2. Definitions
Clinical characteristics (Symptoms of CRS)
Classification
Histopathology and pathomechanism
Comorbidities and associated conditions
Diagnosis
Treatment
3. Rhinosinusitis : inflammation of nose and
paranasal sinuses
Acute rhinosinusitis (<4 weeks )
› purulent nasal drainage, nasal
obstruction, facial pain-pressure-fullness, or
both
Subacute rhinosinusitis (4 and 8 weeks )
CRS (> 8 or 12 weeks ,medical Rx )
› inflammatory condition involve paranasal
sinuses and nasal passages
J Allergy Clin Immunol 2010;125:S103-15
4. 4 major symptoms ( 2 , to make Dx )
› anterior, posterior, or both mucopurulent
drainage
usually opaque white or light yellow
› nasal obstruction or blockage
› facial pain, pressure, and/or fullness
83%, dull pain ,upper cheeks, between eyes, or
in forehead
› decreased sense of smell
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6. CRSsNP CRScNP AFRS
Symptoms present for >12 weeks
Requires >2 of following symptoms
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 AFRS criteria
middle meatus Positive fungal stain or
culture of allergic mucin
AND
IgE-mediated fungal
allergy
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7. CRSsNP (60%)
› Facial pain, pressure, and/or fullness
› Organism : S.pneumoniae, H.influenzae,
M.catarrhalis, S.aureus,S.coagulase-negative
› Glandular hyperplasia and submucosal fibrosis
CRScNP (20-33%)
› Hyposmia/anosmia
› Nasal polyps are typically bilateral
› associated with AERD
› predominance of eosinophils, high levels of
histamine, and Th2 cytokines
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8. AFRS
› Presence of allergic mucin (thick mucus ,light
tan to brown to dark green, degranulated E )
› fungal hyphae in mucin
› evidence of IgE-mediated fungal allergy
Sinus surgery usually required
usually have nasal polyps and
immunocompetent
Pathophysiology :chronic, allergic
inflammation directed against colonizing
fungi
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9. CRS
› Basement memb. Thickening, goblet cell
hyperplasia, subepithelial edema,
mononuclear cell infiltration
› tissue eosinophilia not hallmark of CRSsNP
› 31 untreated CRSsNP, all had <10% E
(overall mean 2%)
› 123 untreated nasal polyp , 108 showed
>10% E (overall mean 50%)
Middleton’s Allergy,principal & practice. Seventh edition
11. IL-8 and IL-3 increased in CRS mucosa
compared to inferior turbinate samples
typical cytokine pattern of CRS
› proinflammatory and neutrophil-associated
cytokines, ( IL-1β, TNF-α, IL-8 ), resulting in
increased neutrophil activation
CRS show Th1- Cytokines (IFN-γ) and
elevated TGF-β , may lead to increased
fibrosis, hallmark of CRSsNP
In contrast to nasal polyps, characterized
by Th2 cytokine pattern (IL-5) and low TGF-β
Middleton’s Allergy,principal & practice. Seventh edition
12. Allergic rhinitis ( 60% of CRS ,perennial )
Immunodeficiency ( hypogammaglobulinemia 12% of adults
with CRSsNP )
GERD
Defect in mucociliary clearance ( cystic fibrosis and
primary ciliary dyskinesia )
Viral infection (role of viral infection in CRS is controversial )
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
asthmatic have evidence of CRS )
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13. 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, air-fluid levels
Evaluated for allergy
› CRS associated with AR adults (60%) and
children (36-60% )
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15. Topical corticosteroid nasal sprays
› recommended for all forms of CRS
› Beneficial effects on nasal and sinus pain
Antihistamines
› helpful in allergic rhinitis
Antibiotics
› used to treat infection if nasal purulence present
( acute exacerbation )
Antifungals
› Indicate only in invasive forms of sinus mycosis or
immunocompromised host
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20. reserved for refractory cases or when relatively
rapid short term improvement is needed
rapid symptomatic improvement, particularly
in nasal obstruction and smell
significant polyp size reduction and reduction
of imaging ( orally 2 weeks)
clinical effects lesser than intranasal steroids
Prednisone 0.5 -1 mg/kg/d with tapered
reduction of 5 - 10 mg every 2 - 3 days over
period of 2 - 3 weeks
Short courses are effective and safe in CRScNP
Immunol Allergy Clin N Am 29 (2009) 657–668
21. Corticosteroids in Children with CRS
› Data in children are limited
› no studies on efficacy of topical corticosteroids
in pediatric CRS
› local corticosteroids are effective and safe in
children with rhinitis
