This document summarizes the medical management of rhinosinusitis (RS) and nasal polyps. It discusses the different types of RS including acute, chronic, allergic, and infectious. Treatment options are provided for each type based on severity and include nasal irrigation, topical and oral corticosteroids, antibiotics, decongestants, and immunotherapy. Surgical management is reserved for severe cases that do not respond to medical therapy. The goal of treatment is to reduce symptoms and recurrence in order to improve quality of life for patients with RS.

1. Medical management
By Dr.Sudha Shahi
Dept of ENT Head and Neck Surgery
Bir Hospital ,NAMS
Kathmandu,Nepal

2.  “When we consider the quality of life impact from
RS related symptoms and the associated emotional
and functional impairments it can be assumed that
RS has a dramatic impact on peoples lives and in
productivity of life.”

6. Brief Recall:
Rhinosinusitis-
Group of disorders characterised by Inflammation of
mucosa of nose and paranasal sinuses.

7. Allergy
Intermittent(Seasonal AR)
Persisitent(Perennial AR)

8. Infection
Acute( 7 days to <4wks)
Viral (majority of cases)
Subacute(4-12wks)
Chronic(>12wks)
Recurrent acute – 4 or more episodes per year, with resolution of
symptoms between attacks
Acute Exacerbation of Chronic- Sudden worsening of CRS with
return to baseline after

9. Others
Occupational irritants and allergens
Vasculitis/granulomatous/autoimmune
Aspirin sensitivity
Allergic fungal sinusitis
Atrophic rhinitis

10.  Others
NARES
Drug induced, rhinitis medicamentosa
Irritant-induced rhinitis
GERD
Underlying diseases(cystic fibrosis, ciliary immotility)
Structural
 Osteomeatal complex
 Deviated nasal septum
 Hypertrophic turbinates
Idiopathic

11. LETS DO
STH
HERE
TIME FOR
SOME AB

12. Allergic Rhinitis
 Allergen avoidance
 Antihistamines:
 First generation mostly avoided d/t sedative
psychomotor retardation and learning impairment d/t
BBB crossing nature of it as compared to
Cetrizine,Fexofenadine,desloratidine .Also possess some
antiinflammatory effect
 Topical Glucorticosteroid:
Best is started before allergen exposure .
Reduce inflammation,hyperreactivity and sense of smell

13. Sodium chromoglycate :
Used for children below 4 yrs in whom topical
corticoseroid is not used often
Decongestants:
Reduce nasal obstruction but long term use might
cause rhinitis medicamentosa
Ipratropium bromide:
Symptomatic relief in rhinorrhea but careful use in
glaucoma and prostatism and might worsen dry
eyes and mouth

14. Systemic Corticosteroids
Occasional intermittent use combined with topical CS
Antileukotrienes:
Effective against congestion and mucus
production.Combined with antihistamine has better
benefits.
Nasal douching :
Helps provide symptomatic relief and clear up the
sinuses

15. Immunotherapy:
Only in selective patients with limited spectrum of
allergies
~ 40% reduction in symptoms and ~80% reduction in
rescue medication requirements
Also helpful in associated bronchial Asthma
Nevertheless patients with chronic Asthma are
excluded from the treatment due to risk of many
side effects

16. Inclusion criteria
 IgE-mediated disease
(+SPT/RAST)
 Inability to avoid allergen
 Inadequacy of drug
 Limited spectrum of
allergies (one or two)
 Patients who understand
risks and limitations of
treatment
Contraindications
 Coexistent asthma
 Patients taking beta-
blockers
 Other
medical/immunologic
 Small children (less than
five years)
 Pregnancy (maintenance
therapy may be continued
in pregnancy)

17. Novel advances
 Sublingual immunotherapy
 Bacterial DNA sequences conjugated with allergen
induces preferential TH1 response and protective T
cell response

18.  Surgery:
 Very limited role and required only in conditions
where there is marked septal deviation or bony
turbinate enlargement which makes topical nasal
sprays usage difficult.

