1. The document summarizes various medical and surgical management options for chronic rhinosinusitis (CRS). It describes the goals of reducing mucosal edema, re-establishing sinus ventilation, and eradicating infective pathogens. 2. Medical management includes antibiotics, steroids, nasal saline douching, antifungals, decongestants, antihistamines, and antileukotrienes. Surgical procedures outlined include endoscopy, antral lavage, inferior meatal antrostomy, Caldwell-Luc procedure, intranasal ethmoidectomy, and transantral ethmoidectomy. 3. The complications of each procedure are also summarized.

1. MEDICAL & SURGICAL
MANAGEMENT OF CRS

2. • Aim:
• Reduce mucosal edema
• Re-establish sinus ventilation
• Eradicate infective pathogens
• To achieve these goals multiple therapies are available.

3. MEDICAL

4. 1. Antibiotics
• Common bacteria:
• H. influenzae
• S. pneumoinae
• S. aureus
• Mpraxella
• Selection:
• Broad spectrum for 3-4 weeks
• In refractory cases extended upto 8-10 weeks.
• Amoxicillin for initial treatment.
• In more severe infection, co-morbidities, resistance to amoxicilin
• Amoxicillin with clavulanic acid
• Newer Quinolones
• Allergic to Penicillin
• Macrolide
• Clindamycin
• Cotrimoxazole
• Tetracycline

5. • Role of Long term Macrolides
• Immunomodulatory property
• Decreases virulence and adhesion of organism
• Reduce inflammation through reducing IL-8 production (antineutrophilic)
altering bacterial biofilm formation and increasing inflammatory cell
apoptosis
• Erythromycin, Clarithromycin

6. 2. Steroids
• Topical:
• Reduce polyp size, improve nasal congestion and rhnorrhea
• Fluticasone, mometasone beclomethasone, budesonide, betamethasone
• For mild CRS, 8-12 weeks OD
• Common side effects of INCS include epistaxis (due to trauma to the septal mucosa), itching,
sneezing and dry nose.
• Sysremic
• Predniolone decreases mucosal infkammation, reduce size of polyp, restores sense of smell.
• Dose: 0.5-1 mg/kg for first 3-4 days then tapering over next 2 weeks
• A maximum of two or three courses should be prescribed within 1 year – failure to control
symptoms despite three systemic courses would suggest the need for surgical intervention.

7. 3. Nasal Saline Douching
• Improve symptoms, through mucus clearance, enhancing ciliary beat
activity, removal of allergen, biofilm or inflammatory mediators, and
protecting sino-nasal mucosa.
• Lavage should be done with proper technique.

8. 4. Antifungal therapy
• Persistent refractory CRS.
• Decrease the antigenic load therefore reduce trigger to chronic
inflammation.
• In a retrospective review by Seiberling and Wormald concluded that
Itraconazole may prolong the time of recurrence.
• Invasive fungal disease – Systemic, IV antifungal therapy and
Debulking of disease.
• AFRS – Surgical clearance, Oral Steroids and Antifungals.

9. • Role of Antifungals in AFRS

10. 5. Decongestants & Anti-Histamines
• Topical - Oxymetazoine, Xylometazoline
• Systemic – Pseudoephidrine, Phenylephrine
• Anti-histamines in those patients who have alergic component.

11. 6. Anti-Leukotriene therapy
• Reduction in absolute eosinophil count in PBF and sputum in AR.
• Montelukast and Zafirlukast

12. Maximal Medical therapy
• Combination of oral antibiotics, oral steroids, topical nasal steroids,
topical decongestnts and saline nasal douching/spray for a period of
4-6 weeks.

