Chronic rhinosinusitis (CRS) is an inflammatory condition of the paranasal sinuses and nasal passages lasting more than 12 weeks. It is classified into subtypes based on symptoms and presence of nasal polyps. CRS affects 12.5-15.5% of people in the US and Europe. Diagnosis involves nasal endoscopy and CT scan showing sinus inflammation or obstruction. Treatment includes topical corticosteroids, antibiotics for acute exacerbations, and surgery for severe cases or nasal polyps. The pathophysiology involves thickening of sinus linings and different cytokine patterns between subtypes.

1. CHRONIC
RHINOSINUSITIS
CHULEEPORN KONGMEESOOK ,MD

2. Outline
•
•
•
•
Definitions
Classification
Diagnosis
Treatment

3. Epidemiology
Prevalence estimated 12.5% - 15.5% in
12.
15.
US and 10.9% in Europe
10.
In children 9.3% acute rhinosinusitis ,
19%
19% chronic rhinosinusitis
Piromchai et al International Journal of General Medicine 2013;6:453-64
2013;6:453Orapan et al Asian Pac J Allergy Immunol 2012;30:146-51
2012;30:146-

4. Definitions
• Rhinosinusitis : Inflammation of nose and
paranasal sinuses
• Acute rhinosinusitis (<4 weeks ) :
(<4
Purulent nasal drainage, nasal
obstruction, facial pain-pressurepain-pressurefullness, or both
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

5. Definitions
• Subacute rhinosinusitis (4-8 weeks )
• CRS (8-12 weeks ,medical Rx ) :
Inflammatory condition involve
paranasal sinuses and nasal passages
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

6. Symptoms of CRS
4 major symptoms (≥ 2 , to make Dx )
(≥
• anterior, posterior, or both mucopurulent
drainage
• nasal obstruction or blockage
• facial pain, pressure, and/or fullness
• decreased sense of smell
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

7. Middleton's allergy:principles and practice 8th edition

8. Definitions of rhinosinusitis
based on disease classification
CRSsNP
CRScNP
AFRS
Symptoms present for >12 weeks
Requires >2 of following symptoms
>2
Anterior or posterior mucopurulent drainage
Nasal congestion
Facial pain/pressure
Decreased sense of smell
Objective documentation
Rhinoscopic examination OR
Radiograph (sinus CT scan preferred)
Bilateral nasal polyps
in middle meatus
AFRS criteria
Positive fungal stain
or culture of allergic
mucin AND
IgEIgE-mediated fungal
allergy
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

9. Classification (Subtypes of CRS)
CRSsNP (60%)
60%)
• Facial pain, pressure, and/or fullness
• Organisms : S.pneumoniae,
S.pneumoniae,
H.influenzae, M.catarrhalis, S.aureus,
H.influenzae, M.catarrhalis, S.aureus,
S.coagulaseS.coagulase-negative
• Glandular hyperplasia and submucosal
fibrosis
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

10. Classification (Subtypes of CRS)
CRScNP (20-33%)
20-33%)
• Hyposmia/anosmia
Hyposmia/
• Nasal polyps are typically bilateral
• Associated with AERD
• Polyp tissue predominance of
eosinophils,
eosinophils, high levels of histamine,
and Th2 cytokines
Th2
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

11. Classification (Subtypes of CRS)
AFRS
Presence of allergic mucin (thick mucus
from light tan to brown to dark green,
degranulated Eos)
os)
Fungal hyphae in mucin
Evidence of IgE-mediated fungal allergy
IgE-
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

12. Classification (Subtypes of CRS)
AFRS
• Sinus surgery usually required
• Usually have nasal polyps and
immunocompetent
• Pathophysiology :chronic, allergic
inflammation directed against colonizing
fungi
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

13. Pathophysiology
• Basement membrane thickening, goblet
cell hyperplasia, subepithelial edema,
mononuclear cell infiltration in CRSsNP
• 31 untreated CRSsNP, <10% Eos (overall
CRSsNP, <10%
mean 2%)
• 123 untreated nasal polyp, 108 showed
>10% Eos (overall mean 50%)
10%
50%)
• Tissue eosinophilia not hallmark of
CRSsNP
Middleton's allergy:principles and practice 8th edition

14. Middleton's allergy:principles and practice 8th edition

15. Pathophysiology
• Typical cytokine pattern
CRS : high IFN-γ, elevated TGF-β
IFNTGFCRSsNP : IL-1β, TNF-α, IL-8
ILTNF- ILCRSwNP : high IL-5, low TGF-β
ILTGF-
Middleton's allergy:principles and practice 8th edition

16. Comorbidities and associated
conditions
• Allergic rhinitis ( 60% of CRS ,perennial )
60%
• Immunodeficiency
( hypogammaglobulinemia 12% of adults with CRSsNP )
12%
• GERD
• Defect in mucociliary clearance
( cystic fibrosis
and primary ciliary dyskinesia )
• Viral infection (role of viral infection in CRS is
controversial )
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

17. Comorbidities and associated
conditions
• Systemic disease
(presenting feature of WG or CSS,
sarcoidosis )
• Anatomical abnormalities
( nasal septal
deviation, concha bullosa deformity, paradoxical curvature
of middle turbinate )
• AERD and Asthma
(20% CRS have asthma ,2/3 of
20%
,2
asthmatic have evidence of CRS)
CRS)
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

18. Diagnosis
Nasal endoscopy
• discolored mucus or edema in middle
meatus or sphenoethmoidal recess
Sinus CT scanning
• sinus ostial narrowing or obstruction
• sinus mucosal thickening or
opacification, airopacification, air-fluid levels
Evaluated for allergy
• CRS associated with AR adults (60%)
(60%)
and children (36-60% )
36-60%
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

19. Middleton's allergy:principles and practice 8th edition

20. Treatment
Topical corticosteroid nasal sprays
• Recommended for all forms of CRS
• Beneficial effects on nasal and sinus
pain
Antihistamines
• Helpful in allergic rhinitis
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

21. Treatment
Antibiotics
• Used to treat infection if nasal purulence
present (acute exacerbation)
Antifungals
• Indicate only in invasive forms of sinus
mycosis or immunocompromised host
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

22. Treatment : CRScNP
• Oral corticosteroids (10-15 days) shrink
10nasal polyps
• Topical corticosteroid nasal sprays
recommended to prevent recurrence of
nasal polyps, although not always effective
• Antileukotriene agents
not FDA approved for treatment of nasal
polyps
• Sinus surgery in severe polyposis
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

23. Treatment : AERD
• Might benefit from aspirin desensitization
and daily aspirin therapy
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

24. Treatment : AFRD
• Sinus surgery establish diagnosis, remove
inspissated mucus and restore sinus
patency
• After surgery nasal polyps, oral
corticosteroids 0.5 mg/kg/day with
gradual tapering dose to control symptoms
• Topical corticosteroid nasal sprays to
control inflammation and prevent
recurrence of nasal polyps
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

25. Indications for sinus surgery
• Persistence of CRS symptoms despite
medical therapy
• Correction of anatomic deformities
• Debulking of advanced nasal polyposis
Mark S. Dykewicz et al J Allergy Clin Immunol 2010;125:S103-15
2010;125:S103-

26. Conclusion
Piromchai et al International Journal of General Medicine 2013;6:453-64
2013;6:453-

27. Piromchai et al International Journal of General Medicine 2013;6:453-64
2013; 453-

28. THANK YOU