DEFINITION

Acute rhinosinusitis

Acute rhinosinusitis may be defined as sinonasal inflammation lasting less than

4 weeks associated with:
- nasal blockage/obstruction/congestion
- nasal discharge anterior/posterior
- facial pain/ pressure
- reduction/loss of smell

In childrens is associated with 2 or more of the following symptoms :

- nasal blockage/obstruction/congestion
- discolored nasal drainage
- cough
 DEFINITION
Acute rhinosinusitis

For both adults and children, inquiry should be made

about symptoms suggestive of allergy (in order to differentiate acute
rhinosinusitis from allergic rhinitis):

- sneezing
- watery rhinorrhea
- watery eyes
- nasal and ocular pruritus

Viral RS lasts less than 10 days

(differential diagnosis from bacterial RS)
 DEFINITION
Recurrent acute rhinosinusitis

defined as 4 episodes per year of ARS with distinct symptom-free intervals

between episodes.

Each episode must meet the criteria for the diagnosis of rhinosinusitis
 DEFINITION
Chronic rhinosinusitis

Chronic rhinosinusitis may be defined as sinonasal inflammation lasting more

than 12 weeks associated with:
- nasal blockage/obstruction/congestion
- nasal discharge anterior/posterior
- facial pain/ pressure
- reduction/loss of smell

This symptoms have a low specificity, so It’s required the presence of:
- signs at the nasal endoscopy (mucopurulent discharge, polyps, signs of
edema)
- radiologic signs

In childrens, cought has more significance than smell alterations.

 DEFINITION
Chronic rhinosinusitis

In both adults and children, is it possible to make a diagnosis of

rhinosinusitis with polyps when there are polyps in nasal cavity/middle
meatus.

Unilateral polyps need further investigations (differential diagnosis from

tumours)

A wide range of inflammatory patterns may act together with anatomical

or functional abnormalities and lead to the development of chronic
rhinosinusitis.
The multifactorial etiology involvs genetic factors, environmental
influences, occupational factors, infection, allergy, immune dysfunction.
 SOCIAL COSTS

Social costs include societal costs related to absence from work or

decreased work productivity because of the disease in progress.

Studies performed in USA report:

- 61.2 million of total workdays lost per year related to ARS/CRS diagnosis
- 3.79 billion-dollars of annual loss

Studies performed in Spain:

- medical costs for each episode (variable according to treatment) from
250 to 490 dollars
- Medical costs+ social costs: between 747 and 820 dollars
 CLINICAL EVALUATION

It involves:
- QoL questionnaire (quality of life)
- clinical history
- physical examination (often including endoscopic exam)
- radiographic evaluation

Actually QoL questionnaires have a better correlation with the

symptomatology intensity

TC provides important informations on the conditions of the nasal cavity

and paranasal sinuses, specially in a surgical point of view.

The use of radiographic investigations and endoscopic exams is to be

redefined in the future in order to be better related to QoL
questionnaires.
 EPIDEMIOLOGY
Acute rhinosinusitis

Incidence: 1-3 annual episodes per adult

It represents 2-10% of reasons why patients recurr to ENT treatments

 PATHOPHYSIOLOGY
Acute rhinosinusitis

Anatomical abnormalities predispose to ARS.

Allergies and infections (bacterial, viral, mycotic) are the basis of ARS.

Environmental pollution, cigarette smoking and working factors have been

related to ARS.

Periapical dental infections may lead to direct inoculation of bacteria in

maxillary sinus.
PATHOPHYSIOLOGY
Acute rhinosinusitis
PATHOPHYSIOLOGY
Acute rhinosinusitis
PATHOPHYSIOLOGY
Acute rhinosinusitis
PATHOPHYSIOLOGY
Acute rhinosinusitis
 DIFFERENTIAL DIAGNOSIS
Acute rhinosinusitis

Bacterial ARS is frequently a complication of a viral form and the

symptoms associated with these conditions often overlap.

The key factor to distinguish each type is the duration.

A persistent disease for more than 10 days or a worsening of symptoms
after the first 5 days generally indicates a post-viral bacterial ARS.

