1

Training Module CPG Management of Rhinosinusitis in

Adolescents & Adults
2
3
 4

LEARNING OBJECTIVES
• To learn on how to diagnose rhinosinusitis
• To learn on risk factors of rhinosisnusitis
• To learn appropriate physical examinations in
diagnosing RS
• To learn common physical findings in RS
• To learn type of reliable imaging & when to do it in
managing RS
• To learn main pathogens in acute vs chronic
bacterial RS
• To learn indication for culture & sensitivity (C&S) in
RS diagnosis
• To learn reliable methods in obtaining specimen for
C&S in RS diagnosis
 5

INTRODUCTION
• Rhinosinusitis (RS) is a common health problem
characterised by mucosal inflammation of the
paranasal sinuses.

• RS can be divided into 2 subtypes based on the

duration of the symptoms:
• acute
• chronic
 6

INTRODUCTION-2
• Clinical presentation of RS includes:
• nasal obstruction or rhinorrhea
• headache
• decreased sense of smell
• postnasal drip
• facial pressure or pain
• fever
• sore throat & cough
 7

INTRODUCTION-3
• RS poses a major health problem, & affects the
quality of life, productivity & finances of its sufferers.

• Predisposing factors for RS are multifactorial, these

include:
• infection
• allergies
• air pollution
 8

EPIDEMIOLOGY
• Acute Rhinosinusitis (ARS) & Chronic Rhinosinusitis
(CRS) are common diseases worldwide
• ARS prevalence rate ranges from 6 - 15%.1
• CRS prevalence rate is between 5 - 15% in Europe,
United States of America & Brazil1; & ranges from
2.7 - 8% in Asia.2

1. Fokkens WJ, et al. Rhinology. 2012 Mar;50(23):1-305

2. Shi JB, et al. Allergy. 2015;70(5):533–9
 9

PREDISPOSING/RISK FACTORS
• Active smokers with concurrent allergic
inflammation have an increased susceptibility to
ARS compared to non-smokers.1
• Current & past exposure to second hand smoke
carries a higher risk of CRS compared with no
exposure.4

4. Reh DD, et al. Am J Rhinol Allergy. 2009;23(6):562–7

 10

PREDISPOSING/RISK FACTORS-2
• Other significant risk or associated factors for CRS
are:
• positive family history4
• asthma5 especially with the presence of CRS with
nasal polyps6
• allergies, chronic bronchitis & emphysema4
• ARS6
• chronic rhinitis6
• gastroesophageal reflux disease6
• sleep apnoea6
• adenotonsillitis6

5. Jarvis D, et al. Allergy Eur J Allergy Clin Immunol. 2012;67(1):91–8

6. Tan BK, et al. J Allergy Clin Immunol; 2013;131(5):1350–60
 11

DEFINITION
• ARS
• worsening of symptoms after 5 days or symptoms
persist after 10 days & less than 12 weeks1
• CRS
• symptoms persisting for >12 weeks8
• Common cold (acute viral RS)
• symptoms <5 days

8. Thomas M, et al. Prim Care Respir J. General Practice Airways Group;

2008;17(2):79–
89
 12

DEFINITION OF ARS
 13

DEFINITION-2
• In ARS:1
• The duration is <12 weeks with complete resolution of
symptoms.

• In CRS:1
• The duration is ≥12 weeks without complete resolution
of symptoms.
 14

DIAGNOSIS
• The diagnosis of RS is usually based on clinical
symptoms & supported by diagnostic imaging or
nasal endoscopy.1

1. Fokkens WJ, et al. Rhinology. 2012 Mar;50(1):1-12

 15

CLINICAL DIAGNOSIS
 16

DIAGNOSIS
• Nasal endoscopy or computed tomography scan is
one the requirement to diagnose RS.
• Past medical history of CRS is therefore sufficient to
make a diagnosis in RS in PHC.
 17

DIAGNOSIS-2
• Viral vs Bacterial
• Majority of ARS cases are viral in origin.1
• Only 0.5 - 2.0% are complicated by bacterial infections
• Clinically it is difficult to differentiate whether RS is
bacterial or viral in origin.
• This may lead to unnecessary antibiotic use for
patients & increase the incidence of antibiotic
resistance.
 18

DIAGNOSIS-3
• Acute bacterial RS is suggested when there are at
least 3 symptoms/signs of:
• discoloured discharge (with unilateral
predominance) & purulent secretion in the nasal
cavity
• severe local pain (with unilateral predominance)
• fever (>38ºC)
• elevated erythrocyte sedimentation rate/C-reactive
protein
• deterioration of symptoms & signs
 19