13. Refractory Sinusitis
• Immunoglobulin infusions.
• Omalizumab – Monoclonal Anti IgE
• Imatinib – Anti eosinophilic and Anti mast cell
• Exogeneous IFN gamma infusion

18. SURGICAL

19. • Goals of surgery are
• to reduce inflamed/diseased tissue
• open natural drainage pathways
• allow for better application of topical therapeutics and rinses.
• Failure of appropriate medical therapy constitutes
• a lack of objective improvement on endoscopy
• opacification seen on CT scans
• as well as a failure to improve symptoms

22. 1. Endoscopy
• First performed by Hirschmann in 1903 using a modified Nitze
cystoscope.
• Speilbergl was the first to introduce an endoscope into the maxillary
sinus via the inferior meatus.
• Hopkins, Professor of Optics, invented a far superior system, based on
solid glass rods, which is now universally used.

23. • Reveal disease not visualized by conventional anterior or posterior
, rhinoscopy.
• Even when the middle meatus is readily examined, only the ‘tip of the
iceberg' is visible and the mucosa may appear normal even in the
presence of sinus disease.

24. Radiology
• Coronal plane: the osteomeatal complex and the base of the skull.
• Axial plane: the posterior ethmoids and sphenoid, views are also
required to optimally show the optic nerve and carotid artery .
• Reconstructed sagittals: the frontal recess

25. • 'Messerklinger' approach: the removal of pathology in the
ostiomeatal complex, suffficient to achieve ventilation and drainage,
thereby addressing the underlying pathophysiology by a conservative
technique;
• The term ' functional' endorsed by Kennedy.
• A more radical extirpation of disease has been proposed by Draf
Wigand particularly related to polyposis, in which an absence of
surgical landmarks and profuse pathology determines a 'back to-
front' approach.

26. • Indications:
1. chronic rhinosinusitis;
2. acute recurrent rhinosinusitis;
3. nasal polyposis;
4. mucocoeles;
5. AFRS
6. repair of CSF leaks;
7.orbital and optic nerve decompression;
8. repair of blow-out fractures;
9. dacrocystorhinostomy;
10.choanal atresia;
11. hypophysectomy;
12.septal and turbinate surgery;
13. mangement of epistaxis;
14.drainage of periorbital abscess;
15.some benign and m ignant tumours.

27. • Contraindications:
• Intracranial complication of acute infection, such as meningitis, subperiosteal
or epidural abscess, cavernous sinus thrombosis or with any visual loss.
• Access to the lateral wall and floor of the maxillary sinus can also be difficult,
particularly in certain cases of revision surgery
• Pathology localized in the lateral frontal sinus may not be technically
accessible andd may require external approaches

28. Technique
• Infundibulotomy: Incise the anterior attachment of the uncinate
process, lift the UP medially to display the infundibulum.
• Care is taken with the site of incision. If this is made too far
anteriorly, the bone is hard overlying the nasolacrimal duct.

29. • The ethmoidal bulla is opened.
• Behind the bulla, a variable space is entered, the retrobullar recess,
which extends above the bulla as the suprabullar recess.
• Superiorly, the skull base may be visible and the anterior ethmoidal
artery may be identified running posterior to the frontal recess.

30. • To open the maxillary antrum, explore the frontal recess, the
posterior ethmoids and sphenoid will depend upon the
extent of disease.
• The posterior ethmoids are entered by piercing the basal
lamella, 3-4mm above the horizontal attachment of the
turbinate adjacent to the vertical attachment of the
turbinate.
• The sphenoid can be opened from the posterior ethmoid, by
entering it as inferiorly and medially as possible from the last
cell.

31. 1: Going lateral to the middle turbinate through the ethmoids
by opening the bulla ethmoidalis, then through the basal
lamella of the middle turbinate to the posterior ethmoids, and
from it locating the sphenoid ostium by the superior turbinate
(transethmoidal sphenoidotomy).
2: Going medial to the middle turbinate between the middle
turbinate and the nasal septum in a direct manner (transnasal
sphenoidotomy).

32. • To enlarge the natural ostium of the sinus rather than use the
posterior ethmoid approach. The ostium is usually 3-4 mm in
diameter and can usually be found by blunt probing approximately 1
cm up on the anterior face of the sphenoid, adjacent to the septum.
• Middle meatal antrostomy is not necessary if the natural maxillary
ostium is found to be patent after uncinectomy.
• If an accessory ostium is present, it should be joined to the natural
ostium to avoid abnormal recirculation of mucus.