The swab is not necessary for the diagnosis of bacterial ARS, but can be of
help for the targeted antibiotic therapy.
 DIFFERENTIAL DIAGNOSIS
Acute rhinosinusitis

According to Fokkens the diagnostic criteria for post-viral bacterial ARS are
duration (7-10 days), particularly pain over teeth and maxilla, purulent
secretions on rhinoscopy, leukocytosis and/or increased ESR or elevated
CRP and fever >38°C.

According to Rosenfeld it is impossible to perform a differential diagnosis

between bacterial and viral ARS based only on clinical observation.
 THERAPY
Acute rhinosinusitis

There is substantial evidence that a bacterial ARS has a high spontaneous

resolution rate and that the costs and side effects of antibiotics may
reduce the potential benefits.

4 recent systematic reviews have compared the effects of antibiotics vs.

placebo with minimal differences.
 THERAPY
Acute rhinosinusitis

In the case of prescription of antibiotics, various agents are indicated for

the bacterial ARS, and the first-line drug is amoxicillin alone or in
combination with clavulanic acid.

The second-line drugs, in case of allergy to amoxicillin or its therapeutic

failure are:
-trimethoprim-sulfamethoxazole
-doxycycline
-fluoroquinolone antibacterials

The duration of treatment must continue for up to a maximum of 10 days.

 THERAPY
Acute rhinosinusitis

The use of intranasal corticosteroids has been widely studied for their
anti-inflammatory and decongestant activities.

Numerous studies report effectiveness in reducing both the intensity and

duration of symptoms.

Compared to the oral administration, the intranasal use reduces the side
effects due to the low systemic bioavailability.
 THERAPY
Acute rhinosinusitis

According to the latest clinical trials, fluticasone propionate 110 μg 1-2

times daily or mometasone furoate 200 μg 1-2 times daily are the most
effective drugs.

Studies on systemic corticosteroids as adjuvant therapy compared to the

local one showed that the methylprednisolone, betamethasone and
prednisolone are the better effect molecules.
 THERAPY
Acute rhinosinusitis

There are no statistically significant evidence for / against the use of

drugs such as ipratropium bromide and mucolytics in decreases the
symptoms intensity.

Studies on patients treated with herbal interventions have shown the

efficacy of herbal extracts such as pelargonium sidoides and cineol.
 COMPLICATIONS
Acute rhinosinusitis
They are classified into:
- Intraorbital complications
- Intracranial complications
- Osseus complications

The overall incidence of large-scale complications of 2.7-4.3 cases per million

inhabitants per year (US data).

•Intraorbital complications:
Preseptal cellulitis
Orbital cellulitis
Subperiosteal abscess
Orbital abscess

Signs / symptoms: conjunctival edema (chemosis), proptosis, eye pain, reduction of

the eyeball movements, high fever, neutrophilia.
 COMPLICATIONS
Acute rhinosinusitis
•Intracranial complications:
Epidural or subdural abscesses
Brain abscess
Meningitis
Cerebritis
Superior sagittal thrombosis
Cavernous sinus thrombosis
Nerve palsy VI n.c.6–228,231,250–252

Signs / symptoms: often nonspecific characterized by high fever and severe headache
to vomiting and papillary stasis (in case of intracranial hypertension), altered mental
status and neurological deficits.

• Osseus complications:
Osteomyelitis of the frontal bones

Signs / symptoms: skin pain and hyperemia with possible intracranial extension of the
disease
 EPIDEMIOLOGY
Chronic rhinosinusitis
Prevalence of CRS without polyposis: 4.9% (US data).

Main predisposing factors:

- Allergy: it is commonly ascertained even if there are no clinical trials to differentiate

between the treatment of CRS in patients with or without allergy.

- Anatomical variations: they differentiate into changes that can alter the
osteomeatal complex and the sphenoethmoidal recess.
• Among the first there are:
Concha bullosa
Paradoxical positioning of the middle turbinate
Haller cells
• Among the latter there are:
Frontal cells type 1-4
Supraorbital cells

Although in several studies are regarded as causal associations they do not seem to
play a key role in the etiopathophysiology.
 EPIDEMIOLOGY
Chronic rhinosinusitis
-Septal deviations : difficult comparison for the classification mode. 2 large reviews:
1. According to Collet, data are contradictory
According to Orlandi, data do not have a statistical power as to establish a clear
association.

