chronic rhinosinusitis
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Chronic RhinosinusitisPresented by Sasikarn Suesirisawad, MDTRANSCRIPT
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Chronic rhinosinusitis
Sasikarn Suesirisawad, MD
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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
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CRSwNP: bilateral, endoscopically visualised polyps in middle meatus.
CRSsNP: no visible polyps in middle meatus, if necessary following decongestant.
Definition
EPOS 2012
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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
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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
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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
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Epidemiology of CRSwNP and CRSsNP
5-15% of general population both Europe and USA.
Prevalence of MD-diagnosed CRS was 2-4%
EPOS 2012
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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
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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
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Immune barrier hypothesis of CRS
EPOS 2012
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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
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Mucosa in CRS: BM thickening, goblet cell hyperplasia, subepithelial edema, mononuclear cell infiltration with few
eosinophils Middleton’s Allergy Principle & Practice, seventh edition
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Numerous subepithelial eosinophils in luminal compartment of early-stage polyp.
Middleton’s Allergy Principle & Practice, seventh edition
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Eosinophils accumulated subepithelially and diffusely in tissue of mature polyp.
Middleton’s Allergy Principle & Practice, seventh edition
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Koen Van Crombruggen et al. J Allergy Clin Immunol 2011;128:728-32.
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Eosinophilic and noneosinophilic form of sinusitis
Spencer C et al. J Allergy Clin Immunol 2011;128:710-20
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Type of CRS
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Endoscopic view of nasal polyps protruding from middle meatus.
Middleton’s Allergy Principle & Practice, seventh edition
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Allergic fungal rhinosinusitis
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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
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CRSsNP received antibiotic plus steroid
Daniel L et al. J Allergy Clin Immunol 2011;128:693-707
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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
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CT scan of fungal infection of right maxillary sinus: heterogeneous opacification
and calcification with increased attenuation.Middleton’s Allergy Principle & Practice, seventh edition
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Daniel L et al. J Allergy Clin Immunol 2011;128:693-707
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Clinical control of CRS
EPOS 2012
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Stepwise evaluation of CRS
Daniel L et al. J Allergy Clin Immunol 2011;128:693-707
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Daniel L et al. J Allergy Clin Immunol 2011;128:693-707
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Daniel L et al. J Allergy Clin Immunol 2011;128:693-707
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Adult with CRS without nasal polyps
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Postoperative treatment for adult with CRS without nasal polyps
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Adult with CRS with nasal polyps
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Postoperative treatment in adult with CRS with nasal polyps
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Children with CRS
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Daniel L et al. J Allergy Clin Immunol 2011;128:693-707