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Chronic Rhinosinusitis: What do we really know?

Chronic Rhinosinusitis: What do we really know?. Jeanette L. Arnold, C-FNP University of Mississippi Medical Center Allergy, Immunology & Rheumatology. JLArnold@umc.edu. Consultant for AAFA- I have no further disclosures. Chronic Rhinosinusitis- Objectives:.

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Chronic Rhinosinusitis: What do we really know?

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  1. Chronic Rhinosinusitis: What do we really know? Jeanette L. Arnold, C-FNP University of Mississippi Medical Center Allergy, Immunology & Rheumatology

  2. JLArnold@umc.edu Consultant for AAFA- I have no further disclosures.

  3. Chronic Rhinosinusitis- Objectives: • Discuss diagnostic criteria for acute and chronic rhinosinusitis • Compare and contrast CRS with acute rhinosinusitis including nasal polyposis and inflammatory mediators • Review recent updates on management of CRS

  4. Diagnosis: What IS Rhinosinusitis? Rhinosinusitis is: • An ‘inflammatory process’ involving the nasal mucosa, mucus membranes of the paranasal sinuses and/or underlying bone. • Classified as acute, subacute, recurrent or chronic based on characteristics including duration and response to therapy UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com; Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47.

  5. Schematic from UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com. Sinus CT courtesy of Dr. Scott Stringer, UMC Otolaryngology

  6. UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com

  7. Acute Sinusitis • Lasts less than 4 weeks • Usually is of viral origin (98% likelihood for acute infectious rhinitis) • Usually self limiting in immunocompetent persons with normal anatomy and physiology • Routine nasophyarngeal cultures not helpful Puhakka T, et al. Sinusitis in the common cold. JACI. 1998; 102 (3): 403-8. Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47. The diagnosis and mangagment of rhinitis: A practice parameter update. JACI 2008; 122: S5.

  8. Subacute Sinusitis • Protracted episodes lasting 4-12 weeks • Incomplete resolution of acute episode • Components of both acute and chronic sinusitis

  9. Recurrent Sinusitis • Defined as 3 episodes of sinusitis in 6 months • Or 4 episodes in 12 months. Chronic Rhinosinusitis • Lasts longer than 12 weeks • May be associated with anatomical dysfunction, • Inflammatory process or • Autoimmune condition Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47.

  10. Chronic Rhinosinusitis: • Possible sequelae can include- • Loss of taste and smell • Development of mucin plugs • Soft tissue displacement • Facial dysmorphism • Bony erosion • Exacerbation of co-morbidities Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47.

  11. Nasal congestion Facial/dental pain Cough Anosmia Headache/body aches Post nasal drip Purulent discharge Signs & Symptoms include: Adapted from The Diagnosis and Management of Rhinitis: An Updated Practice Parameter. JACI, August 2008; 122, 2.

  12. Sinusitis in the Common Cold • Cross sectional study of 197 young adults with sinus symptoms: • 39% had radiographic evidence of sinusitis on day 7 • Symptoms were identical for positive and negative films • Viral infection detected in 81.6% with positive films • No bacterial Ab detected • CRP, Sed rate & WBC low • All patients clinically recovered within 21 days w/o ABIC Puhakka T, et al. Sinusitis in the common cold. JACI. 1998; 102 (3): 403-8.

  13. UpToDate Online 13.2; Chronic Sinusitis; uptodateonline.com

  14. Non-infectious Sinusitis: Allergic and Nonallergic Rhinitis • IgE mechanisms • Other causes include: • hormonal changes • SE of medications • Chemical irritants • Exercise • Weather and temperature changes • GERD • S/S alone do not differentiate Meltzer, E., Nathan, R., et al., Physician perceptions of the treatment and management of allergic and nonallergic rhinitis. Allergy & Asthma Proceedings.Jan-Feb 2009: 30 (1): 75-83.

  15. Rondon, C., Doña, I., et.al. JACI. Evolution of patients with nonallergic rhinitis supports conversion to allergic rhinitis. May 2009 (Vol. 123, Issue 5, Pages 1098-1102). Roughly ¼ converted from NAR to AR within 3-7 years Roughly ¼ developed new co-morbidities w/most common being asthma Jacobs, R., Lieberman, P., et. al. Weather/temperature-sensitive vasomotor rhinitis may be refractory to intranasal corticosteroid treatment Allergy Asthma Proc., March-April 2009 (Vol.30, Num. 2, Pages 120-127) Fluticasone INC Unexpectedly, found that there was no improvement in any measure of efficacy.

  16. Meta-Analysis • Reviewed 1100 articles and 168 abstracts in five languages. Found 49 studies that were done well enough to include in their review. • Used sinus puncture or CT scan as a reference standard. • “Clinical Exam is not a reliable method for diagnosis of acute maxillary sinusitis.” Varonen J Clin Epid53(9);940-8. 2000 Sept.

