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Februari 2017

RHINOSINUSITIS
dr. febriani Endiyarti Sp.THT-KL

Maxillary sinus
1. Ethmoidal bulla
2. Ethmoidal cells
3. Frontal sinus
4. Uncinate process
5. Middle turbinate
6. Inferior turbinate
7. Nasal septum
8. Ostiomeatal complex

A. Infections induce changes in sinus mucosa
Key
Ventilation
B: bulla ethmoidalis
and
IT: inferior turbinate
Drainage
MT: middle turbinate

MS: maxillary sinus
Inflammation

and

Remodeling


Aetiology of rhinosinusitis

Allergy Others
Seasonal Dental, periapical abcess
Perennial Underlying diseases, cystic
Infection fibrosis

Acute Occupational irritants and

allergens
Chronic: specific e.g. Bacterial, fungal or
nonspecific Drug induced, rhinitis
medicmentosa
Possible host defense deficency
Irritants induced rhinitis
Structural
Atrophic rhinitis
Ostiomeatal complex:

Deviated nasal septum
Hypertrophic turbinates

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Classification: chronic rhinosinusitis with and without nasal polyps
2 OR MORE MAJOR SYMPTOMS
DURATION
nasal blockage
ACUTE/intermittent < 12 weeks
anosmia/hyposmia
complete resolution of symptoms
purulent nasal discharge/post-nasal drip
CHRONIC / persistent > 12 weeks
facial pain/pressure
incomplete resolution of symptoms


AND EITHER
endoscopic findings of polyps
mucopurulent discharge

edema or obstruction
OR
CT scan abnormality: mucosal changes within ostiomeatal complex or sinus
cavity
EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: 583-601

Symptoms associated with rhinosinusitis

Major symptoms:
Minor symptoms:
Facial pain/pressure
Headache
Facial congestion/fullness
Fever
Nasal obstruction/blockage
Halitosis
Nasal discharge/purulence/postnasal drip
Fatigue

Hyposmia/Anosmia
Dental pain

Fever
Cough

Ear pain/fullness



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MICROBIOLOGY
Normal sinuses: Free of growth

Acute rhinosinusitis:
Viral

Bacterial (Strept. Pneumoniae,H. Influenzae, M. Catharralis)

Chronic rhinosinusitis:
Anaerobes: Propionibacterium, Bacteriodes, Peptococcus
Aerobes: Staphylococcus, Corynebacterium, Pseudomonas
Fungi (Aspergillus fumigatus, Curvularia, Dreschelaria)
Dental sinusitis: Microaerophilic strept. species

Imaging of sinsuses
MRI: only recommended in tumor diagnosis
CT sinuses: current standard imaging
- Acute rhinosinusitis: only for possible complications
- Chronic sinusitis: only after 4+ weeks of treatment!

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The signs and symptoms of acute sinusitis (>10 days and < 12 weeks):
Prerequisite symptoms

Persistent upper respiratory infection (>10 days)

Persistent muco-purulent nasal or posterior pharyngeal discharge

Cough
Supporting symptoms
Congestion
Facial pain/pressure
Post-nasal drip
Fever

Headache
Anosmia, hyposmia
Facial tenderness
Periorbital edema
Ear pain, pressure
Halitosis

Upper dental pain

Fatigue

Sore throat
Association between viral and bacterial sinusitis
infections
Viral infections

Self-limiting
2 to 3 acute viral respiratory infections per year (6-8 in children)

>80% symptoms resolve in 7-8 days

Often inciting event for development of sinusitis and other respiratory tract infections
.5%2% of cases complicated by acute bacterial infection (>20 million cases)

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 Strength of evidence for treatment of acute rhinosinusitis

Therapy Level Recommendation Relevance

antibiotic Ia (49 A yes: after 5-10days,

studies)
or in severe cases

topical corticosteroid 1b (1 study) A yes

addition of topical Ib (5 studies) A yes

steroid to
antibiotic

oral steroid no evidence D no

(1 study)

addition of oral Ib (1 study) B no

antihistamine

in allergic patients

nasal douche no evidence D no

(3 studies)

decongestion no evidence D Yes as symptomatic

(3 studies) relief

mucolytics no evidence D no
(3 studies)

An update on acute rhinosinusitis management: antibiotics in adults

Cochrane Review Antibiotics for acute maxillary sinusitis

7330 subjects in 32 studies (10 double blind)

antibiotic vs. control (n=5)

newer, non-penicillin antibiotic vs. penicillin class (n=10)
amoxicillin-clavulanate vs. other extended spectrum antibiotics (n=10)
Confirmed radiographically or by aspiration, current evidence is limited but supports penicillin or
amoxicillin for 7 to 14 days. Clinicians should weight the moderate benefits of antibiotic treatment
against the potential for adverse effects

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An update on acute rhinosinusitis management: Antibiotics in acute rhinosinusitis?
Dont treat viral common cold with antibiotics
Use symptomatic treatment in mild acute rhinosinusitis
saline
decongestant
NSAID
Use topical steroids in acute and chronic sinusitis (evidence)

Reserve antibiotics for severe acute presumably bacterial

rhinosinusitis

Prescribe antibiotics based on local resistance patterns

NASAL POLYPOSIS

Prevalence approx. 2- 4%
Asthma in approx. 40-65%

Aspirin sensitivity in 10-15%

Mixed cellular infiltrate with

prominent eosinophilia in 90%

Inflammation with

local IgE production

increased IL-5, eotaxin,

cys-LTs and ECP

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 EVIDENCE-BASED TREATMENT OF CRS

Therapy Level Grade of Relevance

Recommend.

oral antibiotic therapy short term III (4) C no

< 2 weeks

oral antibiotic therapy long term ~ III (6) C yes

12 weeks

topical steroids without II (2) B yes

significant systemic absorption

oral steroid no data - no

available

nasal douche III C yes, for

symptom
relief

decongestion topical/oral no data in - No

single-use

mucolytics IV (1) D no
systemic antimycotics VI D no

topical antimycotics III D no

oral antihistamine Ib (1) B no

in allergic patients

allergic therapy Studies D yes

include
in allergic patients
patients with
NP

allergen avoidance Studies D yes

include
in allergic patients
patients with
NP

proton pump inhibitors III (3) D no

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 EVIDENCE-BASED LONG-TERM ANTIBIOTICS IN CRS

Study Drug Number Time/Dose Effect on Evidence

symptoms

Hashiba et clarithromycin 45 400mg/d clinical III

al,
for 8 to 12 improvement in
1996(379)
weeks 71%

Nishi et al, clarithromycin 32 400mg/d pre- and post- III

1995 (381) Therapy
assesment of
nasal clearance

Gahdhi et al, Prophylatic 26 Not 19/26 decrease III

1993 (382) antibiosis mentioned Of acute

details not exacerbation by

mentioned 50%
7/26 decrease of

acute
exacerbation by

less than 50%

Ichimura et roxithromycin 20 150mg/d clinical III

al, 1996 Roxithromycin 20 for at least improvement
(18) and azelastine 8 weeks and polyp-
1mg /d shrinkage in

52%
Clinical

improvement
and polyp
shrinkage in
68%

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