Acute and Chronic Rhinosinusitis: diagnosis and management: current opinions.

RHINOSINUSITIS:DIAGNOSIS AND TREATMENT

RHINOSINUSITIS:DIAGNOSIS AND TREATMENT

Edoardo Cervoni, M.D.Edoardo Cervoni, M.D.

GP Trainees 27/11/13, Education Centre RPHGP Trainees 27/11/13, Education Centre RPH 11

DiscolosuresDiscolosures

• Grant/Research Support: no disclosure

• Consultant: no disclosure • Major Shareholder: Locumdoctor4u

Ltd. (Locum and Concierge Medical Services)

• I will not be discussing “off-label” uses of medications or investigations

• Grant/Research Support: no disclosure

• Consultant: no disclosure • Major Shareholder: Locumdoctor4u

Ltd. (Locum and Concierge Medical Services)

• I will not be discussing “off-label” uses of medications or investigations

ENT ReferralsENT Referralsi. Most ENT referrals are linked to Audiological and

Otological problems.

ii. Out of 271 consecutive referrals to the RHP ENT Department triaged in 2011, 58% could be potentially managed in Primary Care.

CLPCT NHS Survey 2011 – E Cervoni

GP Trainees 27/11/13, Education Centre RPHGP Trainees 27/11/13, Education Centre RPH

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ENT ReferralsENT Referralsi. Snoring and sleep apnoea were relatively common reasons of

referrals.ii. In a rather significant proportion of cases, relevant information,

with specific reference to the physical examination, were missing.

iii. Among the referrals redirected to the GPwSI in ENT, deafness with wax, epistaxis and blocked nose were the most common complaints.

CLPCT NHS Survey 2011 – E Cervoni


Conditions referredConditions referred

Cervoni E - 2011 GP Trainees 27/11/13, Education Centre RPHGP Trainees 27/11/13, Education Centre RPH

EPOS 2012EPOS 2012


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Inflammation of the nose and paranasal sinuses characeterized by the presence of 2 or more symptoms of which one MUST be nasal obsteruction or rhinorrhoea with:

Inflammation of the nose and paranasal sinuses characeterized by the presence of 2 or more symptoms of which one MUST be nasal obsteruction or rhinorrhoea with:

Endoscopic signs:

- polyps and/or- purulent secretion from the middle meatus and/or- oedema/mucosal obstruction prevalent in the middle meatus

- polyps and/or- purulent secretion from the middle meatus and/or- oedema/mucosal obstruction prevalent in the middle meatus

Associated with and/or CT abnormal

changes:

- mucosal changes at the level of the osteo-meatal complex or of the paranasal sinuses

- mucosal changes at the level of the osteo-meatal complex or of the paranasal sinuses

±facial pain/pressure±hypo/anosmia±facial pain/pressure±hypo/anosmia

RhinosinusitisRhinosinusitis


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Rhinosinusitis may be classified into mild, moderate or severe on the basis of VAS score.

Mild = VAS 0 - 3 Moderate = >3 - 7 Severe = VAS >7 - 10

Mild = VAS 0 - 3 Moderate = >3 - 7 Severe = VAS >7 - 10

To assess the severity of the symptoms the patient is asked to answer the following question:

How painful are the symptoms of your sinusitis?How painful are the symptoms of your sinusitis?

10 cmNo pain Worst possible pain

CLASSIFICATION on severity of the symptoms

CLASSIFICATION on severity of the symptoms


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12 weeks

ACUTE/RECURRENT(complete resolution of the symptoms)

ACUTE/RECURRENT(complete resolution of the symptoms)

CHRONIC(incomplete resolution of the symptoms)

CHRONIC(incomplete resolution of the symptoms)

CLASSIFICATION on duration

CLASSIFICATION on duration


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Sudden onset of its symptoms of which one must be nasal obstruction or rhinorrhoea


And duration <12 weeks

Presence of endoscopic signs of:

•Purulent secretion from the middle meatus•Oedema and/or obstruction of the middle meatus

Presence of abnormal changes to CT imaging


•Purulent secretion from the middle meatus•Oedema and/or obstruction of the middle meatus

Presence of abnormal changes to CT imaging

Acute Rhinosinusitis: clinical features

Acute Rhinosinusitis: clinical features


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Duration of the symptoms < 10 daysDuration of the symptoms < 10 days

Acute viral (common cold)