19. Acute Rhinosinusitis Treatment

20. Viruses
Rhinovirus
Coronaviruses
Influenza virus
Parainfluenza virus
Adenovirus
RSV
Enterovirus

21. Children Adults
Streptococcus pneumoniae (30-43%)
Haemophilus influenzae (20-28%)
Moraxella catarrhalis (20-28%)
Other Streptococcus species (5-7%)
Anaerobes(5-7%)
Streptococcus pneumoniae (20-43%)
Haemophilus influenzae (22-35%)
Streptococcus species (3-9%)
Anaerobes (0-9%)
Moraxella catarrhalis (2-10%)
Staphylococcus aureus (0-8%)
Others(4%)

22. Common for all types of Acute RS:
Hydration
Long-acting topical nasal decongestant
Nasal saline applied with nasal irrigation
device
Topical nasal CCS

24. Antibiotics in Acute bacterial
rhinosinusitis
Don’t treat common viral cold with antibiotic
Reserve for severe, presumably bacterial
Rhinosinusitis
symptoms past 7-10 days:
Antibiotics X 7-14 days (until asymptomatic +5-7 days).
Choices:
Amoxicillin/clavulanate, Cephalosporin, Clarithromycin

25. First choice:
Amoxicillin/clavulate or cephalosporin
Good second choice: Clarithromycin
(Azithromycin, 5-0-(5), may also be quite useful)
Back-ups:
Quinolones
Use Metronidazole plus one of the above or
clindamycin when gram negative is suspected
Topical mupirocin very useful in select cases

26. EPOS JTFPP CPG AS
Uncomp
icated
AVRS
Mild Disease-
Symptoms lasting <5d or
improving thereafter
Decongestants ,Saline or
analgesics
Moderately severe-
Symptoms lasting >.5d or
increasing
Add topical corticosteroids
If no improvement after 14
d
Reconsider rediagnosis
Consider nasal endoscopy
Culture/imaging
Consider antibiotics if
necessary
Severe Disease-
Severe pain and temp >38
Add antibiotics and topical
corticosteroids for 7-14 days
(expected results in 48 hrs)
7-10 days course of
watchful waiting
Antibiotics are
strongly
discouraged
Management primarily
symptomatic
Analgesics and
antipyretics
Oral or topical
decongestants
Topical nasal
CS(Optional)

27. EPOS JTFFP CPG AS
Uncomplicate
d ABRS
Mild Disease-
Symptoms lasting <5d or
improving thereafter
Decongestants ,Saline or
analgesics
Moderately severe-
Symptoms lasting >.5d or
increasing
Add topical corticosteroids
If no improvement after 14 d
Reconsider rediagnosis
Consider nasal endoscopy
Culture/imaging
Consider antibiotics if
necessary
Severe Disease-
Severe pain and temp >38
Add antibiotics and topical
corticosteroids for 7-14 days
(expected results in 48 hrs)
Antibiotics 10-14 d
Choice of agent
based on likely
pathogen consistent
with clinical history
Consider patients
with severe signs
and symptoms at
any time of the
disease (worsening
after 3-5
days,temp>38,
severe facial
pain,unilateral facial
swelling ,sinus
tenderness)
Assess pain and
analgesics
accordingly
Watchful waiting (
without antibiotic i
symptom< 7d)or
mild disease or if pt
likely to F/U
Initiate Antibiotics i
no improvement
after 7d or if it
worsen (Amoxy firs
line)Antibiotics if
severe disease
Antihistamine
Donot use if
nonatopic
symptomatic relief i
recommended

28. EPOS JTFFP CPS AG
ARS in general Intranasal
corticosteroids
Oral CS in severe
disease
Antihistamines
only in allergic
and
Decongestants
Intranasal CS
modestly
benefitial as
adjunctive
therapy in
patients with
reccurent disease
Antihistamines
No data to
recommend use
Topical oral
decongestants
Do not use since
prospective study
ecaluating use are
lacking
Topical CS
optional
Decongestant
optional
Nasal saline
irrigation
optional

29. Conclusion
 Guidelines promulgated by 5 major groups regarding
acute rhinosinusitis (ARS)
 The efficacy of intranasal corticosteroids has been well
established by clinical trial data, and guidelines advise
their use in ARS
 Physicians have been overusing antibiotics which has
been playing a role in resistance

