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CHRONIC CHRONIC CHRONIC CHRONIC CHRONIC CHRONIC CHRONIC CHRONIC RHINOSINUSITISRHINOSINUSITISRHINOSINUSITISRHINOSINUSITISRHINOSINUSITISRHINOSINUSITISRHINOSINUSITISRHINOSINUSITIS
CHULEEPORN KONGMEESOOK ,MDCHULEEPORN KONGMEESOOK ,MD
OutlineOutline
•• DefinitionsDefinitions
•• ClassificationClassification
•• DiagnosisDiagnosis
•• TreatmentTreatment•• TreatmentTreatment
EpidemiologyEpidemiology
�� Prevalence estimated Prevalence estimated 1212..55% % -- 1515..55% in % in
US and US and 1010..99% in Europe% in Europe
In children In children 99..33% acute % acute rhinosinusitisrhinosinusitis ,,�� In children In children 99..33% acute % acute rhinosinusitisrhinosinusitis ,,
1919% chronic % chronic rhinosinusitisrhinosinusitis
PiromchaiPiromchai et al International et al International Journal of Journal of General Medicine General Medicine 2013;6:4532013;6:453--6464OrapanOrapan et al Asian Pac J Allergy et al Asian Pac J Allergy ImmunolImmunol 2012;30:1462012;30:146--5151
Definitions Definitions
•• RhinosinusitisRhinosinusitis : Inflammation of nose and : Inflammation of nose and paranasalparanasal sinusessinuses
•• Acute Acute rhinosinusitisrhinosinusitis (<(<4 4 weeks ) : weeks ) :
PPurulent nasal drainage, nasal urulent nasal drainage, nasal PPurulent nasal drainage, nasal urulent nasal drainage, nasal obstruction, facial painobstruction, facial pain--pressurepressure--fullness, or bothfullness, or both
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20102010;;125125:S:S103103--1515
Definitions Definitions
•• SubacuteSubacute rhinosinusitisrhinosinusitis ((44--8 8 weeks )weeks )
•• CRSCRS ((88--12 12 weeks ,medical Rx ) : weeks ,medical Rx ) :
IInflammatory condition involve nflammatory condition involve paranasalparanasal sinuses and nasal passages sinuses and nasal passages paranasalparanasal sinuses and nasal passages sinuses and nasal passages
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20102010;;125125:S:S103103--1515
Symptoms of CRSSymptoms of CRS
4 4 major symptoms (major symptoms (≥≥ 2 2 , to, to make make DxDx ))
•• anterior, posterior, or both anterior, posterior, or both mucopurulentmucopurulentdrainagedrainage
•• nasal obstruction or blockage nasal obstruction or blockage •• nasal obstruction or blockage nasal obstruction or blockage
•• facial pain, pressure, and/or fullness facial pain, pressure, and/or fullness
•• decreased sense of smelldecreased sense of smell
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin Immunol J Allergy Clin Immunol 20102010;;125125:S:S103103--1515
Middleton's Middleton's allergy:principlesallergy:principles and practice 8th editionand practice 8th edition
Definitions of Definitions of rhinosinusitisrhinosinusitisbased on disease classificationbased on disease classification
CRSsNPCRSsNP CRScNPCRScNP AFRSAFRS
Symptoms present for >12 weeksSymptoms present for >12 weeks
Requires >Requires >2 2 of following symptomsof following symptomsAnterior or posterior Anterior or posterior mucopurulentmucopurulent drainagedrainageNasal congestionNasal congestionFacial pain/pressureFacial pain/pressure
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 2010;125:S1032010;125:S103--1515
Facial pain/pressureFacial pain/pressureDecreased sense of smellDecreased sense of smell
Objective documentationObjective documentationRhinoscopicRhinoscopic examination ORexamination ORRadiograph (sinus CT scan preferred)Radiograph (sinus CT scan preferred)
Bilateral nasal polyps Bilateral nasal polyps in middle in middle meatusmeatus
AFRS criteriaAFRS criteriaPositive fungal stain Positive fungal stain
or culture of allergic or culture of allergic mucinmucin ANDANDIgEIgE--mediated fungal mediated fungal
allergyallergy
Classification Classification (Subtypes of CRS)(Subtypes of CRS)
CRSsNPCRSsNP ((6060%)%)
•• Facial pain, pressure, and/or fullness Facial pain, pressure, and/or fullness
•• Organisms : Organisms : S.pneumoniaeS.pneumoniae, , H.influenzaeH.influenzae, , M.catarrhalisM.catarrhalis, , S.aureusS.aureus, , H.influenzaeH.influenzae, , M.catarrhalisM.catarrhalis, , S.aureusS.aureus, , S.coagulaseS.coagulase--negative negative
•• Glandular hyperplasia and Glandular hyperplasia and submucosalsubmucosalfibrosis fibrosis