EXAMINATION, IMAGING
& LABORATORY
INVESTIGATION
 20

OUTLINE
• History
• Physical examination
• Imaging (CT Scan)
• Laboratory Tests
• Recommendations-3
 21

PHYSICAL EXAMINATION
• Anterior rhinoscopy1
• In ARS, it should be performed at primary care
• Mucosal oedema, nasal inflammation, purulent nasal
discharge, polyps & anatomical abnormalities

• In diagnosing CRS, it has a limited value vs nasal

endoscopy
 22

EXAMINATION IN ARS
EXAMINATION IN ARS-2
23
EXAMINATION IN ARS-3
24
 25

EXAMINATION IN ARS
 26

PHYSICAL EXAMINATION-2
• Nasal endoscopy
• Rigid & flexible nasal endoscope (Fig. 2 & 3)
• Should be performed at ORL centre
• In the diagnosis of ABRS, the sensitivity & specificity
of flexible nasal endoscopy in reference of sinus
radiograph are 97.7% (95% CI 72.41 to 92.97) &
67.3% (95% CI 54.56 to 80.06) respectively.14

14. Berger G, et al. Eur Arch Oto-Rhino-Laryngology. 2011;268(2):235–40

 27

PHYSICAL EXAMINATION-3
• Nasal endoscopy
• The diagnostic values of nasal endoscopy in CRS
compared with CT scan as a gold standard are:
• sensitivity & specificity of 29 to 38% & 93 to 95%
respectively9
• accuracy of positive symptoms at 69.1%4
• PPV ranging from 0.56 to 0.89 & NPV ranging from 0.30
to 0.7615, 16

9. Amine M, et al. Int Forum Allergy Rhinol. 2012;00(0):1–7

15. Bhattacharyya N, et al. Arch Otolaryngol Neck Surg. 2004;130(3):329
16. Wuister AMH, et al. Otolaryngol - Head Neck Surg 2014;150(3):359–64
 28

TYPES OF ENDOSCOPE
NASAL ENDOSCOPY
29
 30

FINDINGS IN
ENDOSCOPY

ARS
 31

CRS WITHOUT NASAL POLYPOSIS

 32

CRS WITH NASAL POLYPOSIS

 33

Mucop
us

Middle
turbinate

Nasal
polyp
34
 35

IMAGING
• Plain radiography has no role in the routine
management of rhinosinusitis.18
• CT scan is the gold standard for radiographic
evaluation of the paranasal sinuses.19
• Had been used in many studies as a reference in
diagnosing bacterial rhinosinusitis20, 21
• Can quantify the extent of inflammatory disease
based on opacification of the paranasal sinuses

18. Scadding GK, et al. Clin Exp Allergy. 2008;38(2):260–75

19. Rosenfeld RM, et al. Otolaryngol - Head Neck Surg (United States)
2015;152:S1–39
20. Kenny TJ, et al. Otolaryngol - Head Neck Surg. 2001;125(1):40–3
21. Elwany S, et al. J Crit Care Elsevier Inc.; 2012;27(3):315.e1–315.e5
 36

IMAGING-2
• Indications for CT scan in RS are:18
• failed medical therapy
• planned for surgery
• atypical or severe disease i.e. unilateral symptoms,
blood-stained discharge, displacement of the eye &
severe pain
37
 38

LABORATORY INVESTIGATION
• Laboratory culture & antibiotic susceptibility (C&S)
tests aim to document bacterial infection &
resistance pattern in bacterial RS.

• Important to ensure:
• appropriate indications
• sampling methods
 39

RHINOSINUSITIS
BACTERIOLOGY
 40

ACUTE BACTERIAL RS (ABRS)

• Main pathogens:
• Streptococcus pneumoniae 26%
• Haemophilus influenzae 28%
• Moraxella catarrhalis 14%
• more common in children
• In acute condition of sinusitis with odontogenic
origin, anaerobic organisms appear to
predominate.
 41

CHRONIC RS
• Bacteriology-different from ABRS

• Main pathogens:
• Staphylococcus aureus 8%
• Enterobacteriaceae
• Pseudomonas spp
 42

INDICATION FOR C&S

• In ABRS, patients who do not respond to first- &
second-line antibiotics, sinus or meatal culture for
pathogen-specific therapy is recommended .22

22. Chow AW, et al. Clin Infect Dis. 2012;54(8):e72–112

 43

INDICATION FOR C&S

 44

OBTAINING C&S SPECIMEN

RELIABLE METHOD
 45

MAXILLARY SINUS TAPS (MST)

