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OBJECTIVES
The objectives of the guideline are (1) to state the criteria of diagnosis of chronic rhinosinusitis in
adults; (2) to evaluate present diagnostic techniques; and (3) to provide treatment options.
LITERATURE SEARCH
This guideline is based on the 1997 Clinical Practice Guideline of the Philippine Society of
Otolaryngology – Head and Neck Surgery and revised according to new evidence. The National
Library of Medicine’s Pubmed Database and Cochrane Reviews Database were searched for
literature using the medical subject headings: “sinusitis”, “sensitivity and specificity” or “likelihood
functions” or “Meta-analysis” for diagnosis; "meta-analysis" or “clinical trials” for therapy.
Individual subject headings are used for each kind of therapy (antiinfectives, decongestants,
saline irrigation, etc.) and diagnostics (x-rays, CT-scan, etc). Literature relevant to chronic
rhinosinusitis were used.
Meta-Analysis 2
Review/Guidelines 2
Clinical Trial (RCT and CT) steroids and Antibiotics (33)*
RCT (other medical therapy) (8)*
CT (other medical therapy) (1)*
Descriptive Studies 5
DEFINITION
RHINOSINUSITIS is a group of disorders generally characterized by inflammation of the mucosa
of the nose and paranasal sinuses.
CHRONIC RHINOSINUSITIS (CRS) is defined as inflammation of the nasal cavity and paranasal
sinuses and/or the underlying bone that has been present for at least 12 weeks characterized by
the presence of (1) nasal congestion, obstruction or blockage with (2) facial pain or pressure, (3)
discolored discharge (anterior or posterior nasal drip), or (4) hyposmia or anosmia.
Presence of nasal polyps will be considered a subgroup of chronic rhinosinusitis due to the
8
different behavior of nasal mucosa of patients with concomitant nasal polyposis.
PREVALENCE
There is no precise local and foreign information regarding prevalence of chronic rhinosinusitis
8
because of lack of accurate epidemiologic data and a uniformly accepted definition.
Foreign data states that rhinosinusitis affects approximately 30 million per year being 1 of 5 usual
complaints during consult with primary physician. Inadequate treatment of rhinosinusitis is often
17
the main cause in its recurrence/persistence. For chronic cases of “sinus trouble” of symptoms
8
more than 3 months, a survey in US showed a prevalence of 15.5% of the total population.
Socio-economic cost of chronic rhinosinusitis was estimated with direct costs amounting to
between 200 to 2,000 euros per patient per year (American and European Data) and indirect
8
costs 1,500 US Dollars per patient per year.
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RECOMMENDATIONS ON THE DIAGNOSIS OF CHRONIC RHINOSINUSITIS
1. The diagnosis of chronic rhinosinusitis may be made on the presence of two or more
symptoms of
1.1 nasal blockage/congestion
1.2 discharge (anterior or posterior nasal discharge)
1.3 facial pain/pressure
1.4 hyposmia or anosmia
1.5 combined with EITHER physical findings based on anterior rhinoscopy*
and/or endoscopy (polyps, mucopurulent discharge from the middle meatus
and edema/mucosal obstruction of the middle meatus) OR CT scan findings
(mucosal changes within the ostiomeatal complex and/or sinuses).
Grade A Recommendation
2. Anterior rhinoscopy remains the first step in examining a patient. Nasal endoscopy
may be performed with or without decongestion.
Grade A Recommendation
Endoscopy can detect small polyps. The classification of nasal polyps, based on size and
extent, is used as a guide in its management. A modification of the Mackay classification will
be used.
Positive endoscopic findings correlate well with CT scan while negative endoscopic findings
19
correlates only in 71% of patients with negative CT results. Endoscopy and CT scan are
necessary procedures prior to surgical management.
Grade B Recommendation
CT scan demonstrates good sensitivity and above average specificity in diagnosing sinusitis
5
in general. Multi-slice CT and High resolution CT show advantage over conventional CT in
3,12
demonstrating chronic rhinosinusitis.
There are only few recent studies to show good correlation between CT scan and severity of
symptoms of chronic rhinosinusitis. CT scan studies however, are very important in the
1,9,11,20
evaluation of disease. It is recommended in failed medical and/or surgical therapy,
and in presence of complications or malignancies. CT scan is routinely used in patients
undergoing endoscopic sinus surgery.
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4. Sinus radiograph series may be used to suggest the presence of chronic
rhinosinusitis. There is only a limited role for plain x-rays in the management of
chronic rhinosinusitis.
Grade C Recommendation
Although rapid, economical and non-invasive, it has limited evaluation of the paranasal
sinuses and the lower third of the nasal cavity. It has high specificity but 50% sensitivity in
diagnosing CRS. Water’s projection may suggest but can not rule out the presence of
22
sinusitis.
