CPG RHINOSINUSITIS

Dr Farid
 Rhinosinusitis  is characterized by mucosal
inflammation of the nose and paranasal sinuses.

INTRODUCTION Rhinosinusitis (RS) is a common health problem

characterised by mucosal inflammation of the
paranasal sinuses.

Although it is a common illness, RS presents a

number of diagnostic and management challenges to
the practicing clinician.
 CLASSIFICATION OF RHINOSINUSITIS
RS can be divided into 2 subtypes based on the duration of the symptoms:
○ Acute
○ Chronic

● The clinical presentation includes nasal obstruction, rhinorrhea,

headache, decreased sense of smell, postnasal drip, facial
pressure or pain, fever, sore throat and cough. Predisposing
factors for RS are multifactorial, which includes infection, allergies,
and air pollution.
EPI common disease worldwide with a reported prevalence
rate ranging from 6 - 15%.
DE
MI prevalence rate of CRS, in Europe, United States of
OL America and Brazil is between 5 - 15%.

OG in the Asian region the prevalence rate reported in

Korea, China and Singapore are 7%, 8% and 2.7%
Y respectively.
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
 PREDISPOSING/RISK FACTORS
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
 DIAGNOSIS: HISTORY
● Inflammation of the nose and the paranasal
sinuses characterised by two or more symptoms,

– Nasal obstruction/ blockage/ congestion

– Nasal discharge (anterior / posterior nasal drip)

+/- Facial pain / pressure

+/- Reduction or loss of smell
 AND AT LEAST ONE OF THE FOLLOWING:

● Endoscopic signs of :
–nasal polyps
–mucopurulent discharge
–mucosal oedema

CT changes – mucosal changes within the ostiomeatal complex and/or

● sinuses

Past history of Chronic Rhinosinusitis (medically diagnosed)

 DEFINITION
IN ARS IN CRS
The duration is <12 The duration is ≥12
weeks with complete weeks without
resolution of complete resolution of
symptoms. symptoms.
DEFINITION OF ARS
RECURRENT ACUTE RHINOSINUSITIS (RARS)

 ARS can occur once or more than once in a defined time period

 usually expressed as episodes/year but with complete resolution of

symptoms between episodes

 defined as ≥ 4 episodes per year with symptom free intervals

SEVERITY OF
DISEASE
VAS (Visual analogue scale )– This is used for assessing
discrete symptoms. The patients can mark on a line the severity
of symptoms. A scale of 5 has been known to affect the quality
of life of the patient.

• Nasal block/ smell/ sneezing/ rhinorhoea/ PND

Classify CRS into mild, moderate and severe disease

• mild = 0 - 3
• moderate = >3 - 7
• severe = >7 - 10
 ACUTE BACTERIAL RHINOSINUSITIS (ABRS)
• Majority of ARS cases are viral in origin with only 0.5 - 2.0% complicated by bacterial
infection

• Difficult to differentiate whether RS is bacterial or viral in origin -> may lead to unnecessary
antibiotic use and increase the incidence of antibiotic resistance.

Main pathogens:
• Streptococcus pneumoniae
• Haemophilus influenzae
• Moraxella catarrhalis [more common in children]
• Anaerobic organisms are predominant in ABRS with dental origin
 AT LEAST three symptoms / signs

– unilateral dicoloured discharge, purulent, greenish

or brownish nasal discharge

ACUTE BACTERIAL – unilateral severe facial pain

RHINOSINUSITIS
(ABRS)
– fever (> 38∘ C)

– elevated ESR or CRP

– deterioration of symptoms and signs

 CLASSIFICATION OF CRS

CRS with nasal polyps (CRSwNP)

- bilateral, endoscopically visualised
polyps in middle meatus

CRS without nasal polyps (CRSsNP)

- no visible polyps in middle meatus
 IN CRS, THE MOST
COMMONLY
INVOLVED
ORGANISMS ARE

• Staphylococcus aureus
• Enterobacteriaceae spp
• Pseudomonas spp

*Bacteriology is different from ABRS

 INTRINSIC CAUSES OF CRS
1. Genetic --- Mucocilliary abnormality (Cystic fibrosis, Primary ciliary dyskinesia)/
structure/ immunodeficiency

2. Acquired --- aspirin hypersensitivity (Samter triad - nasal polyposis, aspirin

sensitivity, and asthma) / autonomic dysregulation/ hormonal (Rhinitis of
pregnancy, Hypothyroidism)

3. Structural --- Neoplasms/ Osteoneogenesis & outflow obstruction/ Retention cysts

and antrochoanal polyps

4. Autoimmune or idiopathic --- Granulomatous disorders/ Sarcoidosis/ Wegener

Granulomatosus/ Vasculitis (Systemic Lupus Erythematosus, Churg-Strauss
syndrome)
 EXTRINSIC CAUSES OF CRS
1. Infectious
• viral
• bacterial - S pneumoniae, H influenzae,M catarrhalis,
• fungal - Aspergillus species, Cryptococcus neoformans, Candida species,
Sporothrix schenckii, Alternaria species
• Parasitic

2. Noninfectious/Inflammation --- Allergic-IgE mediated/ Non-IgE mediated

hypersensitivities/ Pharmacologic/ Irritants

3. Disruption of normal ventilation or mucociliary drainage --- Surgery/ Infection/

Trauma
 HISTORY TAKING
• Nasal obstruction – unilateral, bilateral, constant,
• Discharge –ant or post, purulent, foul smelling, color
• Facial pain/swelling - laterality, nature of pain, locality
• Changes in sense of taste and smell – hyposmia/cacosmia
• Persistent postnasal drip
• Headache - frontal area
• Cough worse when the patient lies down at night.
• Fever
• Halitosis, fever, malaise, sore throat
• Dental pain / recent procedure (upper teeth)
• Orbital sx
• Neurological sx
[Onset / Duration – sx less thn 10days,>10daysbut < 4 weeks or > 3months / Exacerbating
and relieving factors / How may times you had similar sx for past 1 year??? ]
 Children with acute sinusitis may be irritable and
experience vomiting, presumably after gagging on
thick mucous drainage, or prolonged coughing.