• For sinus puncture & aspiration
• Goal standard method in determining the aetiology
of ABRS
• Invasive nature
• Rarely performed
 46

ENDOSCOPICALLY-DIRECTED MIDDLE
MEATAL CULTURE (EDMMC)
• Less invasive compared with MST
• EDMMC is as accurate as MST (based on 2 meta-
analyses):
• Pooled accuracy calculated per culture & per isolate is
comparable at 73%, (95% CI 50 to 88) & 82% (95% CI 65
to 92) respectively in acute & chronic RS.24
• An accuracy of 87.0% (95% CI 81.3 to 92.8) is obtained
when detecting main pathogenic bacteria
(Streptococcus pneumoniae, Haemophilus influenzae
& Moraxella catarrhalis) in ABRS. However, the
accuracy reduced in the detection of all bacteria
(76.3%, 95% CI 69.1 to 83.6).25

24. Dubin MG, et al. Am J Rhinol. 2005;19(5):462–70

25. Benninger MS, et al. Otolaryngol Head Neck Surg.
2006;134(1):3–9
 47

OBTAINING SPECIMEN
FOR C&S
 48

NASAL SWAB CULTURE

• Little predictive value in diagnosing ABRS & CRS.23

23. Desrosiers M, et al. J Otolaryngol - Head Neck Surg BioMed Central Ltd;
2011;40(SUPPL. 2):99–
142
 EDMCC VS SINUS CT SCAN IN
49

DIAGNOSIS OF BACTERIAL RS
• EDMMC has comparable performance with sinus
CT scan as gold standard in the diagnosis of
bacterial RS (sensitivity of 92.8%, specificity of 80.0%
& accuracy of 90.2%).21

21. Elwany S, et al. J Crit Care Elsevier Inc.; 2012;27(3):315.e1–315.e5

 50

MEDICAL THERAPY
• The aims of pharmacotherapy:
• to alleviate symptoms
• to prevent complications

 Range of medications available:

◦ antibiotics
◦ corticosteroids
◦ nasal saline irrigation
◦ anti-histamine
◦ others:
◦ analgesics
◦ decongestants
◦ mucolytics
◦ antiviral agents
 ANTIBIOTICS IN ARS 51

 Minimal to moderate benefits

 Cochrane meta-analyses:
◦ 2009 - a reduced risk of treatment failure in antibiotics
comparing to placebo by 34% within 7 to 15 days (RR=0.66,
95% CI 0.44 to 0.98)26
◦ 2012 - a favourable overall treatment effect of antibiotics
against placebo (OR=1.25, 95% CI 1.02 to 1.53; NNT=18).27

 A large prospective cohort study:28

◦ reduced risk of treatment failure in patients treated with
antibiotics vs without antibiotics (HR=0.3, 95% CI 0.21 to 0.42)
◦ patients with poor orodental condition & those with previous
use of antibiotics in the past 2 months benefited most from this
(HR of 0.04 & 0.09 respectively).

26. Ahovuo-Saloranta A et al. Cochrane Database Syst Rev.

2008; 2014;2:CD000243
27. Lemiengre MB, et al. Cochrane database Syst Rev
2012;10(10):CD006089
28. Blin P et al. Br J Clin Pharmacol. 2010;70(3):418–28
 52

ANTIBIOTICS IN ARS-2
 Adverse effects - mostly gastrointestinal27
 Antimicrobial resistance due to overuse of
antibiotics1
 Streptococcus pneumoniae, Haemophilus
influenza29, 30, 31

1. Fokkens WJ, et al. Rhinology. 2012 Mar;50(23):1-305

29. Ministry of Health M. National Surveillance of Antibiotic Resistance (NSAR).
2010
30. Ministry of Health M. National Surveillance of Antibiotic Resistance (NSAR)
Report. 2014
31. Ministry of Health M. National Surveillance of Antibiotic Resistance (NSAR)
Report. 2011
 53

ANTIBIOTICS IN ARS-3
 There is no significant difference in efficacy
between different antibiotics in ARS.1

 Preferred antibiotics are amoxicillin &

amoxicillin/clavulanate6

 A meta-analysis: a shorter course of antibiotics (3

to 7 days) was as efficacious as a longer one (6 to
10 days).8

8. Falagas ME, et al. Br J Clin Pharmacol. 2009;67(2):161–71

 54

ANTIBIOTICS IN CRS
• Insufficient strong evidence to support the routine
use of antibiotics in CRS.