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 2010;125:S1032010;125:S103--1515
Classification Classification (Subtypes of CRS)(Subtypes of CRS)
CRScNPCRScNP ((2020--3333%)%)
•• HyposmiaHyposmia//anosmiaanosmia
•• Nasal polyps are typically bilateralNasal polyps are typically bilateral
•• Associated with AERDAssociated with AERD•• Associated with AERDAssociated with AERD
•• Polyp tissue predominance of Polyp tissue predominance of eosinophilseosinophils, high levels of histamine, , high levels of histamine, and Thand Th2 2 cytokinescytokines
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--1515
Classification Classification (Subtypes of CRS)(Subtypes of CRS)
AFRSAFRS
��Presence of allergic Presence of allergic mucinmucin (thick mucus (thick mucus from light tan to brown to dark green,from light tan to brown to dark green,degranulateddegranulated EEosos))degranulateddegranulated EEosos))
��Fungal Fungal hyphaehyphae in in mucinmucin
��Evidence of Evidence of IgEIgE--mediated fungal allergymediated fungal allergy
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--1515
Classification Classification (Subtypes of CRS)(Subtypes of CRS)
AFRS AFRS
•• Sinus surgery usually requiredSinus surgery usually required
•• Usually have nasal polyps and Usually have nasal polyps and immunocompetentimmunocompetentimmunocompetentimmunocompetent
•• PathophysiologyPathophysiology :chronic, allergic :chronic, allergic inflammation directed against colonizing inflammation directed against colonizing fungifungi
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--15 15
PathophysiologyPathophysiology
•• Basement membrane thickening, goblet Basement membrane thickening, goblet cell hyperplasia, cell hyperplasia, subepithelialsubepithelial edema, edema, mononuclear cell infiltration in mononuclear cell infiltration in CRSsNPCRSsNP
•• 31 31 untreated untreated CRSsNPCRSsNP, <, <1010% Eos (overall % Eos (overall mean mean 22%)%)mean mean 22%)%)
•• 123 123 untreated nasal polyp, untreated nasal polyp, 108 108 showed showed >>1010% Eos (overall mean % Eos (overall mean 5050%)%)
•• Tissue Tissue eosinophiliaeosinophilia not hallmark of not hallmark of CRSsNPCRSsNP
Middleton's Middleton's allergy:principlesallergy:principles and practice 8th editionand practice 8th edition
Middleton's Middleton's allergy:principlesallergy:principles and practice and practice 88th editionth edition
PathophysiologyPathophysiology
•• Typical cytokine patternTypical cytokine pattern
��CRS : high IFNCRS : high IFN--γ, elevated TGFγ, elevated TGF--ββ
��CRSsNPCRSsNP : IL: IL--11β, TNFβ, TNF--α, ILα, IL--88
��CRSwNPCRSwNP : high IL: high IL--55, low TGF, low TGF--ββ��CRSwNPCRSwNP : high IL: high IL--55, low TGF, low TGF--ββ
Middleton's Middleton's allergy:principlesallergy:principles and practice 8th editionand practice 8th edition
ComorbiditiesComorbidities and associated and associated conditionsconditions
•• Allergic rhinitis Allergic rhinitis ( ( 6060% of CRS ,perennial )% of CRS ,perennial )
•• Immunodeficiency Immunodeficiency
( ( hypogammaglobulinemiahypogammaglobulinemia 1212% of adults with % of adults with CRSsNPCRSsNP ))
•• GERDGERD•• GERDGERD
•• Defect in Defect in mucociliarymucociliary clearance clearance ( cystic fibrosis ( cystic fibrosis
and primary and primary ciliaryciliary dyskinesiadyskinesia ))
•• Viral infection Viral infection (role of viral infection in CRS is (role of viral infection in CRS is
controversial )controversial )
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--15 15
ComorbiditiesComorbidities and associated and associated conditionsconditions
•• Systemic disease Systemic disease (presenting feature of WG or CSS, (presenting feature of WG or CSS,
sarcoidosissarcoidosis ))
•• Anatomical abnormalities Anatomical abnormalities ( nasal ( nasal septalseptal
deviation, deviation, conchaconcha bullosabullosa deformity, paradoxical curvature deformity, paradoxical curvature of middle turbinate )of middle turbinate )of middle turbinate )of middle turbinate )
•• AERD and Asthma AERD and Asthma ((2020% CRS have asthma ,% CRS have asthma ,22//3 3 of of
asthmatic have evidence of CRSasthmatic have evidence of CRS))
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--15 15
DiagnosisDiagnosis
��Nasal endoscopy Nasal endoscopy
