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Medical Management of the Chronic Rhinosinusitis

Medical Management of the Chronic Rhinosinusitis. Bastaninejad , Shahin , MD, ORL & HNS, TUMS Amiralam Hospital. Presentation Outlines. Definition Diagnosis Etiologies Medical Treatments General measures CRSNP- CRSNP+ Recurrent CRS post FESS operation Accessory evaluations

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Medical Management of the Chronic Rhinosinusitis

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  1. Medical Managementof theChronic Rhinosinusitis Bastaninejad, Shahin, MD, ORL & HNS, TUMS Amiralam Hospital

  2. Presentation Outlines • Definition • Diagnosis • Etiologies • Medical Treatments • General measures • CRSNP- • CRSNP+ • Recurrent CRS post FESS operation • Accessory evaluations • Allergy W/U • Immunologic W/U

  3. Definition • Chronic rhinosinusitis is a group of disorders characterized by: • inflammation of the mucosa of the nose and paranasal sinuses for at least 12 consecutive weeks’ duration • Importance: • CRS is a common disorder affecting approximately 13% of the population in the United States annually • in USA, one in five antibiotic prescriptions are for patients with sinusitis symptoms! (acute and chronic)

  4. Presentation Outlines • Definition • Diagnosis • Etiologies • Medical Treatments • General measures • CRSNP- • CRSNP+ • Recurrent CRS post FESS operation • Accessory evaluations • Allergy W/U • Immunologic W/U

  5. Diagnosis the use of symptoms to define CRS is not as effective as for ABRS

  6. 2007

  7. Diagnosis • Continuous symptoms/physical findings for more than 12wks • One of these signs must be present: • Discolored drainage or nasal polyp • Edema of the middle meatus • General or localized edema in other areas • Imaging confirmation (CT-Scan)

  8. CRS

  9. Presentation Outlines • Definition • Diagnosis • Etiologies • Medical Treatments • General measures • CRSNP- • CRSNP+ • Recurrent CRS post FESS operation • Accessory evaluations • Allergy W/U • Immunologic W/U

  10. Etiology • The potential causes of CRS may be numerous, disparate, and frequently overlapping • A unified, accepted understanding of the etiology of CRS is still being sought

  11. Allergy Bacterials Major debatable CRS etiologies Fungi Anatomic Variations

  12. Allergy • The concordance of allergy and CRS ranges from 25% to 50%, with pediatric studies reporting the higher association • In the subpopulation of patients with CRS symptomatic enough to require surgery, allergy is present in 41% to 84% of patients • Perennial hypersensitivity Predominates (especially house dust mite)

  13. Allergic patients with CRS responded more poorly to medical management than allergic patients who did not have CRS • Impact of allergic rhinitis on surgical results in endoscopic sinus surgery  success rate will be diminished about 10% (90%80%) • The etiologic association between allergic rhinitis, and CRS is less clear yet (despite ABRS)

  14. Bacterial Infection • The role ofbacteria in the pathogenesis of CRS,remains elusive, But: • Staphylococcus aureus • Coagulase-negative staphylococcus • Anaerobic • Gram-negative bacteria. • Despite the uncertainties surrounding the etiologic factors associated with CRS, antibiotic therapy has served as a mainstay of treatment mostly of mixed infections, with a median of 3 different bacteries

  15. Why their contribution is elusive? • Relative abundance of eosinophils and the paucity of neutrophilic inflammation in tissue samplesof the most cases of CRS • This inflammatory response may be independent of infection

  16. Probable Mechanisms • Chronic infection • Osteitis • Bacterial allergy • Superantigen (usually from SA) • Biofilms The exact role of bacteria in CRS remains unclear

  17. Osteitis • It is conceivable that bacteria may cause bone pathology by increasing the inflammatory mediators (LT,PG,…) • Impacts of Biofilms in this scenario is evaluated (they release soluble bacterial virulence factors that generate local pathology)

  18. Biofilms • Bacterial biofilms are defined as “an assemblage of microbial cells enclosed in a self-produced polymeric matrix that is irreversibly associated with an inert or living surface • Biofilm formation is probably more likely with gram-negative rods such as Pseudomonas species

  19. Fungi (mechanism) • Chronic Invasive Fungal Sinusitis • Allergic Fungal Sinusitis (charactristics: eosinophilicmucin containing noninvasive fungal hyphae, nasal polyposis, characteristic radiographic findings, immunocompetence, and allergy) • Fungal balls obstruction • Immune Complex (non-IgE inflammation)

  20. At the current time, it appears that multiple conditions may play a direct or contributory role in the pathogenesis of CRS • Current literature supports the important role that bacteria and/or fungi, appear to play in the pathogenesis of CRS