It was concluded for an increased prevalence of RS in patients with septal deviation,

although the impact of this anatomical anomaly is limited. The risk is increased by both
the side of the concave curvature from that of convex curvature, suggesting the alteration
of the air flow at the base of the problem.

In 2008, Mladina and others have classified the septal deviations in 7 different types
according to the degree of deformity. The type 7, said "Passali deformity" is associated
with a statistically signifcant greater risk of developing a CRS.
 EPIDEMIOLOGY
Chronic rhinosinusitis

- Alteration of the mucociliary clearance: a reduction in mucociliary clearance is observed

in all patients with CRS; in some cases this is due to the secretion of toxins by some
bacterial strains (P. aeruginosa, H. influenzae, Streptococcus pneumoniae and S. aureus)
with more or less pronounced suppression of ciliary motility.

These toxins also can create a favorable environment for the development of CRS.
 CLINIC AND DIAGNOSTIC CRITERIA
Chronic rhinosinusitis

The symptoms can be divided into 4 categories :

- Nasal (obstruction, discharge, smell alterations)

- Facial (facial pain, sense of pressure, headache)

- Oropharingeal (cough, halitosis, tooth pain + reflex ear pain)

-Systemic (malaise, fatigue)

Diagnosis of CRS in the case of at least 2 symptoms + CRS objectivity (imaging,

endoscopy).
 THERAPY
Chronic rhinosinusitis

Recommended therapies :
• Nasal irrigation
• Topical corticosteroids

Optional therapies :
• Topical corticosteroids with new delivery devices
• Macrolides

Not recommended:
• Other antibiotics
• Antifungals, topical and oral
 THERAPY
Chronic rhinosinusitis

NASAL IRRIGATION

Local topical therapy for prolonged use

It is possible to use isotonic or hypertonic solutions with better administration at high

volumes(>200 ml)

Advantages: low price, safe strategy, clinical, radiological and objective benefits; good
tolerance, absence of adverse systemic effects

Disadvantages : local irritation, epistaxis, headache, nasal burning, rhinorrhea,

contamination from prolonged use of a single vial
 THERAPY
Chronic rhinosinusitis

TOPICAL CORTICOSTEROIDS

Advantages: improve symptoms and objectivity

Disadvantages: epistaxis, headache

synergistic effect when associated with nasal irrigations

ORAL CORTICOSTEROIDS

Given the risk / benefit ratio unfavorable, there are no recommendations in their use as
monotherapy
 THERAPY
Chronic rhinosinusitis

ORAL ANTIBIOTICS, NOT MACROLIDES, < 3 WEEKS

There are no studies that recommend the use in chronic forms

Side effects: GI disorders, infections of the genitourinary tract, skin rash, Clostridium
difficile colitis

ORAL ANTIBIOTICS, NOT MACROLIDES, > 3 WEEKS

Little literature about it

 THERAPY
Chronic rhinosinusitis

ORAL ANTIBIOTICS, MACROLIDES

Good anti-microbial and anti-inflammatory properties

Advantages: reduce symptoms and improve the endoscopic objectivity; valid in the short-
term therapy

Disadvantages: several side effects, such as potential severe cardiovascular complications;

little benefit on symptoms to withdrawal of therapy
 THERAPY
Chronic rhinosinusitis

ANTIFUNGALS

Topical or systemic use (oral or intravenous)

Not recommended due to lack of studies

 EPIDEMIOLOGY
Chronic rhinosinusitis with polyps
Prevalence of CRS with polyposis: 6.3 per 10,000 inhabitants (Danish data).
Finding in the course of autopsy in 26-42% of cases.

Main predisposing factors :

- Allergy: is among the etiological hypotheses. It is strongly associated with response

T-Helper 2 mediated. In addition were isolated in polypoid tissue high levels of IL-5
and IL-13

- Anatomical variations: may contribute to the pathophysiology, even if the degree of

alteration is not directly related to the severity of the disease.

- Mucociliary clearance dysfunction: it has a greater impact in the CRS with polyps
than in the without polyps form.

- ASA: the correlation between the use of aspirin, asthma and polyposis (Samter
triad) is widely studied.
 DIAGNOSTIC CRITERIA AND DIFFERENTIAL DIAGNOSIS
Chronic rhinosinusitis with polyps

The diagnostic criteria are the same of CRS without

polyps, which is of course added the evidence of polyps.