30.  The aim of treatment is to reduce signs and
symptoms ,quality of life of patient and prevent the
recurrence.

31. Chronic inflamed mucosa
Neutrophils and mononuclear cells in CRSsNP
Eosinophils in CRSwNP
Possible chronic infection
Bacteria
Fungi
Superantigens
Biofilms
Osteitis

32. Children Adults
Anaerobes
Other Streptococcus species
Staphylococcus aureus
Streptococcus pneumoniae
Haemophilus influenzae
Pseudomonas aeruginosa
Anaerobes
Other Streptococcus species
Haemophilus influenzae
Staphylococcus aureus
Streptococcus pneumoniae
Moraxella catarrhalis
Common organisms in CRS

33. Chronic
Rhinosinusitis Nasal Polyps
Nasal Polyps
The spectrum of sinus disease
Rhinosinusitis
- Eosinophils +

34. Treatment
Few well-conducted clinical trials in chronic
rhinosinusitis. Further studies are needed in well-
characterized patients.
Based on the evidence available initial therapy is
medical
Aim to reduce symptoms and signs decrease
morbidity and prevent disease progression or
recurrence.
CRS usually responds incompletely to therapy and
may need to be continued long-term

35. Hydration (6 - 8 glasses of water per day)
Antibiotics only if clear evidence of infection: use X 14-21+
days (until asymptomatic +7 days).
Choices: cephalosporin, amoxicillin/clavulanate,
clarithromycin, quinalone
Long-acting nasal decongestant, BID X 3-7 days
(oxymetazoline)
Nasal saline with nasal irrigation device
Topical nasal CCS
Reduce to lowest effective dose, to maintain remission

36. Prevalence approx. 2- 4%, 25% of CRS
Asthma in approx. 40-65%
Aspirin sensitivity in 10-15%
Mixed cellular infiltrate with
prominent eosinophilia in 90%
Inflammation with
 local IgE production
 increased IL-5, eotaxin,
cys-LTs and ECP

38. Treatment of underlying condition
Continue treatment of sinusitis
Topical corticosteroids
Pulmicort, budesonide
Budesonide solution (Pulmicort Respules)
Fluticasone (Flovent
Systemic corticosteroids
Prednisone 20-30 mg
Kaliner MA. Current Review of Allergic Diseases. Philadelphia, Pa: Current Medicine, Inc., 1999.

39.  Antibiotics
 Long term prophylaxis with macrolids group of
drug (8 wks )found to reduce the polyp size ot 50%
in 21 patients and better response in ptns with
normal IgE levels and inversely proportional in
eosinophil count in blood and mucosa

40. Mupiricin ointment
Topically or dissolved in sinus lavage
Consider oral or topical anti-fungal treatment
Possible benefits in paediatric Upper airway infcetion
Needs more studies
Polypectomy

41. Medical polypectomy
 All patients should have a trial of medical treatment
before surgery unless the nature of the polyps is in doubt.
 Smaller polyps may respond to topical corticosteroid
only.
 Larger polyps may respond to a medical polypectomy

42. Medical polypectomy
Prednisolone 0.5mg/kg each morning for 5–10 days
PLUS Betamethasone nasal drops two drops per nostril
tds in the ‘head upside down’ position for 5 days, then
twice daily until the bottle runs out
 Maintenance therapy with fluticasone (drops, spray) or
mometasone (spray) is recommended as these have lower
bioavailability, unlike betamethasone nasal drops .

43.  All forms of topical INS may delay the re-growth of nasal
polyps. Polyps tend to recur, and it is recommended that
treatment is continued for the long-term.
 However, no evidence for how long treatment should be
continued although this will vary, with more aggressive
inflammatory polyps rich in eosinophils and IL-5
requiring prolonged treatment.

44. Surgery
 A randomized prospective study of patients with polypoid
or non-polypoid CRS demonstrated that there was no
difference between patients who received medical
treatment (topical corticosteroid, nasal douching and long-term erythromycin)
compared with those who underwent endoscopic sinus
surgery combined with topical nasal steroids.
 , Clinical and Experimental)

45. CRS without Nasal polyp

47. Allergen avoidance
 There is no strong evidence regarding its
effectiveness in CRS but mostly in cases with
positive allergic history together with positive SPT it
might be useful.

