Chronic rhinosinusitis

Sasikarn Suesirisawad, MD

Definition

Chronic Rhinosinusitis (with or without NP) in adults ≥ 2 symptoms one of which should be either nasal

blockage/obstruction/congestion or nasal discharge(ant/post drip) or

± Facial pain/pressure ± reduction or loss of smell

for ≥12 weekswith validation by telephone or interview.

Questions on allergic symptoms (sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes) should be included.

EPOS 2012

CRSwNP: bilateral, endoscopically visualised polyps in middle meatus.

CRSsNP: no visible polyps in middle meatus, if necessary following decongestant.

Definition

EPOS 2012

CRS for primary care and non-ENT specialists

Symptoms ≥ 12 weeks ≥ 2 symptoms one of which should be either nasal

blockage/obstruction/congestion or nasal discharge (ant/post nasal drip):

± facial pain/pressure, ± reduction or loss of smell;

Signs (if applicable)•nasal examination•oral examination: posteriordischarge; exclude dental infection.

Additional diagnostic information• questions on allergy should be added and, if positive, allergy testing should be performed.

Not recommended: plain x-ray or CT-scan EPOS 2012

CRS for ENT specialists

Symptoms ≥ 12 weeks

≥ 2 symptoms one of which should be either nasal

blockage/obstruction/congestion or nasal discharge (ant/post nasal drip):

± facial pain/pressure,

± reduction or loss of smell;

Signs

• ENT examination, endoscopy;

• review primary care physician’s diagnosis and treatment;

• questionnaire for allergy and if positive, allergy testing if it

has not already been done.EPOS 2012

CRS in children

≥ 2 symptoms

one of which should be either nasal blockage/obstruction/congestion

or nasal discharge(ant/postnasal drip) or

± Facial pain/pressure

± Cough

for ≥12 weeks

with validation by telephone or interview.

Questions on allergic symptoms (sneezing, watery rhinorrhea, nasal

itching, and itchy watery eyes) should be included.EPOS 2012

Epidemiology of CRSwNP and CRSsNP

5-15% of general population both Europe and USA.

Prevalence of MD-diagnosed CRS was 2-4%

EPOS 2012

Factor associated with CRS Ciliary impairment Allergy Asthma Aspirin sensitivity Immunocompromised state Genetic factor Pregnancy and endocrine state Local host factor Biofilm Environmental factor Iatrogenic factor H.pylori and laryngopharyngeal reflux Osteitis

Pathogenesis

Defect in barrier and/or innate immune

response of sinonasal epithelium.

Increase microbial colonization, accentuated

barrier damage.

Defect in STAT 3(CRSwNP)

Inappropriated Th2 adaptive response

Local autoantibody

Biofilm EPOS 2012

Immune barrier hypothesis of CRS

EPOS 2012

Comparison of major cells and mediators in CRS vs NP. TGF-β, a key mediator inducing fibrosis, is increased in

CRS, but decreased in NP.Middleton’s Allergy Principle & Practice, seventh edition

Mucosa in CRS: BM thickening, goblet cell hyperplasia, subepithelial edema, mononuclear cell infiltration with few

eosinophils Middleton’s Allergy Principle & Practice, seventh edition

Numerous subepithelial eosinophils in luminal compartment of early-stage polyp.

Middleton’s Allergy Principle & Practice, seventh edition

Eosinophils accumulated subepithelially and diffusely in tissue of mature polyp.

Middleton’s Allergy Principle & Practice, seventh edition

Koen Van Crombruggen et al. J Allergy Clin Immunol 2011;128:728-32.

Eosinophilic and noneosinophilic form of sinusitis

Spencer C et al. J Allergy Clin Immunol 2011;128:710-20

Type of CRS

Endoscopic view of nasal polyps protruding from middle meatus.

Middleton’s Allergy Principle & Practice, seventh edition

Allergic fungal rhinosinusitis 

Bent -Kuhn diagnostic criteria

Nasal polyposis Fungi on staining Eosinophilic mucin without fungin

invasion into sinus tissue Type I hypersensitivity to fungi and Characteristic radio findings with soft

tissue differential densities on CT scaning

EPOS 2012

CRSsNP received antibiotic plus steroid

Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

CT scans nasal polyps. (A) Central disease, an early stage. (B) Nearly total ‘white-out,’ a late

stage.Middleton’s Allergy Principle & Practice, seventh edition

CT scan of fungal infection of right maxillary sinus: heterogeneous opacification

and calcification with increased attenuation.Middleton’s Allergy Principle & Practice, seventh edition

Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

Clinical control of CRS

EPOS 2012

Stepwise evaluation of CRS

Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

Adult with CRS without nasal polyps

Postoperative treatment for adult with CRS without nasal polyps

Adult with CRS with nasal polyps

Postoperative treatment in adult with CRS with nasal polyps

Children with CRS

Daniel L et al. J Allergy Clin Immunol 2011;128:693-707