Chronic rhinosinusitis (CRS) is defined as inflammation of the nose and paranasal sinuses characterized by two or more symptoms for at least 12 weeks, one of which must be either nasal blockage/congestion or nasal discharge. CRS subtypes include CRS with nasal polyps (CRSwNP) and CRS without nasal polyps (CRSsNP). Diagnosis involves symptom assessment, nasal endoscopy, and sometimes CT scans or allergy testing. Risk factors include allergy, asthma, aspirin sensitivity, smoking and genetic factors. Treatment involves nasal saline irrigation, corticosteroids and surgery.

1. Sasikarn Suesirisawad, MD

2.  Chronic Rhinosinusitis (with or without NP) in adults
 ≥ 2 symptoms
 one of which should be either nasal
blockage/obstruction/congestion or nasal
discharge(ant/post drip) or
 ± Facial pain/pressure
 ± reduction or loss of smell
for ≥12 weeks
with validation by telephone or interview.
Questions on allergic symptoms (sneezing, watery
rhinorrhea, nasal itching, and itchy watery eyes) should be
included.
EPOS 2012

3.  CRSwNP: bilateral, endoscopically visualised
polyps in middle meatus.
 CRSsNP: no visible polyps in middle
meatus, if necessary following decongestant.
EPOS 2012

4.  Symptoms ≥ 12 weeks
 ≥ 2 symptoms one of which should be either nasal
blockage/obstruction/congestion or nasal discharge (ant/post
nasal drip):
 ± facial pain/pressure,
 ± reduction or loss of smell;
 Signs (if applicable)
•nasal examination
•oral examination: posteriordischarge; exclude dental infection.
 Additional diagnostic information
• questions on allergy should be added and, if positive, allergy testing
should be performed.
 Not recommended: plain x-ray or CT-scan
EPOS 2012

5.  Symptoms ≥ 12 weeks
 ≥ 2 symptoms one of which should be either nasal
blockage/obstruction/congestion or nasal discharge (ant/post nasal drip):
 ± facial pain/pressure,
 ± reduction or loss of smell;
 Signs
• ENT examination, endoscopy;
• review primary care physician’s diagnosis and treatment;
• questionnaire for allergy and if positive, allergy testing if it
has not already been done.
EPOS 2012

6.  ≥ 2 symptoms
 one of which should be either nasal blockage/obstruction/congestion or nasal
discharge(ant/postnasal drip) or
 ± Facial pain/pressure
 ± Cough
for ≥12 weeks
with validation by telephone or interview.
 Questions on allergic symptoms (sneezing, watery rhinorrhea, nasal itching, and
itchy watery eyes) should be included.
EPOS 2012

7.  5-15% of general population both Europe and
USA.
 Prevalence of MD-diagnosed CRS was 2-4%
EPOS 2012

8.  Ciliary impairment
 Allergy
 Asthma
 Aspirin sensitivity
 Immunocompromised state
 Genetic factor
 Pregnancy and endocrine state
 Local host factor
 Biofilm
 Environmental factor
 Iatrogenic factor
 H.pylori and laryngopharyngeal reflux
 Osteitis

10.  Defect in barrier and/or innate immune response
of sinonasal epithelium.
 Increase microbial colonization, accentuated
barrier damage.
 Defect in STAT 3(CRSwNP)
 Inappropriated Th2 adaptive response
 Local autoantibody
 Biofilm
EPOS 2012

12. EPOS 2012

13. Comparison of major cells and mediators in CRS vs NP. TGF-β, a key
mediator inducing fibrosis, is increased in CRS, but decreased in NP.
Middleton’s Allergy Principle & Practice, seventh edition

14. Mucosa in CRS: BM thickening, goblet cell hyperplasia, subepithelial edema,
mononuclear cell infiltration with few eosinophils
Middleton’s Allergy Principle & Practice, seventh edition

15. Numerous subepithelial eosinophils in luminal compartment
of early-stage polyp.
Middleton’s Allergy Principle & Practice, seventh edition

16. Eosinophils accumulated subepithelially and diffusely
in tissue of mature polyp.
Middleton’s Allergy Principle & Practice, seventh edition

17. Koen Van Crombruggen et al. J Allergy Clin Immunol 2011;128:728-32.

18. Spencer C et al. J Allergy Clin Immunol -

20. Endoscopic view of nasal polyps protruding from middle meatus.
Middleton’s Allergy Principle & Practice, seventh edition

24.  Nasal polyposis
 Fungi on staining
 Eosinophilic mucin without fungin invasion
into sinus tissue
 Type I hypersensitivity to fungi and
 Characteristic radio findings with soft tissue
differential densities on CT scaning
EPOS 2012

26. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

27. CT scans nasal polyps. (A) Central disease, an early stage.
(B) Nearly total ‘white-out,’ a late stage.
Middleton’s Allergy Principle & Practice, seventh edition

30. CT scan of fungal infection of right maxillary sinus: heterogeneous opacification
and calcification with increased attenuation.
Middleton’s Allergy Principle & Practice, seventh edition

31. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

32. EPOS 2012

33. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

36. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

38. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

45. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707