezing, itchy watery eyes, clear rhinorrhea,
or nasal congestion.
• CT sinus demonstrates well-aerated sinuses with minimal to no mucosal
thickening.
Does this patient have nasal or sinus disease?

4. What are the criteria for diagnosis of CRS duration
wise ?

5. Chronic Rhinosinusitis (with or without NP) in adults is defined as:
Diagnostic criteria for rhinosinusitis
Symptoms should be correlated by either endoscopic
and/or radiological findings
Primary symptoms (requires at least one to be present,
but if both present it is sufficient to make diagnosis on
the basis of symptoms)
Nasal blockage/obstruction/ congestion
Nasal discharge (anterior/ posterior)
Additional symptoms (may also be present and at least
one is needed if only one of the primary symptoms is
present)
Facial pain/pressure Olfactory dysfunction
Hyposmia/anosmia
Duration >10 days, <3 months = acute >3 months = chronic
Endoscopy (any of these)
Nasal polyps
Mucopurulent discharge (middle meatus)
Oedema/mucosal obstruction in middle meatus
CT scan findings
(as well as or instead of endoscopic findings)
Mucosal changes within the ostiomeatal complex
and/or sinuses

6. AAOHNS 15

7. How you assess the severity of the symptoms and
its effect on QOL ?

9. QOLmeasurementSNOT22

10. How you can classify CRS ?

11. chronic
sinusitis
CRSsNP
CRSwNP

13. Etiology of CRS

14. SystemicdiseasesassociatedwithCRS

16. Examination

17. Lund-Kennedy score of endoscopic assessment

18. CT scanning or (MRI)?
• MRI for diagnosis is discouraged because of increased cost and
hypersensitivity (overdiagnosis) in comparison to CT without contrast.
• An important role of CT imaging in CRS with or without polyps is to
exclude aggressive infections or neoplastic disease that might mimic
CRS or ARS.
• Osseous destruction, extra-sinus extension of the disease process,
and local invasion suggest neoplasia. If any such findings are noted,
MRI should be performed to differentiate benign obstructed
secretions from tumor and to assess for spread outside the nasal
cavity and sinuses.

19. Lund-Mackay score of CT scan

20. Other condition specific investigations
Allergy testing - skin prick testing or RAST
• Nasal brushings for cytology
• Nasal biopsy for exclusion of neoplasia, to
look for
granulomas/vasculitides or to examine for
evidence of
eosinophilia and fungal hyphae
• Blood tests – full blood count (serum
eosinophilia),
ANCA (Wegener’s granulomatosis), ACE
(sarcoidosis)
• Olfactory testing:
❍ Psychophysical (threshold (quantitative) and
iscrimination/identification (qualitative))
❍ Olfactory event-related potentials (OERPs) (objective)
•
Physiological testing
❍ Peak inspiratory nasal flow
❍ Rhinomanometry
❍ Acoustic rhinometry
❍ Mucociliary clearance (saccharin test)
• Ciliary function testing
❍ Ciliary beat frequency
❍ Ciliary beat pattern analysis Electron microscopy

21. Classification for the finding of nasal polyps

24. Aspirin-exacerbated respiratory disease (AERD, Samter’s Triad)
• often very extensive, with significantly higher radiological CT scores
than non-AERD patients with nasal polyps
• They can be difficult to treat and have a higher rate of recurrence

25. TOPICAL INTRANASAL THERAPY FOR CHRONIC
RHINOSINUSITIS
• saline nasal irrigation
• topical intranasal corticosteroids
• or both for symptom relief of CRS.

26. Saline irrigation
• improvement in mucous clearance
• enhanced ciliary activity
• disruption and removal of antigens
• biofilms and inflammatory mediators
• direct protection of the sinonasal mucosa

27. Topical Intranasal Steroids
• Corticosteroids are effective as anti-inflammatory agents due to their
actions on reducing proinflammatory and increasing antiinflammatory
gene transcription, reducing airway inflammatory cell infiltration, and
suppressing proinflammatory mediators, cell chemotactic factors, and
adhesion molecules
• topical nasal steroid sprays are indicated for long-term treatment of
nasal polyps in the setting of CRS If no response is seen within
3 months, a short course of oral corticosteroids is reasonable to try

28. Side effect of topical steroids
• minor (epistaxis, headache, and nasal itching)
• Patients on long-term topical nasal need regular ophthalmic
monitoring

29. Antibiotics
• Chronic topical or intravenous antibiotics for CRS with nasal polyps is
not recommended, but select oral antibiotics, especially the
macrolide class, may be beneficial because of their anti-inflammatory
effects.

31. Surgical
• Surgical management is considered for patients who have failed to
respond to maximal medical treatment and for those with
complications.
• Functional endoscopic sinus surgery aims to improve sinus ventilation
and drainage as well as removing polyps. The extent of surgery varies
with the extent of disease, the surgeon’s individual practice and
available technology.