Corticosteroids in Pregnant CRS
› US FDA classified intranasal steroids as category
C, except for budesonide (B, early pregnancy)
› oral corticosteroids during first trimester should
be restricted to lifethreatening conditions (oral
clefts reported )
Immunol Allergy Clin N Am 29 (2009) 657–668
22. in vitro data
› amphotericin B nasal lavages are ineffective
at 250 mg/mL when used for 6 consecutive
weekly (effective in killing fungi )
1 uncontrolled prospective trial and 4
DBPC studies effect of topical
amphotericin B nasal lavage and nasal
sprays in CRScNP,CRSsNP failed to show
benefit
Immunol Allergy Clin N Am 29 (2009) 677–688
23. retrospective review of 23 patients from
Australia with refractory allergic fungal
sinusitis (AFS) and nonallergic fungal sinusitis
› Use itraconazole 100 mg twice daily for 6 months
› improvement 19 patients
› disease-free at 6 months 11 patients
RCT study of patients with eosinophilic
fungal disease required to assess the
efficacy of antifungal therapies
Immunol Allergy Clin N Am 29 (2009) 719–732
26. Block production of proinflammatory
cytokines, eg.IL-8 and (TNF-a)
effects on neutrophil migration and
adhesion
changes to mucus secretion and
synthesis
nonbacteriostatic/cidal microbial
activity
Immunol Allergy Clin N Am 29 (2009) 689–703
27. suppress the NO release from pulmonary
macrophages after immune complex
injury in rats
lower LTB4 and neutrophils
(erythromycin)
reduce goblet cell secretion in response
to LPS in animal models
Immunol Allergy Clin N Am 29 (2009) 689–703
32. Topical saline irrigation
› improve symptom scores and symptom control in CRS
› In unoperated sinuses, effect limited to nasal cavity
› In cystic fibrosis , hypertonic more effective than isotonic
› other CRS patients benefit from isotonic irrigations
Mucus modifiers
› theoretically improving mucociliary transport
› Guaifenesin 1200 mg twice daily reduced congestion
,postnasal drainage
› limited data related to CRS management
› Anticholinergics
› blocks parasympathetic input to mucus glands and
reduces rhinorrhea
› may lead to increased thickness of secretions and
paradoxically worsen postnasal drainage
Immunol Allergy Clin N Am 29 (2009) 719–732
33. Leukotriene modulators
› Leukotriene receptor antagonist (montelukast)
› added to INCS can improve symptom scores in CRS
patients
› 5-Lipoxygenase inhibitor (zileuton)
› RCT, significant improvement in olfaction in patients
with CRS and concomitant aspirin sensitive asthma
Decongestants ( little role in CRS )
› Topical
› Systemic
Lifestyle modification
› Stop smoking, get adequate sleep, exercise regularly,
avoid pollution
Immunol Allergy Clin N Am 29 (2009) 719–732
34. CRScNP
oral corticosteroids (10-15 days) to shrink
nasal polyps
Topical corticosteroid nasal sprays
› recommended to prevent recurrence of
nasal polyps, not always effective
Antileukotriene agents
› not FDA approved for treatment of nasal
polyps
sinus surgery in severe polyposis
J Allergy Clin Immunol 2010;125:S103-15
35. AERD : might benefit from aspirin
desensitization and daily aspirin
therapy, no contraindications to aspirin
therapy
Desensitization can improve asthma
control and prevent continued growth of
NPs, but not usually cause NP regression
Immunol Allergy Clin N Am 29 (2009) 719–732
36. AFRS
› Sinus surgery establish diagnosis
› remove inspissated mucus
› restore sinus patency
› Nearly all have nasal polyps
› After surgery, oral corticosteroids ,0.5
mg/kg/d, with gradual tapering to control
symptoms
› Topical corticosteroid nasal sprays to control
inflammation and prevent recurrence of
nasal polyps
J Allergy Clin Immunol 2010;125:S103-15
37. Functional endoscopic sinus surgery (FESS)
› procedure of choice for refractory CRS.
indications for FESS
› persistence of CRS symptoms despite medical therapy
› correction of anatomic deformities believed to be
contributing to persistence of disease
› debulking of advanced nasal polyposis
principal goal of FESS
› restore patency to ostiomeatal unit
Additional goals of FESS
› correction of septal deformities
› Removal of severe concha bullosa deformity
› restoration of patency to frontal sinus
J Allergy Clin Immunol 2010;125:S103-15
Immunodeficiency is rare in patients with CRScNP or AFRS.possible extraesophageal manifestation of gerd. mechanism is believed to be due to direct reflux of gastric acid into the pharynx and nasopharynx, causing inflammation of the sinus ostium and leading to sinusitisotherwise healthy subjects and are not clearly epidemiologically linked to an increased risk of sinusitis