- Symptoms oncrease after 5 days

- Persistence of the symptoms after 10 days, but for less than 12 weeks

- Symptoms oncrease after 5 days

- Persistence of the symptoms after 10 days, but for less than 12 weeks

Acute post-viral

Presence of at the least 3 symptoms and/or signs:

-Purulent secretion

-Pain with unilateral preponderance

-Fever (>38 C)

-Raised ESR and CPR

-Worsening of the symptoms after a phase of remission

Presence of at the least 3 symptoms and/or signs:

-Purulent secretion

-Pain with unilateral preponderance

-Fever (>38 C)

-Raised ESR and CPR

-Worsening of the symptoms after a phase of remission

Bacterial post-viral

Acute rhinosinusitis: typesAcute rhinosinusitis: types


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Viral infection of the upper airways

Allergic rhinitis

It is characterized by rhinorrhoea (which is not purulent), senstion of nasal obstruction, itchy nose, sneezing (spontaneus regression of the symptoms or following treatment)

Associated to ophtalmological symptoms/signs

It is characterized by rhinorrhoea (which is not purulent), senstion of nasal obstruction, itchy nose, sneezing (spontaneus regression of the symptoms or following treatment)

Associated to ophtalmological symptoms/signs

Confirmed positivity to a common allergenConfirmed positivity to a common allergen

Odontogenic

Absence of nasal signs and symptomsAbsence of nasal signs and symptoms

Acute rhinosinusitis: differential diagnosisAcute rhinosinusitis: differential diagnosis


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Sudden appearance of two or more symptoms of which ine should be nasal obstruction or rhinorrhoea


Duration >12 weeks


•Nasal polyps•Muco-purulent secretion from the middle meatus•Oedema and/or obstruction of the middle meatus

Presence of CT abnormalities


•Nasal polyps•Muco-purulent secretion from the middle meatus•Oedema and/or obstruction of the middle meatus

Presence of CT abnormalities

CHRONIC RHINOSINUSITISCHRONIC RHINOSINUSITIS


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Without nasal polyps

With nasal polyps

Types of chronic rhinosinusitis

Types of chronic rhinosinusitis


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This disequilibrium determines an activation of TH2 immune response.The response is characterized by the production of cytokines which may differ depending of the specific nature of the chronic inflammatory response.


Usually unilateral, with occasional purulent secretion

Characterized by high levels of IL-4, IL-5 and IL-13.

The high levels of IL-5 observed on those patients affected by allergic fungal rhinosinusitis highlights who this condition may be considered independently from oesinophils dysfunction disease.

Allergic fungal rhinosinusitisAllergic fungal rhinosinusitis


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Allergic fungal rhinosinusitis


Invasive form• Acute fulminant• Chronic: - granulomatous - invasive

Non-invasive form• Allergic fungal rhinosinusitis• Fungal ball


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NOTE: surgery must be associated to antibiotic therapy and corticosteroids aiming to reduce the inflammatory component and/or infective. There is scientific evidence to support the use of topical steroids, antibiotics and antifungal drugs.


Diagnosis is based on CT, MRI and pathology results


Chronic rhinosinusitis:- Without asthma or allergy- Whitout asthma, but with allergy- With asthma and allergy- With asthma, but without allergy- With allergy to aspirin- Allergic fungal- Cystic fibrosis


DIAGNOSIS

- Anamnesis- Anterior rhinoscopy- Nasal endoscopy- Nasal swab- CT- MRI- Biofilm Research


Little role of plain x-rays(Skinner et al., 1991)

Maxillary sinus

Ethimoid

Sphenoid

Nasal cavity

F.N.*

3%

55%

43%

3%

20%

-

1%

4%

77%

36%

52%

93%

F.P.** A.D.***

False negatives: Rx normal/pathological mucosaFalse positives: Rx pathological/ normal mucosa Diagnostic accuracy: Rx findings/Intra-operative findings in keeping with Rx

***

***GP Trainees 27/11/13, Education Centre RPHGP Trainees 27/11/13, Education Centre RPH

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DIAGNOSIS


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ESTENSIONE DELLA PATOLOGIA

PRESENZA DI INTERRUZIONE DELLE LIMITANTI OSSEE

PRESENZA DI ANOMALIE ANATOMICHE

• Extension of the disease

• Presence of bone eroisions

• Presence of anatomical variances with possible operative challenges

• Extension of the disease

• Presence of bone eroisions

• Presence of anatomical variances with possible operative challenges


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OsteitisOsteitis


Does not offer details of bone structures

Overestimes presence of mucosal abnormalities

Does not offer details of bone structures

Overestimes presence of mucosal abnormalities


Excellent visualization of soft tissues.

