Acute and Chronic Rhinosinusitis: diagnosis and management: current opinions.

Edoardo Cervoni, M.D.

RHINOSINUSITIS:
DIAGNOSIS AND
TREATMENT
GP Trainees 27/11/13,
Education Centre RPH

1

Discolosures
• Grant/Research Support: no
disclosure
• Consultant: no disclosure
• Major Shareholder: Locumdoctor4u
Ltd. (Locum and Concierge Medical
Services)
• I will not be discussing “off-label”
uses of medications or investigations

ENT Referrals
i.

Most ENT referrals are linked to Audiological and
Otological problems.

ii.

Out of 271 consecutive referrals to the RHP ENT
Department triaged in 2011, 58% could be potentially
managed in Primary Care.

CLPCT NHS Survey 2011 – E Cervoni


3

ENT Referrals
i.

Snoring and sleep apnoea were relatively common reasons of
referrals.
ii. In a rather significant proportion of cases, relevant information,
with specific reference to the physical examination, were missing.
iii. Among the referrals redirected to the GPwSI in ENT, deafness with
wax, epistaxis and blocked nose were the most common
complaints.

CLPCT NHS Survey 2011 – E Cervoni

4

Conditions referred

Cervoni E - 2011


EPOS 2012


6

Rhinosinusitis
 Inflammation of the nose and
Inflammation of the nose and
paranasal sinuses characeterized
paranasal sinuses characeterized
by the presence of 2 or more
by the presence of 2 or more
symptoms of which one MUST be
symptoms of which one MUST be
nasal obsteruction or rhinorrhoea
nasal obsteruction or rhinorrhoea
with:
with:
±facial pain/pressure
±hypo/anosmia
±hypo/anosmia

Associated with
and/or  CT abnormal changes:

 Endoscopic signs:
- polyps and/or
- polyps and/or
- purulent secretion from the middle
- purulent secretion from the middle
meatus and/or
meatus and/or
- oedema/mucosal
oedema/mucosal obstruction
obstruction
prevalent in the middle meatus
prevalent in the middle meatus


- mucosal changes at the level
- mucosal changes at the level
of the osteo-meatal complex or
of the osteo-meatal complex or
of the paranasal sinuses
of the paranasal sinuses

7

CLASSIFICATION
on severity of the symptoms

Rhinosinusitis may be classified into mild, moderate or
severe on the basis of VAS score.
Mild = VAS 0 - 3 Moderate = >3 - 7 Severe = VAS >7 - 10
Mild = VAS 0 - 3 Moderate = >3 - 7 Severe = VAS >7 - 10
To assess the severity of the symptoms the patient is asked
to answer the following question:
How painful are the symptoms of your sinusitis?
How painful are the symptoms of your sinusitis?
No pain

10 cm


Worst possible
pain

8

CLASSIFICATION
on duration
12 weeks

ACUTE/RECURRENT

(complete resolution of the symptoms)
(complete resolution of the symptoms)

CHRONIC

(incomplete resolution of the symptoms)
(incomplete resolution of the symptoms)


9

Acute Rhinosinusitis:
clinical features
Sudden onset of its symptoms of which one must be nasal
obstruction or rhinorrhoea
±hypo/anosmia
±hypo/anosmia
And duration <12 weeks

Presence of endoscopic signs of:
••Purulent secretion from the middle meatus
Purulent secretion from the middle meatus
••Oedema and/or obstruction of the middle meatus
Oedema and/or obstruction of the middle meatus
Presence of abnormal changes to CT imaging
Presence of abnormal changes to CT imaging

10



Acute rhinosinusitis:
types
Acute viral (common cold)
Duration of the symptoms < 10 days
Duration of the symptoms < 10 days

 Acute post-viral
-- Symptoms oncrease after 5 days
Symptoms oncrease after 5 days
-- Persistence of the symptoms after 10 days, but for less than
Persistence of the symptoms after 10 days, but for less than
12 weeks
12 weeks

 Bacterial post-viral
Presence of at the least 3 symptoms and/or signs:
Presence of at the least 3 symptoms and/or signs:
-Purulent secretion
-Purulent secretion
-Pain with unilateral preponderance
-Pain with unilateral preponderance
-Fever (>38 C)
-Fever (>38 C)
-Raised ESR and CPR
-Raised ESR and CPR