•• discolored mucus or edema in middle discolored mucus or edema in middle meatusmeatus or or sphenoethmoidalsphenoethmoidal recess recess
��Sinus CT scanning Sinus CT scanning
•• sinus sinus ostialostial narrowing or obstructionnarrowing or obstruction•• sinus sinus ostialostial narrowing or obstructionnarrowing or obstruction
•• sinus mucosal thickening or sinus mucosal thickening or opacificationopacification, air, air--fluid levels fluid levels
��Evaluated for allergyEvaluated for allergy
•• CRS associated with AR adults (CRS associated with AR adults (6060%) %) and childrenand children ((3636--6060% )% )
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--1515
Middleton's Middleton's allergy:principlesallergy:principles and practice 8th editionand practice 8th edition
TreatmentTreatment
��Topical corticosteroid nasal sprays Topical corticosteroid nasal sprays
•• Recommended for all forms of CRSRecommended for all forms of CRS
•• Beneficial effects on nasal and sinus Beneficial effects on nasal and sinus pain pain
��Antihistamines Antihistamines
•• Helpful in allergic rhinitis Helpful in allergic rhinitis
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--15 15
TreatmentTreatment
��Antibiotics Antibiotics
•• Used to treat infection if nasal purulence Used to treat infection if nasal purulence present (acute exacerbation)present (acute exacerbation)
��AntifungalsAntifungals��AntifungalsAntifungals
•• Indicate only in invasive forms of sinus Indicate only in invasive forms of sinus mycosis or mycosis or immunocompromisedimmunocompromised hosthost
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 2010;125:S1032010;125:S103--1515
Treatment : Treatment : CRScNPCRScNP
•• Oral corticosteroids Oral corticosteroids ((1010--15 15 days) shrink days) shrink nasal polypsnasal polyps
•• Topical corticosteroid nasal sprays Topical corticosteroid nasal sprays
recommended to prevent recurrence of recommended to prevent recurrence of nasal polyps, although not always effectivenasal polyps, although not always effectivenasal polyps, although not always effectivenasal polyps, although not always effective
•• AntileukotrieneAntileukotriene agents agents
not FDA approved for treatment of nasal not FDA approved for treatment of nasal polypspolyps
•• Sinus surgery Sinus surgery in severe in severe polyposispolyposis
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--1515
Treatment : Treatment : AERDAERD
•• Might benefit from aspirin desensitization Might benefit from aspirin desensitization and daily aspirin therapyand daily aspirin therapy
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--1515
Treatment : Treatment : AFRDAFRD
•• Sinus surgery Sinus surgery establish diagnosis, remove establish diagnosis, remove inspissatedinspissated mucus and restore sinus mucus and restore sinus patencypatency
•• After surgeryAfter surgery nasal polyps, nasal polyps, oral oral corticosteroidscorticosteroids 00..5 5 mg/kg/day with mg/kg/day with corticosteroidscorticosteroids 00..5 5 mg/kg/day with mg/kg/day with gradual tapering dose to control symptomsgradual tapering dose to control symptoms
•• Topical corticosteroid nasal sprays Topical corticosteroid nasal sprays to to control inflammation and prevent control inflammation and prevent recurrence of nasal polypsrecurrence of nasal polyps
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 20102010;;125125:S:S103103--1515
Indications for sinus surgeryIndications for sinus surgery
•• Persistence of CRS symptoms despite Persistence of CRS symptoms despite medical therapymedical therapy
•• Correction of anatomic deformitiesCorrection of anatomic deformities
•• DebulkingDebulking of advanced nasal of advanced nasal polyposispolyposis•• DebulkingDebulking of advanced nasal of advanced nasal polyposispolyposis
Mark Mark S. S. DykewiczDykewicz et al et al J Allergy Clin J Allergy Clin Immunol Immunol 2010;125:S1032010;125:S103--1515
ConclusionConclusion
PiromchaiPiromchai et al International et al International Journal of Journal of General Medicine General Medicine 2013;6:4532013;6:453--6464
PiromchaiPiromchai et al International et al International Journal of Journal of General Medicine General Medicine 20132013;;66::453453--6464
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