  17. Scan Interpretation • 80% of CT scans are abnormal in viral rhinosinusitis if obtained within seven days of the onset of illness. • 45-50% of asymptomatic individuals will have findings of mucosal edema on MRI scanning. • Films don’t take into account the normal edema phase of the normal nasal cycle Gwaltney JM, Philips CO, et al. NEJM 1994:330:25-30; Collins JK Vital Health Statistics 1997; Gordis Rhinology 1997; Patel J. Laryng Otol 1996. Gordis Rhinology 1997.

  18. The problem with radiography is… • Edema phase of the normal nasal cycle (unilateral nasal congestion q 1-4 hours) • Common cold • Allergic/vasomotor rhinitis • Interpretation varies Collins JK Vital Health Statistics 1997;Gordis Rhinology 1997; Patel J. Laryng Otol 1996

  19. Evaluate for: • Allergies- consider skin testing or IgE assay • Asthma- consider PFT (pre and post) • Anatomical obstruction- including nasal polyposis • sinus CT +/- rhinoscopy • mucosal thickening is significant at >6mm in an adult and >4 mm in a child • focus on OMC

  20. Chronic sinusitis • Chronic infectious sinusitis • usually secondary to primary immunodeficiencies, cystic fibrosis, or anatomic defects. • Non-infectious chronic sinusitis • thought to be inflammatory disease: “hyperplastic” or “eosinophilic” sinusitis

  21. Pathogenesis: Infectious and inflammatory components are likely to be involved- Neither one alone explains the disease. • Infection is often present and may obscure the underlying inflammatory process. • Colonization is hard to differentiate from infection. • Allergy is often present and may alter the inflammatory response to infection or other stimuli.

  22. Key distinction: What is the evidence for distinct pathogenesis? Chronic rhinosinusitis (CRS) CRS without NP CRS with NP

  23. Adapted from Rhyoo 1999, Nonoyama 2000, Demoly 1997, Bachert 1998, Rudack 1998

  24. Consider: • GERD • Aspirin hypersensitivity • CF, esp. in children with nasal polyps • Fungal sinusitis • Primary immunodeficiency • (IgG subclasses not initial labs) • Motility disorder • Autoimmune condition Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47

  25. Link between AR and Asthma is strong • Neurologic and inflammatory “crosstalk” between conditions • 78% of patients with asthma have AR • 38% of pt. with AR have concomitant asthma • 3-4 fold higher incidence as asthma in AR than in non allergic children Meltzer, E., Blaiss, M., et al. Burden of allergic rhinitis: Results from the Pediatric Allergies in America survey. JACI. Sept. 2009: 124:3: S43-S70.

  26. Summary:Treatment Options: • Viral: conservative therapies designed to promote drainage with comfort measures and tincture of time including but not limited to: • INC, saline nasal lavage • AR: Avoidance of allergens, patient education, INC/pharmacotherapy, anti-infectious tx and immunotherapy if appropriate Joint TaskForce on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47.

  27. Bacterial Sinusitis • Broad spectrum ABIC for 14-21 days • Maintain drainage • No benefit for mucolytics or antihistamines in bacterial sinusitis (??) • No good data RE use of decongestants • Some recent studies suggest INC helpful • Saline mechanically helpful; no clear data to indicate which method is most helpful Joint Task Force on Practice Parameters, The diagnosis and management of sinusitis: A practice parameter update. JACI 2005; 116: S13-47

  28. Above all else, do no harm. • Do intranasal solutions negatively effect nasal physiology? • Infused ofloxacin, betadine, hydrogen peroxide, amphotericin B, itraconazole, clotrimazole over nasal respiratory cells • Noted a strong dose dependant decrease in ciliary beat frequency. Gosepath J, et al Am J Rhinol 16(1):25-31 2002

  29. Recalcitrant CRS: investigation and managementWoodbury, Kristin; Ferguson, Berrylin J. CurrOpin in Otolaryngol Head Neck Surg. 2011 Feb: 19 (1): 1-5 • Literature review commentary vs. meta-analysis • Long term (@ least 12 wks.) macrolide ABIC- use supported, esp. in pt. with low or normal IgE • 1% baby shampoo nasal saline irrigation- no controlled trials or randomized studies • Citric acid zwitterionicirrigations destroyed the sinus cilia (85% were denuded) • Topical amphotericin B- ineffective • Mupirocin irrigations- more successful than vancomycin or ciprofloxin • Manuka honey irrigations- in vitro study looks interesting

  30. Take home points: • Rhinitis of less than 7-10 day duration typically is less likely to benefit from oral antibiotics • Look for presence of nasal polyps to direct management • Look for fungus on surgical pathology to direct care • Keep those doggies draining (OMC)

  31. JAI-NET: technique for yoga cleansing of the sinuses

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