-Worsening of theEducation Centre RPHa phase of remission
-Worsening of the symptoms after a phase of remission
symptoms after

11

differential diagnosis


Viral infection of the upper airways

 Allergic rhinitis
Confirmed positivity to a common allergen
Confirmed positivity to a common allergen
It is characterized by rhinorrhoea (which is not
It is characterized by rhinorrhoea (which is not
purulent), senstion of nasal obstruction, itchy nose,
purulent), senstion of nasal obstruction, itchy nose,
sneezing (spontaneus regression of the symptoms
sneezing (spontaneus regression of the symptoms
or following treatment)
or following treatment)
Associated to ophtalmological symptoms/signs
Associated to ophtalmological symptoms/signs

 Odontogenic
Absence of nasal signs and symptoms
Absence of nasal signs and symptoms

12

CHRONIC RHINOSINUSITIS
Sudden appearance of two or more symptoms of which ine
should be nasal obstruction or rhinorrhoea
±hypo/anosmia
±hypo/anosmia
Duration >12 weeks
••Nasal polyps
Nasal polyps
••Muco-purulent secretion from the middle meatus
Muco-purulent secretion from the middle meatus
••Oedema and/or obstruction of the middle meatus
Oedema and/or obstruction of the middle meatus
Presence of CT abnormalities
Presence of CT abnormalities


13

Types of chronic rhinosinusitis
 With nasal polyps

 Without nasal polyps


14

15

This disequilibrium determines an activation of TH2 immune response.
The response is characterized by the production of cytokines which may
differ depending of the specific nature of the chronic inflammatory
response.


16

Allergic fungal
rhinosinusitis
Usually unilateral, with occasional purulent secretion
Characterized by high levels of IL-4, IL-5 and IL-13.
The high levels of IL-5 observed on those patients affected by allergic fungal
rhinosinusitis highlights who this condition may be considered
independently from oesinophils dysfunction disease.


17

Allergic fungal rhinosinusitis


18

Invasive form
• Acute fulminant
• Chronic: - granulomatous
- invasive
Non-invasive form
• Allergic fungal rhinosinusitis
• Fungal ball

19

NOTE: surgery must be associated to antibiotic therapy and
corticosteroids aiming to reduce the inflammatory component
and/or infective.
There is scientific evidence to support the use of topical steroids,
antibiotics and antifungal drugs.


20

Diagnosis is based on CT, MRI and pathology results


21

Chronic rhinosinusitis:
- Without asthma or allergy
- Whitout asthma, but with allergy
- With asthma and allergy
- With asthma, but without allergy
- With allergy to aspirin
- Allergic fungal
- Cystic fibrosis

22

DIAGNOSIS
- Anamnesis
- Anterior rhinoscopy
- Nasal endoscopy
- Nasal swab
- CT
- MRI
- Biofilm Research


23

Little role of plain x-rays
(Skinner et al., 1991)
F.N.*

F.P.**

A.D.***

3%

20%

77%

Ethimoid

55%

-

36%

Sphenoid

43%

1%

52%

3%

4%

93%

Maxillary sinus

Nasal cavity

* False negatives: Rx normal/pathological
** mucosa
*** False positives: Rx pathological/ normal 27/11/13,
GP Trainees
mucosa Diagnostic accuracy: Education Centre RPH
Rx findings/Intraoperative findings in keeping with Rx

24

DIAGNOSIS


25

• Extension of the disease
• Presence of bone eroisions
• Presence
of
anatomical
variances
with
possible
operative challenges

ESTENSIONE DELLA PATOLOGIA

PRESENZA DI INTERRUZIONE DELLE LIMITANTI OSSEE

PRESENZA DI ANOMALIE ANATOMICHE

26

Osteitis


27

Does not offer details of bone structures
Does not offer details of bone structures
Overestimes presence of mucosal abnormalities
Overestimes presence of mucosal abnormalities


28

Excellent visualization of soft tissues.
Excellent visualization of soft tissues.
Helpful to assess neoplastic pathology
Helpful to assess neoplastic pathology
Helpful to assess the extension of inflammatory processes.
Helpful to assess the extension of inflammatory processes.