  21. Anatomic Variants • May predispose to earlier obstruction of the sinuses, allowing for the development of CRS, although strong evidence is lacking

  22. Presentation Outlines • Definition • Diagnosis • Etiologies • Medical Treatments • General measures • CRSNP- • CRSNP+ • Recurrent CRS post FESS operation • Accessory evaluations • Allergy W/U • Immunologic W/U

  23. Steroids • Topical (INCS): Four of the five clinical trials demonstrated significant improvement in symptoms • Although systemic steroids are widely used, no RCTs have investigated their use in CRS without polyposis

  24. Antibiotics • There is a lack of RCT in the literature regarding to this topic, however, no difference between antibiotics was noted • But nowadays, Macrolids are in particular attention because in addition to antibacterial effects, macrolides have some interesting antiinflammatory effects akin to those of corticosteroids

  25. Also macrolides can possibly decrease biofilmformation and overall bacterial virulence • Regimens (3mo duration): • ErythromycinEthylsuccinate: 400 q6h up to 2wk, then 400 BD up to 10wk • Clarithromycin: 500 q12h up to 2wk, then 500 daily up to 10wk

  26. Nasal douching • At least four RCTs have shown improvement in symptoms, quality of life and endoscopy and imaging findings • Nasal saline irrigation has been shown to potentially provide more benefit than nasal saline spray in patients with CRS • A 2007 Cochrane review concluded that nasal saline appears to have benefits as an adjunctive treatment for CRS

  27. Antifungal agents • To date no convincing evidence of their efficacy over and above saline douching has been provided

  28. Decongestants • No RCTs have been performed in CRS

  29. Mucolytics • There is little evidence in the literature for the use of mucolytics such as bromhexine

  30. Antihistamines • There is no evidence to support the use of antihistamines in CRS, and they are not recommended

  31. Bacterial lysates • These entities have included 5 bacterial lysates (Enterococcus faecalis autolysate, Klebsiella pneumoniae, Streptococcus pneumoniae, Streptococcus pyogenes, and Haemophilus influenza). • In a multicenter RCT in 284 patients who had CRS, the use of a mixed bacteria lysate reduced symptom scores significantly

  32. Immunomodulators and immunostimulants • G-CSF and Gama-IFN not show significant improvement

  33. Proton Pump inhibitors • The importance of GERD as a cause of CRS is unknown, but it may be more important in the pediatric population than in adults • No RTCs have shown benefit • GERD may be more of a comorbid state than a cause of CRS

  34. Leukoteriene modifiers • Montelukast (10mg once a day), a leukotriene receptor antagonist, has been shown in a few open studies to benefit CRS patients with nasal polyposis

  35. Aspirin Desensitization Therapy • Aspirin desensitization is shown to reduce the number of episodes of sinusitis and to decrease polyp recurrence and the need for additional surgery

  36. Conclusion • To date, however, because of the paucity of properly conducted trials, no absolute recommendation for a ‘correct regimen’ can be given

  37. CRS without nasal polyps • INCS for 3-6mo • Nasal Douching with N/S • Macrolide for 3mo • Mucolytics • On failures, perform culture guided therapy • If failed again  Proceed with FESS operation

  38. CRS with nasal polyps • INCS for undisclosed time! • Nasal Douching with N/S • Macrolide administration for 3mo • Oral corticosteroids for 10 days (20-40mg) • Montelukast

  39. Recurrence of CRS post FESS surgery • Under 8 wk  Endoscopy: • Nl. INCS • Abn. • Technical  CT scan • Nontechnical (infection) Cx • After 8 wk  Endoscopy: • Nl. CT scan • Abn. • Technical  CT • Nontechnical (infection) Cx

  40. AECRS • Antibiotics that cover both the common ABRS and CRS organisms are effective in reducing the exacerbation of AECRS • Aggressive anti-inflammatory agents such as systemic steroids may also be necessary

  41. Presentation Outlines • Definition • Diagnosis • Etiologies • Medical Treatments • General measures • CRSNP- • CRSNP+ • Recurrent CRS post FESS operation • Accessory evaluations • Allergy W/U • Immunologic W/U

  42. Accessory evaluations • Allergy studies may be ordered for patients: • who fail to improve • who have symptoms consistent with both allergy and CRS at the beginning • Allergy skin prick testing is considered the study of choice

  43. For patients who continue to fail aggressive medical and surgical management, immunodeficiency may be present: • Selective IgA deficiency • Common variable immunodeficiency • Hypogammaglobulinemia • Also HIV

  44. Thank You!

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