33. • Ostium can be enlarged posteriorly and anteriorly and inferiorly,
taking care to avoid the nasolacrimal duct.
• Widening Types described by Daniel Simmons
• Type I: <1 cm
• Type II: 1-2 cm
• Type III: 2-3 cm
• Type IV: >3 cm

34. • Conservation of mucosa in the frontal recess, particularly in the
absence of frontal sinus infection so as to avoid scarring.
• The frontal recess is usually an hourglass restriction rather than a
'duct' and is often found situated medial to an opening of a
suprabullar ethmoidal cell which extends over the orbital roof.
Removal of this cell, so-called 'uncapping' the egg will open access to
the frontal sinus.

37. Post operative care
• Prophylactic broad-spectrum antibiotics for 2 weeks, combined with
alkaline nasal douche and an intranasal steroid preparation.
• Diffuse polyposis: oral steroids reducing dosage (prednisolone 30
mg/20 mg/10 mg/day each for one week).

38. 2. Antral lavage
• Indications:
• Diagnosis of and treatment of rhinosinusitis.
• Acute maxillary sinusitis which has failed to respond to conservative
medication and as an adjunctive procedure to external drainage for acute
orbital complications.
• Insertion of an indwelling catheter through which daily irrigation could be
performed until the quantity and quality of secretion improves.
• Aspiration devices, for example Sinujet, have been developed to provide
microbiological culture.
• Sinoscopy.

39. • Contraindications:
• < 3 years: The proximity of the orbital floor and the teeth in the small maxillary sinus of a
child makes it hazardous.
• Hypoplastic maxilla with thick bony walls.
• In the presence of trauma which may have disrupted the orbital floor.

40. • Tchnique:
• A Tilley-Lichtwiz trocar and cannula are used for the puncture.
• This is passed under the attachment of the inferior turbinate up to
the genu.
• Holding the patient's head steady, the trocar is directed towards the
tragus of the ipsilateral ear.
• Pressure accompanied by a gentle boring action for perforating the
inferior meatal wall at its thinnest point.

41. • The trocar is advanced until it abuts
the opposite antral wall and then is
withdrawn several millimetres .
• The trocar is then removed.
• Collect the washings.
• The washout is performed using a
Higginson syringe and sterile normal
saline or water at 37°C.
• Care should also be taken not to
introduce air during the procedure as
fatal air embolus has been described.

42. • Complications:
• Haemorrhage.
• Breaching of the anterior wall leading to pain and swelling of the
cheek.
• Perforation of the orbital floor leads to immediate pain.
• Under GA, bulging of the orbital contents may be observed.
• Excessive zeal on introduction of the cannula can lead to penetration
of the lateral or posterolateral wall , but this is rare.

43. 3, Inferior meatal antrostomy
• Indications
• Acute, recurrent and chronic maxillary sinusitis which h failed to respond to
conservative management.
• It relies upon gravitational drainage and aeration to effect improvement sinus
mucosa and may therefore benefit in cystic fibrosis and primary ciliary
dyskinesia.

44. • The inferior turbinate is elevated with an elevator.
• Perforate the inferior meatus at the highest point under
the genu of the turbinate where the bone is thinnest.
• Enlargement is then performed all directions
• Anatomical constraints limit the size of the antrostomy
but, ideally, at least 2 x 1 cm windows are fashioned for
long-term patency.
• Care should be taken to lower the inferior edge as
much as possible to the inevitable sump which results
between the floor of the nasal cavity and that of the
maxillary sinus.
• The ,inferior edge may be covered with a mucosal flap.

45. • Complications:
• Haemorrhage: Posteriorly, the inferior meatal branch of the lateral
sphenopalatine artery.
• Anterior extension may damage branches of the anterior superior alveolar
nerve plexus leading to altered dental sensation.
• Damage to the nasolacrimal duct orifice rarely

46. Caldwell – Luc Procedure
• Indications:
• Chronic maxillary sinusitis;
• removal of foreign bodies, such as a dental root or amalgam;
• closure of oro antral fistula;
• Dental cysts involving the antrum
• access to the pterygomaxillary fissure and pterygopalatine fossa;
• removal of recurrent antrochoanal polyps;
• access to the orbital floor for elevati o n and
• stabilzation for fractures or 'imploding' antra
• Contraindications:
• Avoided in children due to damage to secondary dentition.