29


30

DIAGNOSIS


31

European guidelines
for the treatment of
rhinosinusitis and nasal
polyps


32

“EVIDENCE BASED MEDICINE”

Categories
Ia

Evidence from meta-analysis of randomised controlled trials
Evidence from meta-analysis of randomised controlled trials

Ib

Evidence from at least one randomised controlled trials
Evidence from at least one randomised controlled trials

IIa

Evidence from at least one controlled study without randomisation
Evidence from at least one controlled study without randomisation

IIb

Evidence from at least one other type of quasi-experimental study
Evidence from at least one other type of quasi-experimental study

III

Evidence from non-experimental descriptive studies, such as
Evidence from non-experimental descriptive studies, such as
comparative studies, correlation studies, and case-control studies
comparative studies, correlation studies, and case-control studies

IV

Evidence from expert committee reports or opinions or clinical
Evidence from expert committee reports or opinions or clinical
experience of respected authorities, or both
experience of respected authorities, or both


33

Shekelle et al., BMJ 1999

Acute rhinosinusitis: therapy


34

Acute rhinosinusitis: therapy

Antibiotic thereapy is indicated
only when strictly required
(confirmed bacterial infection,
fever and severe pain)


35

Acute rhinosinusitis: length of antibiotic therapy
Short treatments appear to have the same effectiveness of longer antibiotic
courses


36

Acute rhinosinusitis: type of antibiotic treatmen


37

Acute rhinosinusitis: topical steroid therapy


38

Acute rhinosinusitis: combined therapy

(steroid and oral antibiotic)

Corticosteroids when combined with
oral antibiotics appear to be
particularly effective in producing a
prompt improvement of the
symptoms – evidenca IA
Duration of treatment 3-5 days


39

Acute rhinosinusitis: complications
Between 3,7% and 20%
Can be:
• Orbital (60-75%) ,
• Intracranial (15-20%)
• Bones (5-10%).
Sinusites account for 10% of the intra-cranial complications, and up to 90% of the
orbital complications.


40

treatment summary

Chronic rhinosinusitis without nasal
polyposis
topical steroids

Only 2 recent papers have reported a significant benefit of topical steroids versus
placebo.
Anatomical factors and type of device to affect effectiveness of the treatment.


42

polyposis
topical steroids


43

polyposis
topical steroids


44

polyposis
topical steroids


45

polyposis
topical antibiotics

There is no evidence of benefits resulting from topical antibiotic therapy.


46

polyposis
oral antibiotics

There is no evidence of benefits from antibiotic therapy < 4 weeks(short term), if
there is no evidence of infection on the basis of microbiology results.
Macrolids are the only class of antibiotics to have shown some benefits (Ib)


47

Chronic rhinosinusitis with nasal polyposis
topical steroids


48


49

Rinosinusite cronica con poliposi nasale
terapia corticosteroidea sistemica


50

Chronic rhinosinusitis with nasal polyposis
topical steroids


51

Rinosinusite cronica con poliposi nasale
terapia antibiotica sistemica

GP Trainees
Non ci sono evidenze sulla 27/11/13, antibiotica topica
terapia

52

When surgery?
Experience

Common sense

Knowledge of
the pathology


53

WHY SURGERY?

Remove paranasal obstruction
Improve ventilation and drainage of sinuses
Reduce number of exacerbations
Reduce complications
Improve quality of life


54

PROBABILITY OF SUCCESS OF
ENDOSCOPIC SURGERY

Maximal

Poor paranasal sinuses ventilation
Recurring sinusitis
Sinusitis affwecting only one sinus
“Fungus ball”
Mucocele
Antral polyp
Orbital/intra-cranial complications


55


56

PROBABILITY OF SUCCESS OF
ENDOSCOPIC SURGERY
Rhinosinusitis with macropolyposis

Intermediate

Minimal

Rhinosinusitis with asthma
ASA-Syndrome

Cystic Fibrosis
Kartagener’s S.
Congenital disorders

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Acute and Chronic Rhinosinusitis: diagnosis and management: current opinions.

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