• Macrolides administered by ORL specialists in CRS

for its anti-inflammatory properties.
RECOMMENDATION ON
55

ANTIBIOTICS
 56

CORTICOSTEROIDS
• Intranasal (INS) & oral
• It reduces the inflammation & oedema of the nasal
mucous membrane rendering resolution of RS
symptoms.
 57

CORTICOSTEROIDS-2
 Improve patency of
ostiomeatal complex
by reduction in
mucosal swelling
 Immunomodulator
 Stabilise mast cells
 Block formation of
inflammatory
mediators
 Inhibit chemotaxis of
inflammatory cells
 INS CORTICOSTEROIDS 58

 ARS:
◦ 2 good meta-analyses showed that INS significantly
improved symptoms of ARS compared with placebo in 14
- 21 days. However, the effects were small.
◦ Higher doses of mometasone furoate led to better
improvement of symptoms. The side effects were mild to
moderate.34, 35
 CRS:
◦ 2 meta-analyses found that INS given between 16 & 52
weeks duration was more efficacious than placebo.
 Reduction in polyp size with a mean difference of 0.43 (95% CI
0.25 to 0.61)36
 Improvement of symptoms, SMD= - 0.37 (95% CI - 0.60 to -
0.13)37
 No difference in side effect between the INS group &
placebo37
◦ However, there was no difference in endoscopic score
between the 2 groups (SMD= -0.37, 95% CI -0.84 to 0.11)37
34. Zalmanovici Trestioreanu A, et al. Cochrane Database Syst Rev. 2013;(12):CD005149
35. Hayward G, et al. Ann Fam Med. 2012;10(3):241–9
36. Joe SA, et al. Otolaryngol - Head Neck Surg. 2008;139(3):340–7
37. Snidvongs K, et al. Cochrane Database Syst Rev. 2011;(8):CD009274
 59

INS CORTICOSTEROIDS-2
 Common adverse effects
◦ Nasal irritation, mucosal bleeding & crusting

 Lessen the adverse effects by:

◦ Propylene glycol contained in the preparations
◦ Switching to a aqueous delivery system
◦ Concomitant nasal saline

 Compliance & correct technique

TECHNIQUE OF INS
60

ADMINISTRATION
 61

ORAL CORTICOSTEROIDS IN ARS

 Oral corticosteroids (30 mg/day for 7 days) is
significantly more effective than placebo in
improvement of symptoms up to 12 days.
 Side effects of oral corticosteroids are limited &
mild.38, 39
 Possibility of exacerbation of bacterial infection

38. Venekamp RP, et al. Fam Pract. 2012;29(6):706–12

39. Venekamp RP, et al. CMAJ 2012;184(14):E751–7
 62

ORAL CORTICOSTEROIDS IN CRS

 Short-term oral corticosteroids (25 mg/day for 2
weeks) is significantly more effective than
placebo in reduction of nasal polyp size &
hyposmia score up to 10 weeks.
 Oral corticosteroids causes transient suppression
of adrenal function & increase bone turnover. 40

40. Vaidyanathan S, et al. Ann Intern Med. 2011;154(5):293-302

RECOMMENDATION ON
63

CORTICOSTEROIDS
 64

SALINE IRRIGATION
• Facilitates mechanical removal
• mucus
• infective agents
• inflammatory mediators
• Decreases crusting
• Increases mucociliary clearance (MCC)

• Nasal saline irrigation is recommended to be used in

ARS.1
 65

SALINE IRRIGATION-2
 Cochrane systematic review:41
◦ saline irrigation was efficacious as a treatment
adjunct for managing the symptoms of CRS
(SMD=1.42, 95% CI 1.01 to 1.84).
◦ no difference in the efficacy between isotonic &
hypertonic saline irrigation (p= 0.14).

41. Harvey R, et al. Evidence-Based Child Heal A Cochrane Rev J 2008;3(3):459–

95:CD006394
 66

SALINE IRRIGATION-3
• Adverse events are minor:41
• nasal burning
• irritation
• nausea
RECOMMENDATION ON SALINE
67

IRRIGATION
 68

ANTI-HISTAMINE
 There is an increase prevalence of allergic rhinitis
(AR) in patients with CRS, although the role of
allergy in the development of CRS remains
unclear.23
 Antihistamine controls sinusitis symptoms in AR.
 Current data yields insufficient evidence to
recommend antihistamines for treatment of CRS in
non-allergic rhinitis patients.1, 23, 42

23. Desrosiers M, et al. J Otolaryngol - Head Neck Surg BioMed Central Ltd;
2011;40(SUPPL. 2):99–142
42. Braun JJ, et al. Allergy. 1997;52(6):650–5
 69

