2. Epidemiology in India
International Journal of
Otorhinolaryngology and Head and Neck
Surgery
Khan AR et al. Int J Otorhinolaryngol Head
Neck Surg. 2020 May;6(5):969-973
http://www.ijorl.com
3. Cont..
Quality of life
Sleep quality
Productivity
Economic burden for the health care system.
4. Introduction
Clinical syndrome, rather than a specific disease.
Consensus (EPOS 2020)
1) CRS is typically an ante-grade process with the mucosal inflammation triggered
by a dysfunctional interaction between exogenous agents inhaled through the
nose and the host immune system.
2) specific causal factors likely vary in importance in individual patients leading to
different types or patterns of tissue inflammation.
3) the clinical characteristics (phenotypes),natural history and response to
treatment will depend on endotype.
5. Definition of CRS( EPOS 2020)
Inflammation of the nose and paranasal
sinuses,
characterised by two or more symptoms,
one of which should be either nasal
blockage / obstruction / congestion or
nasal discharge (anterior / posterior nasal
drip).
With or without-
-facial pain/pressure;
-reduction or loss of smell;
for ≥12 weeks.
• endoscopic signs of:
- nasal polyps and/or
- mucopurulent discharge primarily from
middle meatus
and/or
- oedema/mucosal obstruction primarily
in middle meatus
and/or
• CT changes:
- mucosal changes within the ostio-
meatal complex and/or sinuses.
6. CRS in children
Chronic rhinosinusitis (with or without nasal polyps) in children is defined
as:
presence of two or more symptoms one of which should be either nasal
blockage / obstruction / congestion or nasal discharge (anterior/posterior
nasal drip)
+/-facial pain/pressure;
+/-cough
For more than 12 weeks.
8. Bacteria
The newer molecular microbiome data has provide support for the
hypothesis that dysbiosis of the community as a whole, as opposed to
individual organisms, may trigger mucosal inflammation.
Depletion of two genera (Corynebacterium and Peptonophilus) was
associated with CRS.
Pathogens such as Haemophilus influenzae, Streptococcus
pneumoniae,Pseudomonas aeruginosa, Moraxella catarrhalis and S. aureus
can all form sinonasal biofilms in CRS patients,
9. Viruses
virus infection might contribute to development and exacerbations of CRS,
via damaged airway barrier.
Viruses commonly associated are- rhinovirus, respiratory syncytial virus
and influenza virus, corona virus.
10. Fungi
Recent work has suggested that an innate immune defect
(possibly in TLR4) may account for fungal accumulation in the
sino-nasal cavities of AFRS patients.
Fungi have intrinsic protease effects that induce Type 2 cytokine
signalling leading to the accumulation of eosinophilic mucin.
Same protease effects should foster a type 2 response, leading to
local and systemic IgE responses to fungal antigen.
11. Other environmental & host factor
Ciliary impairment- primary ciliary dyskinesia.
Smoking
Environmental pollution-cleaning agents, metal dust, animals, moisture/mould/mildew,
poisonous gas
Obstructive sleep apnoea
Metabolic syndrome and obesity
Low vit-D3
Alcohol hyper-responsiveness
12. Cont..
Genetic association - biological role: a. immune system related; b. epithelial
barrier related; c. difficult to categorize.
13. Inflammatory mechanisms of CRS
The inflammatory mechanisms of chronic rhinosinusitis (CRS) are the
molecular pathways leading to the establishment of the mucosal
inflammation and tissue remodelling that characterizes this broad
syndrome.
-Multiple inflammatory mechanisms
-Interacting dynamically,
-variable patterns of tissue inflammation.
-Mucosal barrier penetration by environmental agents also involves Type1, 2 and 3
pathways.
-CRS response is chronic and polyclonal.
20. Approach in a patient with CRS
History
Physical examination
Nasal endoscopy
CT scan of PNS
Diagnosis
Management
21.
22. Olfactory dysfunction
Distinct clinical features of CRS related olfactory
dysfunction-
1. Fluctuation of the olfactory complaint
2. Gap between ortho-versus retronasal olfactory
function.
3. Low threshold and preserved identification
scores.
4. Steroid-dependent reversal.
23. Facial pain
Moderate to severe pain.
There is no correlation between the
location of facial pain and abnormalities.
24. Nasal endoscopy
Identification of oedema, pus and/or polyps.
Assessment of sinus cavities following surgery.
Microbiological sampling when needed.
Response assessment.
Documentation.
25. Objective nasal patency measurement
peak nasal inspiratory flowmetry: objective
measure of nasal patency.
This measure correlates best with subjective
nasal patency.
Diagnostic.
Evaluation of treatment
26. Diagnostic imaging in rhinosinusitis
Imaging is used to assess:
• Corroboration of clinical symptoms and
endoscopic findings
• Anatomy and anatomical variants
• Pathology
• Diagnosis
• Extent.
