8, No: 1
Jan - Jun 2012. Page 1 - 44
review article
Introduction
Chronic rhinosinusitis (CRS) is
one of the most frequent otorhinolaryngologic diseases encountered
in everyday practice. It is thus a
common enough medical condition,
but one in which the diagnosis and
prognosis depend on symptoms,
signs, clinical judgement and radiological evaluation. This is often
not very straightforward; numerous
investigators have attempted to
characterize this condition based on
various factors. Some of these are as
follows: Symptom scores, Computed
Tomography scores, Endoscopic findings, Surgical findings, Culture results
and Histopathology results.
CRS is a group of disorders characterized by inflammation of the
mucosa of the nose and paranasal
sinuses of at least 12 consecutive
weeks duration. In addition, osteitis
of the underlying bone can occur.
Several factors, both intrinsic and
extrinsic contribute to the development of CRS.
The management approach to
a patient presenting with CRS is in
a logical stepwise fashion with the
goal of maximizing his/her medical
management and symptom relief.
In the setting of failure of medical
management, functional endoscopic
sinus surgery (FESS) is now the widely
accepted surgical modality.
*Dept. of ENT, AIMS, Kochi.
Methods
Information used to write this
paper has been collected essentially
as part of a post-graduate dissertation accepted by the National Board
of Examination. Standard texts,
articles from indexed Journals and
various sources in the electronic data
bases using the key words chronic
rhinosinusitis, nasal polyposis and
functional endoscopic sinus surgery
were used to do the background
study. Preference was given to more
recent studies.
Incidence
Chronic rhinosinusitis (CRS) is a
common disease affecting over 30
million individuals globally each
year with more than 200,000 people
annually requiring surgical intervention1. It is reported to be more
prevalent than arthritis or hypertension, affecting between 5% and 15%
of studied populations2 according to
western literature. It is a common
problem that exacts a high cost in
terms of direct health care as well as
lost productivity.
Definition
Rhinosinusitis is a group of disorders characterized by inflammation of
the mucosa of the nose and paranasal
sinuses. Chronic rhinosinusitis is a
group of disorders characterized by
Mucociliary
clearance of
frontal sinus
Osteomeatal
complex
TABLE 1
Factors associated with diagnosis of rhinosinusitis3
(Requires two major factors or one major and two
minor factors)
Major factors
Mucociliary
clearance of
maxillary
sinus
Fluid
collected in
sinus
Minor factors
Headache
Nasal obstruction/
blockage
Nasal discharge/
purulence/
Halitosis
Discoloured postnasal
drainage
Fatigue
Hyposmia/ anosmia
Dental pain
Cough
Ear pain/pressure/
fullness
Fig. 3: Coronal study of Computed tomography of paranasal sinus showing opacification and diffuse mucosal
thickening of maxillary and ethmoid sinuses, right > left
6
Normal
Findings
Positive
Findings
Allergic
Anti-allergic
treatment
Discharge
Polyps
Culture &
sensitivity directed
antimicrobials
Protocol treatment
(Including oral
steroids)
Consider
CT PNS
Sinus system
Maxillary
Anterior ethmoidal
Posterior ethmoidal
Sphenoidal
Frontal
Ostiomeatal complex
Total points for each side
Right Left
0,1and 2 0,1and 2
0,1and 2 0,1and 2
0,1and 2 0,1and 2
0,1and 2 0,1and 2
0,1and 2 0,1and 2
0, and 2 0, and 2
0-12
0-12
Conclusions
An improved understanding of the underlying disease process has led to an evolution in the treatment
of CRS.
Detailed recording of the clinical symptoms and
physical findings, followed by diagnostic nasal endoscopy (DNE) and CT scan of PNS play a crucial role in
the diagnosis, prognosis and follow-up of CRS patients.
Medical therapy has begun to shift from antibiotics
and decongestants to a combination of topical steroids,
systemic steroids, decongestants, antihistamines and
antibiotics. Surgical treatment of CRS, still a crucial
component of the overall treatment plan, has shifted
from radical to a more conservative, yet complete approach. Although important, surgery alone does not lead
to a long term disease free state.
A comprehensive management plan incorporating
both medical and surgical care remains the most likely
way to provide long term disease control for CRS. The exact combination continues to be debated. Nevertheless,
use of long term topical steroids and regular followup of all patients seem to be the best option till date.
References
1) Murugappan Ramanathan, Jr, MD; Ernst W. Spannhake,
PhD; Andrew P. Lane, MD. Chronic Rhinosinusitis with
Nasal Polyps is Associated with Decreased Expression of
Mucosal Interleukin 22 Receptor. Laryngoscope October
2007;117:1839-42
Recent advances
The role of various inflammatory mediators CD3,
CD25, IFN-r, TGF-B, IL-1, MMP in the pathogenesis of
CRS and thereby the role for targeted therapy is gaining
attention17.
Ramanathan et al demonstrate IL-22R1 mRNA and
protein expression on nasal epithelial cells. Failure of
medical and surgical therapy in CRSwNP is associated
with significantly decreased expression of IL-22R118.
Studies have shown the role of biofilm detection
in characterization of CRS. BacLight/ confocal scanning laser microscope (CSLM) and fluorescence in
situ hybridization (FISH) / CSLM are complementary
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13) Timothy L, Smith. Objective testing and quality of life evaluation in candidates with Chronic Rhinosinusitis; Am J Rhinol
2003;17(6):351-6
20) Boris Tolsdorff, Virtual Reality: A New Paranasal Sinus Surgery Simulator Laryngoscope 2010; 120:420-7