ANTI-HISTAMINE-2
• First generation
• chlorphenarimine, diphenhydramine
• Second generation
• loratadine, terfenadine, cetrizine
• Third generation
• fexofenadine, desloratadine, levocetrizine
• The newer generations are less sedative
 70

RECOMMENDATION ON
ANTI-HISTAMINE
 71

OTHER MEDICATIONS
• There is insufficient recent evidence on the
following treatment in rhinosinusitis:
• analgesics
• decongestants
• mucolytics
• antiviral agents
 OTHER MEDICATIONS -
72

ANALGESICS
• Provide symptomatic relief in both viral & bacterial
infections of the upper respiratory passages in RS23
 OTHER MEDICATIONS - 73

DECONGESTANTS
 MCC improves significantly with oxymetazoline
after 20 minutes.44
 Topical or systemic decongestants may offer
additional symptomatic relief in VRS, however their
ability to prevent ABRS is unproven.19
 In local context, decongestants is prescribed in
ARS.

19. Rosenfeld RM, et al. Otolaryngol - Head Neck Surg (United States)
2015;152:S1–39
44. Inanli S, et al. Laryngoscope. 2002;112(2):320–
OTHER MEDICATIONS -
74

DECONGESTANTS-2
 OTHER MEDICATIONS - 75

MUCOLYTICS
• There is no evidence to support the use of
mucolytics in RS.1
• Commonly available mucolytic are bromhexine
and guaifenesin - has not proven to be effective in
reducing symptoms of sinusitis.
OTHER MEDICATIONS - ANTIVIRAL 76

AGENTS
• There is no evidence of antiviral agents used
effectively in treating patients with RS.
SUMMARY OF TREATMENT
77

RELEVANCE
 78

MEDICATION DOSAGE,
INDICATIONS & SPECIAL
PRECAUTIONS IN RS
 MEDICATION DOSAGE,
INDICATIONS & SPECIAL
79

PRECAUTIONS IN RS
80
 ACUTE RHINOSINUSITIS
81

Early Urgent

• persistent symptoms • periorbital

despite optimal therapy edema/erythema
• frequent recurrence (≥4 • displaced globe
per year) • double vision
• suspected malignancy • restricted eye movement
• immunodeficiency • reduced vision
• severe frontal headache
• forehead swelling
• neurological
manifestation
• septicaemia
 82

Pott’s puffy tumour Periorbital

(forehead /frontal oedema/erythema
swelling)
 83

CHRONIC RHINOSINUSITIS

Early Urgent

• failed a course of • Severe pain or swelling

optimal medical of the sinus areas
therapy (lower threshold for
• >3 sinus infection per immunocompromised
year patients e.g.
• suspected fungal uncontrolled diabetes,
infections, end stage renal failure,
granulomatous disease HIV)
or malignancy
• immunodeficiency
 84

COMPLICATION
• Acute
• Dental abscess
• Orbital Abscess, Optic neuropathy
• Bony erosion
• Intracranial
• Chronic
• Mucocoele formation
• Osteitis
• Metaplstic bone formation
• Descending infections – OM, pharyngitis, tonsillitis,
pneumonia
 85

MODE OF SPREAD
• Bony dehiscence – lamina propria, floor of orbit,
intraorbital canal
• PNS development – frontal sinus absent at birth,
ethmoid and maxillary
• Thrombophlebitis
• Dental – first and 2nd premolar
• Lymphatic channels – subperiosteal abscess formation
• Subarachnoid space via perineurla space of olfactory
nerve
CT SCAN OF ARSS WITH ORBITAL
86

COMPLICATION
 87

CASE 1
• A 21-year-old female presents to Klinik Kesihatan
with right painful periorbital swelling for 2 days. It is
associated with right foul smelling nasal discharge
& fever for 1 week. She has history of allergic rhinitis.

• Examination reveals right periorbital swelling. There

is no proptosis & ophtalmoplegia. Anterior
rhinoscopy shows bilateral hypertrophy inferior
turbinates.
 Q1. WHAT IS THE BEST STEP OF 88

MANAGEMENT AT THIS
POINT?
A.Start oral antibiotic & give appointment
within 1 week to review the progress of
the symptoms.
B. Refer urgently to ENT
specialist/secondary or tertiary center
with ENT service.
C.Do paranasal sinus radiography to see
the air fluid level in the sinuses.
D.Start nasal decongestant & intranasal
steroid spray.
 89

ANSWER 1
***At this stage. the diagnosis is ARS with orbital
complication

B. Any orbital complication of ARS need urgent

referral to ENT.