48. Nasal douching
Safe, inexpensive,symptomatic relief
Adverse events
Sodium load should be considered in hypertensive
patients.
Place in therapy
Addition to therapy in chronic rhinosinusitis, nasal
polyposis and rhinitis. Effective in primary ciliary
dyskinesia

49. Neti pots
The Neti pot originated in India in Ayurvedic medicine.(
VALIDATED BY SCIENTIFIC EVIDENCE) Neti is Sanskrit for “nasal
cleansing.”
Nasal irrigation provides short-term symptomatic relief
and may improve nasal mucociliary clearance. It removes
mucus not only from the nose but also from the maxillary
and ethmoid sinuses.
BUT one should be careful not to overdo it.

52. Topical intra-nasal corticosteroids
 Act by suppression of inflammation at multiple points in the
inflammatory cascade .
Nasal drops are preferable for nasal polyposis and probably
also for chronic rhinosinusitis.
 These should be used in the ‘head upside down’ position in order to reach the
ostiomeatal complex (OMC),
50% of ptns not responding to topical sprays are responsive to
fluticasone nasules

54.  Adverse events
 Local nasal irritation, sore throat and epistaxis (10% )
(Benzalkonium chloride)
 Hypothalmic-pituitary axis suppression
 Raised intra-ocular pressure (glaucoma)

55.  Place in therapy
First-line therapy for rhinosinusitis. Topical steroid
drops should be used initially in nasal polyposis and in
cases with severe obstruction.Routinely used in long term
and reduce the recurrence of nasal polyps.
 A suggested regime for adults is 0.5mg/kg

56. Used for:
 Severe nasal obstruction
 Short-term rescue medication for uncontrolled
symptoms on conventional pharmacotherapy

58. Systemic glucocorticosteroids.
Oral corticosteroids should be used briefly and always in
combination with a topical nasal corticosteroid.

59.  Intra-nasal decongestants.
The a1-agonist ephedrine and a2-agonist xylometazoline
are sympathomimetics( increase nasal vasoconstriction).
Combined with a topical corticosteroid such as Dexa-
Rhinaspray duoTM, short term use is helpful in
exacerbations of rhinosinusitis with nasal blockage

60.  Adverse events
 Regular use can lead to rhinitis medicamentosa with
tachyphylaxis rebound effect.Nasal irritation may increase
rhinorrhoea.
 Place in therapy
Brief use of 10 days is advised
o To avoid rebound effect for eustachian tube dysfunction
when flying
o In children with acute otitis media to relieve middle ear
pain/pressure post –URTI
o To reduce nasal/sinus congestion
o To increase nasal patency before the intranasal administration
of nasal steroids.

61. Antibiotics
 Role in CRS is still controversial
Two routes;
 Topical –Abandoned due to incidence of hyposmia but use
of tobramycin instilled into maxillary sinuses in cystic
fibrosis is helpful
 Benefitial in upper airway diseases in children
 Short-term (2 weeks) can be used for AE of rhinosinusitis
with or without the guidance of middle meatal swabs

62.  Long term prophylaxis
 Trials of long-term oral antibiotics (>12 weeks), especially
macrolides, have demonstrated symptomatic and objective
improvement similar to endoscopic sinus surgery
 Reduction in mortality from diffuse panbronchitis and
improved sinus symptoms
 The improvement shown increases with time and may
relate to anti-inflammatory reactions in macrolides.

63. Anti-leukotrienes
There are no RCTs on the use of anti-leukotrienes in
rhinosinusitis, but efficacy in nasal polyposis has been
demonstrated.(`50 %respond to some degree)
Adverse events
Usually well tolerated; occasional headache,
gastrointestinal symptoms or rashes. Occasional reports
of Churg-Strauss syndrome which may relate more to
steroid withdrawal rather than a direct effect of the drug,
although further long-term evaluation is needed.