Grade C Recommendation
6. Tests to assess nasal airway patency can be done for research purposes.
No Recommendation
Grade A Recommendation
2. The duration of antibiotic therapy may be for a minimum of two weeks. It may be
extended to four weeks when necessary.
Grade C Recommendation
The data supporting the use of antibiotics in this condition are limited and lacking in terms of
randomized placebo controlled clinical trials. Based on available evidence, CRS is treated
with a four week course of oral antibiotics with evaluation every two weeks. Therapy can be
extended to 12 weeks after which further work-ups and surgical management can be done.
However, the panel, taking into consideration the cost of antibiotics, opted for a shorter
duration of treatment. If there is no response to therapy after two weeks, another antibiotic
may be used.
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3. The choice of antibiotics for CRS depends on the local culture-resistance studies and
clinical response. A monotherapy or a combination of antibiotics may be used.
Grade B Recommendation
Ideal antibiotic should cover Beta-lactamase producing bacteria, Gram (+) specifically
Staphylococcus aureus and Streptococcus Pneumonia, and Gram (-) organisms as well as
anaerobic organisms.
The benefit of long-term, low-dose macrolide treatment seems to be that it is, in selected
cases, effective when steroids fail. The exact mechanism of action is not known, but it
probably involves down-regulation of the local host immune response as well as
downgrading of the virulence of the colonizing bacteria. Placebo-controlled studies should be
performed to establish the efficacy of macrolides if this treatment is to be acceptable as
evidence-based medicine.
Grade B Recommendation
Double-blind data show a positive effect of the addition of local corticosteroid treatment to
oral antibiotics in the treatment of acute exacerbation of chronic rhinosinusitis.
There is some evidence for an effect of intranasal steroids on CRS particularly with
intramaxillary instillation of steroids. No side effects were seen, including any increased
signs of infection. For chronic rhinosinusitis, budesonide aqueous nasal spray improve
14
symptoms of disease more in allergic than in non-allergic patients. There is benefit for
intrasinus administration of topical budesonide to allergic patients with chronic rhinosinusitis
following surgery in the improvement of symptoms score as well as parameters for
13
inflammation.
Grade C Recommendation
6. Nasal saline douche can be used for symptomatic relief of symptoms of CRS during
10,18
medical therapy and even after surgical management.
Grade B Recommendation
There is research-based evidence for adjunctive use of hypertonic or isotonic saline in the
treatment of CRS.
Grade C Recommendation
Grade C Recommendation
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9. For chronic rhinosinusitis, it should be initially managed maximally with medical
16
therapy. Surgical therapy is an option for refractory cases.
Grade A Recommendation
There is limited data comparing medical management with that of surgical management of
CRS. Maximal medical management may mean a 3 month course of antibiotics, nasal
douche, topical steroids and other modalities.
Sinus surgery is effective treatment for chronic sinusitis that is refractory to maximal medical
8
therapy.
10. Other indications for sinus surgery are orbital complications and intracranial
complications
Grade A Recommendation
Grade A Recommendation
2. Grade 1 nasal polyps are managed with intranasal corticosteroid for 4 to 6 weeks. If
with positive response, it is continued on a maintenance basis. If there is no
response, oral systemic steroids may be added.
Grade A Recommendation
3. Grade 2 nasal polyps are managed with short term systemic steroids and intranasal
steroids. They may be given concurrently or sequentially.
3.1 Concurrent treatment- short term systemic steroids and intranasal steroids.
Grade B Recommendation
Grade C Recommendation
4. Patients with grade 1 and grade 2 polyps not responding to medical therapy may
warrant surgical therapy.
Grade C Recommendation
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5. There is divergence in the management of Grade 3 polyps. They may be managed
medically or surgically.
Grade C Recommendation
There is scarcity of data for the long term treatment outcome for nasal polyposis. However,
in CRS with nasal polyposis, topical steroids have been used to improve the sense of smell
8
both in medically treated and postoperative patients. A combined oral and topical short-term
steroid is effective in reducing mucosal inflammation and symptoms in chronic polypoid
rhinosinusitis. Indication for the short-term steroid can be as a preoperative therapy to
decrease extent of surgical procedures, time and risks of surgery. (Its exact role on the
7
outcomes of surgery is unclear.)
Grade C Recommendation
Grade C Recommendation
46
References
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Algorithm for Chronic Rhinosinusitis with and without Nasal Polyposis
OPTIONS:
CT scan
Surgical Option
Shift antibiotic
Topical Steroid therapy
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(continued from previous page)
Antibiotic Therapy
(+/-) Topical Steroid
Nasal Douche
Y
Improvement of Continue Antibiotics
Symptoms?
Shift Antibiotics
Y
Improvement of
Symptoms?
CT Scan
Surgical Option
(+/-) Prolonged subsequent
antibiotic therapy
49