A & D. This patient shouldn’t be managed in

primary care as the patient need assessment by
ENT & the management is according to
Chandler’s classification. Patient need urgent
referral within 24 hours to ENT.

C. Plain radiography has no role in the routine

management of RS.
 90

CHANDLER’S
CLASSIFICATION
 INDICATIONS OF REFERRAL FOR 91

ARS

Early referral Urgent referral

• Persistent symptoms despite • Periorbital

optimal therapy oedema/erythema
• Frequent recurrence (≥4 • Displaced globe
per year) • Double vision
• Suspected malignancy
*Early referral : within 2 weeks
• Ophtalmoplegia/restricted
• Immunodeficiencies eye
**Urgent referral : within 24 movement
hours
MANAGEMENT OF ARS FOR PRIMARY CARE & NON-ORL
CENTRE 92
 93

CASE I (CONT.)
• The patient is referred to ENT specialist within 24
hours. She complains of increasing pain of the right
eye.

• Examination reveals right periorbital swelling with

ecchymosis. There is no ophtalmoplegia &
proptosis. Nasal endoscopy shows mucopurulent
discharge from the right middle meatus.
 Q2. WHAT IS THE BEST 94

MANAGEMENT
OPTION AT THIS POINT?
A. Culture & sensitivity of the nasal discharge
B. Admission & urgent referral to Ophthalmology team
C. Early referral to Ophthalmology team
D. Surgical intervention
 95

ANSWER 2
A. C&S is one of the investigation & no urgency.

B. Urgent referral to Ophthalmology is essential to assess

for eye status.

C. Early referral is too late.

D. Surgical intervention is not the option.

 96

SCENARIO 1
• The patient agrees for admission & urgent referral
to Ophthalmology Clinic.

• Eye assessment: Normal (visual acuity, relative

afferent pupillary defect, colour vision, intraocular
pressure)

Q3. What is the diagnosis?

 97

ANSWER 3
 Acute rhinosinusitis with pre-septal
cellulitis
 Q4. WHAT IS THE SUBSEQUENT
98

MANAGEMENT?
A. Broad spectrum IV antibiotic
B. Computed tomography scan of paranasal
sinuses & orbit
C. Broad spectrum IV antibiotic which cross blood
brain barrier
D. Systemic decongestant
 99

ANSWER 4
A. Broad spectrum IV antibiotic is not adequate
because the infection in the orbit could spread
to the brain through orbital apex.

B. CT scan PNS & orbit is not essential investigation

at this point.

C. Broad spectrum IV antibiotic which cross blood

brain barrier is the compulsory treatment)
D. Systemic decongestant is a supportive treatment
 100

SCENARIO 2
• The patient’s symptoms are worsening despite 24
hours of medical therapy.
• Right eye movement is restricted.
• Her visual acuity is deteriorating from 6/12 to 6/24.
 Q5. WHAT SHOULD BE THE 101

MANAGEMENT AT THIS
POINT?
A. Increase the antibiotic dosage.
B. Do computed tomography of paranasal sinuses
& orbit.
C. Increase the frequency of nasal douching.
D. Increase the intranasal corticosteroids dosage.
 102

ANSWER 5
A. No
B. CT scan to look for intraorbital abscess
C. No
D. No
 103

SCENARIO 2 (CONT.)
• CT scan of paranasal sinuses & orbit:
• Opaque of right maxillary & ethmoid sinuses
• Abscess formation in medial subperiosteal region of
the orbit

• The patient is advised for surgery to avoid loss of

vision.
 104

SCENARIO 2 (CONT.)
• Patient agrees for emergency surgery.
• Endoscopic sinus surgery & right orbital
decompression is performed.
• Post-surgery, vision improves & intraocular pressure
is normal.
• The patient discharged home on day 4 post-
surgery.
105
 106

SURGICAL
INTERVENTION
SURGICAL INDICATIONS IN ARS
107
SURGICAL INDICATIONS IN CRS
108
 109

No clinical
improvement
after 24-48
hrs of IV
ARS antibiotics

Indicatio Orbital or
intracranial
n of complication
Surgery s
Fail optimal
CRS medical
therapy
110
 FUNCTIONAL ENDOSCOPIC SINUS 111

SURGERY (FESS)
A Cochrane systematic
review & a Health
Technology Assessment
Uses showed that FESS is a
endosco safe surgical procedure
pe with minor complications
ranging from 1.1 to
Most 20.8%45, 49
common
surgical Minimally
treatmen invasive
t techniqu
e
Improvement of ventilation Restoration of nasal cavity &
paranasal sinuses physiological
function

45. Dalziel K, et al. Health Technol Assess. 2003;7(17):iii, 1-

159
 112

Nasal
obstruction

Headach Loss of
e smell
FESS
Symptomatic
improvement

Postnasa Polyp
l drip size
 113

CASE 1
• A 30-year-old female presents to klinik kesihatan
with complaints of low grade fever, nasal
congestion with clear nasal discharge, watery
eyes, mild persistent facial pain & muscle aches for
3 days.