47. • Technique:
• Incision is made down to the bone in the gum margin, 3mm above
and parallel to the gingivolabial fold from the posterior edge of the
lateral incisor to the first or second molar tooth (3-4 cm).
• Incision does not directly overlie the opening in the anterior face of
the maxilla so as to lessen the risk of a fistula.

48. • The mucoperiosteal flap is then dissected superiorly with a periosteal
elevator to expose the anterior wall of the sinus, taking care to avoid
damage to the infraorbital nerve just below the orbital rim.

49. • The anterior wall is opened in the canine fossa where the bone is
relatively thin.
• The opening n be enlarged to produce a hole large enough to provide
access, for example to allow removal of the sinus mucosa
(approximately 1-1.5 cm diameter) or introduction of an endo scope
and instrument .

50. • Inferior extension may lead to damage to the teeth and their nerve
supply and laterally bleeding may be encountered from the
anterolateral branches of the sphenopalatine artery.
• A large inferior meatal antrostomy (2 x 1 cm) is fashioned as
previously described. Pac ng of the nasal cavity and occasionally of
the antrum via the antrostomy is sometimes required.
• Suturing of the buccal incision is recommended with absorbable
sutUre material .
• The patient should be advised against overenthusiastic blowing of the
nose for at least a week.

51. • Complications:
• Pain and soft tissue swelling are minimized by attention to surgical
technique.
• Haemorrhage can occur from the anterior wall or inferior meatal
antrostomy.
• Paraesthesia due to damage of the infraorbital nerve may be
temporary or permanent.
• Damage to the teeth and their innervation can lead to alteration in
dental sensation and occasionally devitalization and discolouration of
the teeth.
• Oroantral fistula.

52. Intranasal Ethmoidectomy
• Indications:
• Chronic rhinosinusitis associated with nasal polyposis.
• Contraindications:
• Superseded by an endoscopic approach to this area, as without adequate
visualization it is particularly hazardous.

53. • Technique:
• The ethmoidal labyrinth is cleared between vertical
attachment of the middle turbinate medially and
the lamina papyracea laterally.
• The ethmoids may be cleared superiorly until the
hard white bone of the fovea ethmoidalis is seen.
• Thee posterior system may be entered by traversing
the basal lamella of the middle turbinate.
• The sphenoid may also be entered, though taking
care to do so as inferiorly and medially as possible
from the posterior ethmoid system.

54. • Complications:
• Injury to the lamina papyracea may lead to haemorrhage which can produce a
periorbital haematoma.
• Posterior tracking of the haematoma leads to proptosis and risks visual loss,
necessitating removal of packing and orbital decompression via an external
approach.
• Direct injury to the orbital periosteum can lead to prolapse of fat into the
surgical field, followed by direct damage to the medial rectus muscle and
optic nerve.
• Dural injury via the medial ethmoidal roof can result in a cerebrospinal fluid
leak.

55. Transantral ethmoidectomy ( Jansen-Horgan
Procedure)
• Indications:
• Chronic antroethmoiditis.
• As a route for orbital decompression.
• Technique:
• After performing a routine Caldwell -Luc approach, the posterior ethmoid cells are
opened through the antrum by pushing a closed forceps upwards, medially and
posteriorly at the upper and inner angle of the antrum, in the direction of the
opposite parietal eminence.
• Those cells which can be safely reached are cleared though the angle of approach
will inevitably limit access.
• It may be combined with an intransal ethmoidectomy to clear the anterior cells more
effectively.

56. Conclusion
• Surgery considered in Refractory cases.
• Pre-operative counselling of patient is must regarding surgery, its
benefit, possible compliccations and need of post operative
medication.
• Conventional surgeries used in certain cases such as revision surgeries
or while dealing with complications

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