64. Place in therapy
Anti-leukotrienes may be used in patients with aspirin-
sensitive rhinosinusitis, asthma and nasal polyposis. Some
patients with aspirin sensitivity appear to show marked
improvement.

65. Aspirin desensitisation
 Oral aspirin desensitization followed by regular daily
dosing may cause significant improvement.
 There is some evidence suggesting that oral doses as low
as 100mg daily maybe effective and this could potentially
circumvent some of the adverse effects associated with
oral aspirin.
 However, side-effects including gastrointestinal bleeding
at high doses .The efficacy of the regular administration of
topical intranasal lysine aspirin therapy remains under
investigation.

66. Nasal
 Lysine aspirin the soluble aspirin used for diagnosis
of aspirin sensitivity has found to have resulted into
prolonged polyp free interval in both aspirin
sensitive and aspirin tolerant patients.
 It has shown to be associated with reduction of
cysteinyl leukotriene receptors which are
upregualted in nasal mucosa of aspirin sensitive
individuals.

67. Immunotherapy
 Immunoglobulin replacement therapy in humoral
deficiency syndromes( frank hypogammaglobinemia
to IgA and other subclasses deficiencies)
Bacterial vaccines
 Used previously but no strong evidence of benefitial
effect

68.  Other therapies
Diuretics
 Frusemide found to reduce the recurrence of polyps
if administered nasally to post polypectomy patients
over a prolonged periods
 Similarly amiloride used in cystic fibrosis also
suggested as topical therapy for nasal polyps

69. Azelastine:
An open study suggests that this may have some benefit in
nasal polyposis
Nitric Oxide donors:
NO has bactericidal properties and is manufactured inPNS.
NO levels are raised in inflammation but decreased in
CRSprobabaly due to ostiomeatal complex obstruction.
hence increased. NO levels is a landmark for successful
therapy.
eg.Arginine

70.  Diet
 Alcohol,preservative,high salicylate food exacerbate
 Milk mucus promoter

71.  In case of ocupational ,food induced,drug induced,irritant
induced avoidance of the causitive factor
 Intranasal anticholinergics (Ipratropium bromide)
 Nasal decongestants
 Topical steroids and antihistamines
 Azelastine
 Silver nitrate and botulinum if no response to conventional
therapy
 Intranasl capsacain once daily for 5 weeks
 Surgical aproach if turbinate hypertrophy with resistant with
medical response
 Ethmoid and Vidian neurectomies

72. Allergic fungal sinusitis
Aggressive nasal Rx
Budesonide nasal washings, 500 ug BID
Itraconazole, oral
100 mg BID x 6 months
100 mg QD x 12 months
Monitor LFT, IgE Q 3 mos
Consider surgery if unresponsive
Surgery with the removal of all affected tissue, followed by
topical corticosteroids

73. Fungal rhinosinusitis
Open studies of douching with antifungals such as
amphotericin have been reported as beneficial
 Antifungals
 Placebo-controlled trials of amphotericin nasal
douching are negative .
 Oral terbinafine has also failed to show any activity
under double-blind conditions

74. Churg-Strauss syndrome
 This is a combination of severe asthma, nasal polyposis,
eosinophilia and eosinophilic vasculitis with granulomas.
It should be suspected in patients with severe disease
requiring frequent courses of oral corticosteroids.
About 50% of patients are ANCA positive.). If the
diagnosis of Churg-Strauss syndrome is suspected,
specialist referral to a vasculitis clinic is advisable for
further mangement

75. Specific Chronic Infections

76. Nasal Tuberculosis
Lupus vulgaris(nodular forms),Ulcerative forms,sinus
granuloma
 Tubercular treatment ; 4 drug regimen 4HRZE+4HR
Syphilis
TT;Parenteral penicillin preferred DOC
 Local treatment includes crust removal,alkaline nasal
douches ,yellow mercury oxide oint locally

77.  Hereditary syphillis
 Local cleansing
 Yellow mercury oxide oint.
 Nasal douching
 Antisyphillitic medication
 Leprosy
 Direct intranasal administration of rifampin reduce
M.Leprae load much faster than when given orally
 Rifamicin 600mg first 2 days on alternate days three times
aweek
 Clofazimine 100mg alternate day three times a week
 Dapsone 100mg daily