28. Biopsy
To confirm diagnosis, to assist in endotyping of inflammatory disease and for
research purposes.
To explore the differential diagnosis (inflammation, respiratory
epithelial adenomatoid hamartoma (REAH), infection, granuloma
/ vasculitis, tumour).
To confirm severity of inflammation, cellular composition e.g. eosinophils
bacterial and fungal elements.
To determine nature of relationship e.g. invasive or non-invasive fungus.
29. Biomarkers of type 2 disease
Main biomarkers are- Eosinophils
IgE levels
Periostin
34. AR, NAR and CRS
Significant Overlap.
The radiologic sign of an
obstructed ostio-meatal
complex is a sign of CRS.
35. Indication of surgery
patients with sinus disease refractory to a trial of primary medical therapy.
As the aim of surgery is to improve the severity of patient’s symptoms, the
decision to operate should only be made in patients with symptomatic disease,
with the exception of patients with actual or impending complications.(EPOS
2020)
36. FESS IN CRS
Creates a sinus cavity that incorporates the natural ostium-
• Allows adequate sinus ventilation.
• Facilitates mucociliary clearance.
• Facilitates instillation of topical therapies.
37. Future challenges in CRS
Better understanding of: 1) the aetiologic factors that drive CRS with a goal
towards prevention.
2) Pathophysiologic inflammatory mechanisms and relevant endotype
biomarkers with a goal toward targeted therapy.
3) Molecular mechanisms of barrier and tissue remodeling that may play a role
in persistence and recurrence.
38. Treatment evidence and recommendations
for adult CRS
Therapy Level of evidence GRADE recommandation
Short term antibiotics for CRS 1b- No effect on symptomatology apart
from significantly reduced postnasal
drip symptom scores at week 2 .
Long term antibiotics for CRS 1a- uncertain whether or not the use of
long-term
antibiotics has an impact on patient
outcomes in adults with CRS
Topical antibiotics 1b- Topical antibacterial therapy does
not seem to be more effective than
placebo in improving symptoms..
39. Cont..
Therapy Level of evedance GRADE recommandation
Nasal corticosteroids 1a There is high-quality evidence that
long term use of nasal
corticosteroids is effective and safe
for treating patients with
CRS. They have impact on nasal
symptoms and quality of life
improvement,When administered
after endoscopic sinus surgery, nasal
corticosteroids prevent
polyp recurrence.
-Well tolerated.
-Low side effect.
40. Cont..
Therapy Level of evidence GRADE recommendation
Corticosteroid-eluting implants 1a The placement of corticosteroid-
eluting sinus implants in the
ethmoid of patients with recurrent
polyposis after sinus
surgery reduces the need
for surgery and reduces nasal
polyp score
Systemic corticosteroids 1a A short course of systemic
corticosteroid, with or without
local corticosteroid treatment
results in a significant reduction
in total symptom score and nasal
polyp score.
41. Therapy Level of evidence GRADE recommendation
Antihistamines 1b There is insufficient evidence to
decide on the effect of
the regular use of antihistamines
the treatment of patients with
Anti-leukotrienes 1b- does not recommend montelukast
use unless in situations where
patients do not tolerate nasal
corticosteroids.
Decongestant 1b In situations where the nose is
blocked, the temporary addition
a nasal decongestant to nasal
corticosteroid treatment can be
considered
42. Therapy Level of evedance Recomammandation
Nasal irrigation with saline 1a The steering group advises the use
of nasal saline irrigation with
isotonic saline or Ringer’s lactate
with or without the
addition of xylitol, sodium
hyaluronate,
Aspirin treatment after
desensitization (ATAD) with oral
aspirin in N-ERD
1a can be a treatment for N-ERD
patients with
CRSwNP whenever there is
confidence in the patient’s
compliance.
Low salicylate diet 1b Diets, like low salicylate diet have
been shown to improve
scores and may improve symptoms
compared to
a normal diet
43. Therapy Level of evidence recommandation
Local and systemic antifungal
treatments
1a- Local and systemic antifungal
treatments do not have a positive
effect of QOL, symptoms and signs
of disease in patients
with CRS
Anti-IgE 1b Anti-IgE therapy has been
as a promising biologic therapy for
CRS
Anti-Il-5 1b Mepolizumab that showed a
significant reduction in patients’
need for surgery and an
improvement in symptoms.
44. Other medical therapy with poor evidence
Probiotics
Muco-active agents
Herbal treatment
Acupuncture and traditional Chinese medicine
Nasal furosemide
Capsaicin
PPI
Phototherapy
Filgastrim
Colloidal nasal silver spray
47. Dupilimab
Dupilumab is a fully human monoclonal antibody to the IL-4 receptor a subunit,
which inhibits signalling of IL-4 and IL-13 that is given as a subcutaneous
injection.