They must be distinguished from the classical form:

- Antrochoanal polyp
- Inverted papilloma
- Cavernous hemangioma
- Schwannoma
- Juvenile angiofibroma
- Squamous cell carcinoma
- Neuroblastoma
- Lymphoma
- Encephalocele

Fundamental in DD are: endoscopy with biopsy for histological examination and imaging.
 THERAPY
Chronic rhinosinusitis

Recommended therapies :
• Nasal irrigations
• Topical and systemic corticosteroids (short therapies)

Optional therapies:
• Macrolides
• Leukotriene antagonists

Not recommended:
• Other antibiotics
• Topical and oral antifungals
 THERAPY
Chronic rhinosinusitis

TOPICAL CORTICOSTEROIDS

Given before or after surgery

Advantages: improvement in symptoms and endoscopic objectivity; reduction in the risk

of recurrence

Disadvantages: epistaxis, nasal irritation, headache

 THERAPY
Chronic rhinosinusitis

ORAL CORTICOSTEROIDS

Subjective and objectivity improvement in the short-term therapy

It is possible to extend the administration up to 8-12 weeks with higher risk of side effects

Side effects: GI disturbances, temporary alteration of hypothalamic-pituitary-adrenal axis,

insomnia, increased bone resorption
 THERAPY
Chronic rhinosinusitis

ORAL ANTIBIOTICS, NOT MACROLIDES, < AND > 3 WEEKS

There are no data favorable to its use in this type of pathology

ORAL ANTIBIOTICS, MACROLIDES

They appear to reduce the risk of post-operative recurrence of polyposis and improve
symptoms resolution
Few data about it, for proper risk / benefit ratio

ANTIFUNGAL

Topical or systemic use (oral or intravenous)

Not recommended due to lack of studies
 THERAPY
Chronic rhinosinusitis

INTRAVENOUS ANTIBIOTICS

Unfavorable risk / benefit ratio

Side effects: thrombophlebitis, neutropenia, DVT, rising liver enzymes, rash, bleeding

Useful in patients with systemic complications

TOPICAL ANTIBIOTICS

Not recommended for variations in concentration, for local side effects and the possibility
of developing bacterial resistance
 THERAPY
Chronic rhinosinusitis

LEUKOTRIENE ANTAGONISTS

Montelukast may be a valid alternative to the different types of topical corticosteroids

Improve symptoms resolution in patients unresponsive or intolerant to topical

corticosteroids

TERAPIE TOPICHE ALTERNATIVE

Surfactants, xylitol, colloidal silver: not indicated for this type of pathologies
 RHINO-SINUS SURGERY
Surgery is indicated in case of failure of the MMT (maximal medical therapy); It is very
uncommon a surgical therapy without first an appropriate medical therapy.
 RHINO-SINUS SURGERY

Endoscopic sinus surgery is the gold standard in the absence of response to medical
treatment.

The fundamentals are pre-operative medical treatments, which are not intended to treat
CRS, but to create the best possible conditions to perform surgery.

Many studies on the administration of preoperative topical corticosteroids have shown a

reduction of intraoperative bleeding, reduced surgical time and a better surgical field.

Many studies describe a pre-operative antibiotic therapy with improvement in symptoms

but no evidence of changes in operating conditions. There is no significant difference in
the effect of various types of antibiotics used.
 COROLLARY TO SURGICAL TECNIQUE

The septoplasty can be performed as additional procedure in patients undergoing

ESS, especially to improve the surgical field when there are major septal deviations.

Removal or preservation of the middle turbinate is debated, given its role in

humidification, in heating and directionality of air flows. If the turbinoplasty is done
correctly, there are no differences on either the ostiomeatal complex remote
condition and on the possible formation of synechiae

There are various types of post-operative nasal packing, although it is not

considered essential in most cases.
 POSSIBLE SURGICAL COMPLICATIONS

In experienced hands they are unlikely; between these :

- Fistula rhino-CSF
- Orbital hematoma
- Profuse bleeding
- Orbital penetration
- Meningitis
- Venous thrombosis
- Permanent or temporary blindness
- Diplopia

The most frequent factors related to complications are:

- Age
- Revision surgery
- Anatomical variations
- Poor operator experience.