78. Atrophic Rhinitis
 Regular nasal cleansing
 Nasal douching with hypertonic alkaline saline
(sodium bicarb:Sodium diborate:sodium chloride)1;1;2 in
280 ml of water followed by solution of 25 percent glucose
in glycerine to inhibit proteolytic organisms
 Human placental extract systemically and locally
 Rifampicin 600mg oral for 12 weeks good results

79.  Underlying diseases(Cystic fibrosis,Wegners
granulomatosis)
Azathioprine ,cyclophosphamide or cotrimoxazole in
addition to the symtomatic management

80. Structural
 Obstruction of Osteomeatal complex
 Decongestant
 Nasal douching
 Topical CS
 Review at 6 wks

81. Further medical therapy
 Oral CS few days plus Topical for long term
 For nasal polyposis
 Trial of leukotriene for nasal polyposis
 Antibiotics
 Aspirin

82. Rhinosinusitis in children
Common problem;may be related to underlying immune
deficiency (innate or acquired) or to allergy
Like OME, usually resolves with maturation (~7 years)
Medical treatment including douching should be instigated, with
surgery reserved for acute severe problems or for those patients
with severe chronic symptoms not responding to medical therapy
.

84. Few clinial studies in Rhinosinusitis and their
guidelines brief comparision

85. EPOS
 CRSsNP
 Mild(VAS 0-3)
 Topical CS
 Nasal Lavage if failure after 3 months treat as moderate
or severe
 Moderate /severe(VAS >3-10)
 Topical CS
 Nasal lavage
 Longterm macrolide therapy
 Culture
 Cases that improve
 Follow up + nasal lavage ,topical CS +/- long term
macrolide therapy
Mild = VAS 0 - 3 Moderate = >3 - 7 Severe = VAS >7 - 10

86.  CRScNP
Mild (VAS 0-3)
 TopicalCS sprayfor 3 months
 if benefitial continue and review every 6 months
 If no improvement ,add short course of oral CS
 If still n oimprovement ,consider CT assess as
surgical candidate
 If improved after 1 month switch to topical CS
drops,review after 3 months

87. Moderate (VAS 3-7)
 Topical CS drops for 3 months
 if beneficial continue and review every 6 months
 If no improvement after 3 m ,add short course of oral CS
 If still no improvement ,consider CT and evaluate as
surgical candidate
 If improved after 1 month switch to topical CS drops

88. Severe (VAS >7-10)
 Short course of oral CS +topical CS for 1 month
 If beneficial topical CS drops only and review after 3
months
 If no improvement consider CT and evaluate as
surgical candidate

89. JTTFP
Antibiotics:
Role is controversial; may be useful for acute exacerbation of chronic
disease
Intranasal corticosteroids:
May be modestly beneficial as adjunctive therapy
Antihistamines:
Possible role in CRS if underlying risk factor is allergic rhinitis
Topical and oral decongestants:
Prospective studies evaluating use are lacking
Antifungal agents:
Role has not yet been established

90. Take preventive measures to minimize symptoms and exacerbations of
CRS
Saline nasal irrigation
Good hand hygiene to prevent acute viral RS
Assess the patient for factors that could modify management
(eg, allergic rhinitis, cystic fibrosis, immunocompromised state,
ciliary dyskinesia, anatomic variation)

91. Conclusion
 Guidelines promulgated by different groups regarding CRS are not in
complete agreement regarding best practices
 The efficacy of intranasal CS has been well established by clinical trial data,
and guidelines advise their use in CRS
 Physicians have been overusing antibiotics which has been playing a role in
resistance
 There has been a push for clinical trials examining CRS with nasal polyposis,
CRS without nasal polyposis, and allergic fungal rhinosinusitis as distinct
entities; however, few such trials have been conducted to date, and more
data are needed to help clinicians treat these conditions appropriately.
 The value of antibiotics for treatment of CRS is still unproven

92.  References
 Scott Brown,BASCI guidelines ,
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Primary ciliary dyskinesia. Acta Otorhinolaryngol Belg 2000; 54:317–
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