Helpful to assess neoplastic pathology

Helpful to assess the extension of inflammatory processes.

Excellent visualization of soft tissues.

Helpful to assess neoplastic pathology

Helpful to assess the extension of inflammatory processes.



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DIAGNOSIS


European guidelines for the treatment of rhinosinusitis and

nasal polyps


“EVIDENCE BASED MEDICINE”

Shekelle et al., BMJ 1999

Evidence from meta-analysis of randomised controlled

trials

Evidence from at least one randomised controlled trials

Evidence from at least one controlled study without

randomisation

Evidence from at least one other type of quasi-

experimental study

Evidence from non-experimental descriptive studies, such

as comparative studies, correlation studies, and case-

control studies

Evidence from expert committee reports or opinions or

clinical experience of respected authorities, or both

Evidence from meta-analysis of randomised controlled

trials

Evidence from at least one randomised controlled trials

Evidence from at least one controlled study without

randomisation

Evidence from at least one other type of quasi-

experimental study

Evidence from non-experimental descriptive studies, such

as comparative studies, correlation studies, and case-

control studies

Evidence from expert committee reports or opinions or

clinical experience of respected authorities, or both

Ia

Ib

IIa

IIb

III

IV

Ia

Ib

IIa

IIb

III

IV

Categories


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Acute rhinosinusitis: therapy


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Acute rhinosinusitis: therapy

Antibiotic thereapy is indicated only when strictly required(confirmed bacterial infection, fever and severe pain)


Acute rhinosinusitis: length of antibiotic therapy

Short treatments appear to have the same effectiveness of longer antibiotic courses


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Acute rhinosinusitis: type of antibiotic treatment


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Acute rhinosinusitis: topical steroid therapy


Acute rhinosinusitis: combined therapy (steroid and oral antibiotic)

Corticosteroids when combined with oral antibiotics appear to be particularly effective in producing a prompt improvement of the symptoms – evidenca IA

Duration of treatment 3-5 days


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Acute rhinosinusitis: complications

Between 3,7% and 20%Can be:

• Orbital (60-75%) , • Intracranial (15-20%)• Bones (5-10%).

Sinusites account for 10% of the intra-cranial complications, and up to 90% of the orbital complications.


Acute rhinosinusitis: treatment summaryAcute rhinosinusitis: treatment summary

Chronic rhinosinusitis without nasal polyposis

topical steroids

Only 2 recent papers have reported a significant benefit of topical steroids versus placebo.Anatomical factors and type of device to affect effectiveness of the treatment.



topical steroids



topical antibioticsThere is no evidence of benefits resulting from topical antibiotic therapy.



oral antibioticsThere is no evidence of benefits from antibiotic therapy < 4 weeks(short term), if there is no evidence of infection on the basis of microbiology results.

Macrolids are the only class of antibiotics to have shown some benefits (Ib)


Chronic rhinosinusitis with nasal polyposis

topical steroids


Rinosinusite cronica con poliposi nasaleterapia corticosteroidea sistemica


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Chronic rhinosinusitis with nasal polyposis

topical steroids


Rinosinusite cronica con poliposi nasaleterapia antibiotica sistemica

Non ci sono evidenze sulla terapia antibiotica topicaGP Trainees 27/11/13, Education Centre RPHGP Trainees 27/11/13, Education Centre RPH

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When surgery?

ExperienceExperience

Common senseCommon sense Knowledge of the pathologyKnowledge of the pathology


WHY SURGERY?

Remove paranasal obstructionImprove ventilation and drainage of sinusesReduce number of exacerbationsReduce complicationsImprove quality of life


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PROBABILITY OF SUCCESS OF ENDOSCOPIC SURGERY

Poor paranasal sinuses ventilationRecurring sinusitisSinusitis affwecting only one sinus“Fungus ball”MucoceleAntral polypOrbital/intra-cranial complications

Maximal



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Cystic Fibrosis

Kartagener’s S.Congenital disorders

Rhinosinusitis with macropolyposis

Rhinosinusitis with asthma

ASA-SyndromeIntermediate

Minimal

PROBABILITY OF SUCCESS OF ENDOSCOPIC SURGERY


Acute and Chronic Rhinosinusitis: diagnosis and management: current opinions.

Health & Medicine

Transcript of Acute and Chronic Rhinosinusitis: diagnosis and management: current opinions.