• She requests a course of medications including

antibiotics.
 Q1. WHAT IS THE POSSIBLE
114

DIAGNOSIS?
A. Acute viral rhinosinusitis
B. Acute bacterial rhinosinusitis
C. Chronic rhinosinusitis
D. Allergic rhinitis
 115

ANSWER 1
• In ARS, the duration is <12 weeks.
• In CRS, the duration is >12 weeks with no resolution of
symptoms.
• Differentiation between AVRS or ABRS are based on
symptoms. ABRS is suggested when there are at least 3
symptoms or signs:
• discoloured discharge (with unilateral predominance)
& purulent secretion in the nasal cavity
• severe local pain (with unilateral predominance)
• fever (38oC)
• elevated ESR, C-reactive protein
• deterioration of symptoms & signs (double sickness)
• Allergic rhinitis is defined as the presence of nasal
obstruction/rhinorrhea, itchiness of nose & eyes, &
sneezing.
 116

CASE 1 (CONT.)
• Patient describes mild right facial discomfort for
which analgesics provides minimal relief. She has
no toothache.
• She works as a storekeeper & her husband smokes
one pack of cigarettes a day.
• She is not on any other medications except
inhalers for her asthma.
• She was under ENT follow-up for her allergic rhinitis
& was found to have deviated nasal septum &
inferior turbinate hypertrophy.

Q2. List the risks factors & explain the

pathophysiologic factors giving rise to
ARS?
 117

ANSWER 2
• Passive smoker
• Dust exposure
• Bronchial asthma
• Allergic rhinitis
 118

ANSWER 2
• Environmental pollutants or allergens (cigarette
smoke & dust) & allergic rhinitis can lead to
changes in mucociliary action or initiate
inflammation, thus leading to thickened mucous
secretions & establishing a proliferation of viruses
&/or bacteria.
• Asthma & RS often coexist, & may represent a
spectrum of the same disease entity (one airway
hypothesis).
*Anatomical variation e.g. deviated nasal
septum is not a risk factor for RS.
 119

CASE 1
• Mr. R, 17-year-old boy, chronic smoker, presents at
Klinik Kesihatan with 2-week history of fever, right-
sided nasal blockage, nasal discharge & facial
pain. Anterior rhinoscopy is normal.

• He is treated with intranasal saline irrigation,

intranasal corticosteroids spray, antibiotics &, both
oral & intranasal decongestants.

• The symptoms persist despite 2 weeks of treatment.

 120

QUESTION 1
• What is the best management option at this point?
A. Take a nasal swab for culture & sensitivity testing
B. Change treatment to broad spectrum antibiotics
C. Arrange for plain radiography of paranasal
sinuses
D. Refer for full ENT assessment
 121

ANSWER 1
A. Nasal swab should not be performed in RS.
• Nasal swab cultures are of little predictive value in
diagnosing ABRS & CRS.
• When necessary, bacterial cultures in CRS should be
performed either via endoscopic culture of the
middle meatus or maxillary tap, but not by simple
nasal swab.
B. Proper C&S result is required before change/add
another antibiotics.
C. Plain radiograph MAY BE helpful only in ARS.
D. ORL referral should be done at this point for nasal
endoscopy & middle meatal swab for C&S.
 122

CASE 1 (CONT.)
• Patient agrees for further assessment at ORL clinic.

• Nasal endoscopic findings:

• Purulent discharge in the right middle meatus with
oedematous & hyperaemic mucosa.

Q2. What is the diagnosis?

 123

ANSWER 2
• Right Acute Bacterial Rhinosinusitis (ABRS)
 124

CASE 1 (CONT.)
• C&S taken endoscopically from the middle meatus

• Patient is admitted as he has fever & mildly

dehydrated.
• Responds to intravenous antibiotics
• Discharged on day 3 of admission with a 7 day
course of oral antibiotics
 125

CASE 1 (CONT.)
• 2 weeks after discharge, patient presents again at
KK with fever & right-sided purulent nasal
discharge with orbital pain & diplopia.

• He does not complete the oral antibiotics following

discharge from the hospital.

• On examination:
• lethargic looking, febrile, right periorbital redness &
swelling

Q3. What is the possible diagnosis

 126

ANSWER 3
• Recurrent ABRS with orbital complication
 127

QUESTION 4
• What is your next step of management?
 128

ANSWER 4
• URGENT referral to ORL
• Need to exclude intraorbital/intracranial
complications (e.g. right orbital cellulitis, periorbital
abscess, orbital abscess, extradural abscess)
• Urgent CT scan of paranasal sinuses to confirm
diagnosis & for any subsequent surgical intervention
 129

NES - PURULENT
DISCHARGE
 130

CASE 2
• A 35-year-old male presents to klinik kesihatan with
bilateral nasal obstruction for 2 years. The
symptom has worsened for the past 6 months. He
also complains of hyposmia & postnasal discharge.
He has no history of allergy.

• Anterior rhinoscopy reveals bilateral inferior

turbinate hypertrophy.

• Patient is treated with intranasal corticosteroids &

nasal saline irrigation.
 131

SCENARIO 1
• Patient is reviewed after 4 weeks. He claims the
symptoms have improved.

Q6. What is the next step of

management?
A. Stop the medication & monitor the symptoms.
B. Continue the medication (intranasal
corticosteroids & nasal saline irrigation).
C. Refer to ENT specialist.
D. Start nasal decongestant.
 132

ANSWER 6
B. The intranasal corticosteroids & nasal saline
irrigation should be continued for at least 4
months & the evaluation should be done after
that if the medication can be reduced to
maintenance dose according to the symptoms.
 133

SCENARIO 2
• Patient is reviewed after 4 weeks. However, he
claims that the symptoms worsen with the
medication given.

Q7. What is the next step of

management?
A. Refer to ENT specialist/secondary or tertiary
centre with ENT service.
B. Follow-up for another 3 months.
C. Start oral antihistamine.
D. Start nasal decongestant.
 134

ANSWER 7
A. Referral to ENT should be made after fail a
course of optimal medical treatment.
Antihistamine should only be given to patients
that have allergic rhinitis symptoms.
MANAGEMENT OF CHRONIC RHINOSINUSITIS FOR
PRIMARY CARE & NON-ORL CENTRE 135
 136

INDICATIONS OF
Early referral REFERRAL FOR
Urgent CRS
referral
• Failed a course of • Severe pain or
optimal medical swelling of the sinus
therapy areas (lower
• >3 sinus threshold for
infections/year immune-
• Suspected fungal compromised
infections, patients e.g.
granulomatous uncontrolled
disease or diabetes, end-stage
malignancy renal failure, HIV)
• Immunodeficiencies
*Early referral : within 2 weeks
**Urgent referral : within 24 hours
 137

SCENARIO 2 (CONT.)
• Patient is reviewed by the ENT specialist.
• Nasal endoscopic examination reveals bilateral
nasal polyposis grade 2 with mucopurulent post-
nasal discharge.

Q8. How would treat this patient?

A. Medical therapy for 2 weeks
B. Medical therapy for 16 - 52 weeks
C. Surgical intervention
D. Alternative management
 138

ANSWER 8
B. The accepted duration for optimum medical
therapy is 16 - 52 weeks.

A. The duration of treatment is too short for chronic

rhinosinusitis

C. Surgical intervention only to be considered if

failed medical therapy.

D. Alternative management is not an option.

 139

SCENARIO 3
• Patient is started on medical treatment & reviewed
after 4 months. The symptoms improve.

Q9. What is the next management?

 140

ANSWER 9
• Patient is to continue the medication until review.

• If the symptoms improve, the medication may be

continued on maintenance dose.
 141

SCENARIO 3 (CONT.)
• During review, patient complains of worsening
symptoms.

Q10. What is the next step of

management?
A. Discuss with patient regarding surgical
intervention.
B. Stop the intranasal corticosteroids since the
medication does not serve any benefit.
C. Start on long-term oral corticosteroids for 3
months.
D. Start complementary alternative medication.
 142

ANSWER 10
A. Functional endoscopic sinus surgery should be offered
in patients with CRS who fail optimal medical
treatment.

B. Intranasal corticosteroids should be continued despite

patient does not have any improvement & after
surgery as well.

C. Long-term oral corticosteroids should not be

considered.
• Short-term oral corticosteroids should be given as follows:
o ARS (30 mg/day for 1 week)
o CRS (25mg/day for 2 weeks)

D. Complementary alternative medicine is not one of

treatment of choice.
• There is insufficient evidence to support the use of
complementary alternative medicines in RS.
143
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THANK YOU