Snoring and coughing due to associated postnasal

drip. Halitosis. Nasal obstruction with mouth breathing
• Past Medical/Surgeries/ Hospital admission hx

• Predisposing factors – smoking, AR, immunodeficiency (DM, cancer, HIV,

Organ Transplantation Or using Systemic Steroid) and known anatomic
abnormalities (DNS, nasal polyposis, any previous surgery), foreign body
insertion

• Patients with a history of nasal polyposis should be asked about

allergies to aspirin or NSAID (significant relationship between aspirin or
NSAID allergy, nasal polyposis, and asthma) => termed "Samter's triad" /
"triad asthma"). Defects in mucociliary clearance - Kartagener syndrome,
Cystic fibrosis IgA deticiencq, Ciliary dysmotility ,Idiopathic

Social hx – household pets, smoking

Allergies hx, Medication hx, Family hx – asthma, OSA, nasal polyps
 PHYSICAL EXAMINATION
• Full head and neck examination (lymphadenopathy)

• Sinus palpation is performed to evaluate facial tenderness or

swelling

• Oral cavity / oropharynx : integrity of the palate and dentition

and to look for evidence of postnasal drip. Oropharyngeal
erythema and purulent secretions may be noted. Dental caries
may be present.
 PHYSICAL EXAMINATION
Orbital symptoms
– Visual changes
– Extraocular motion abnormal
– Proptosis
– Periorbital inflammation/soft tissue edema
– Periorbital erythema/cellulitis

Intracranial, central nervous system complications

– Altered mental status
– New changes in neurologic exam
– Meningeal signs (stiff neck with inability to chin tuck, persistent vomiting and severe
headache)
ANTERIOR RHINOSCOPY

- CAN BE PERFORMED WITH A SIMPLE OTOSCOPE/ THUDICUM SPECULUM

- HYPEREMIA AND SWELLING OF THE INFERIOR TURBINATES, SEPTUM DEFORMITIES,
PURULENT SECRETIONS FROM THE SINUSES (MIDDLE MEATUS), MUCOSAL OEDEMA
AND POLYPS
- LIMITED VALUE IN DIAGNOSING CRS

Nasal Endoscopy

- Flexible or rigid nasal endoscopy

- visualization of the sinus ostia and assessment of purulent discharge from the sinuses.
- evaluate middle meatus and ostiomeatal complex, posterior nasal structures,
nasopharynx
• Nasal mucosal erythema, edema
• Purulent secretions within the middle meatus
• Nasal obstruction due to deviated nasal septum or hypertrophied turbinates
• Nasal polyps
 IMAGING
Plain radiography has no role in the routine management of rhinosinusitis.

CT scan is the gold standard for radiographic evaluation of the paranasal sinuses

Indications for CT scan in RS

• failed medical therapy
• planned for surgery (Evaluation of anatomy )
• atypical or severe disease, i.e. unilateral symptoms, blood-stained discharge,
displacement of the eye and severe pain
• Evaluation of chronic refractory sinusitis, complications of sinusitis and suspected
malignancy

• MRI – intracranial complications are suspected

 LABORATORY TESTS
• Laboratory culture and antibiotic susceptibility (C&S)

• Patients who do not respond to first- and second-line antibiotics -> sinus or meatal culture for
pathogen-specific therapy is recommended

• Bacterial cultures in CRS should be performed either via endoscopic culture of the middle meatus or
maxillary tap but not by simple nasal swab -little predictive value in diagnosing (intrinsic bacterial
flora that normally resides in the nasal cavity)

• Endoscopically-directed middle meatal culture (EDMMC) – less invasive

• Maxillary Sinus Taps (MST) for sinus puncture and aspiration – gold standard, rare, due to invasive.
 COMPLICATIONS OF SINUSITIS

ACUTE CHRONIC

Local (DOBI)
• Dental --- abscess • Mucocele
• Orbital • Pyocele
• Bony • Descending infection
• Intracranial
OM
General
Pharyngitis & tonsillitis
• Toxic shock syndrome Persistent laryngitis
 ORBITAL
COMPLICATIONS

• Usually secondary to ethmoid sinusitis esp in young

adult/ children
• In adult, CRS is common cause

Chandler’s classification
I – preseptal cellulitis
II – orbital cellulitis
III – subperiosteal abscess
IV – orbital abscess
V – cavernous sinus thrombosis
Subperiosteal abscess
- Abscess between periorbita & sinus wall (extraconal)
- Decrease vision , Ophthalmoplegia, Proptosis
- CT scan of sinus with contrast, coronal cut showing left subperiosteal medial and superior abscesses
( arrow ). FIRST PIC
• CT scan of sinus with contrast, axial cut showing a right medial subperiosteal abscess. SECOND PIC
 Orbital abscess
• Abscess within space defined by ocular muscles (intraconal)
- rapid, acute deterioration of vision, ophthalmoplegia and proptosis
- Severe pain
- Cranial nerve involvement (sup orbital syn, orbital apex syn)

Cavernous sinus thrombosis

• Development of bilateral ocular signs is the classic feature of patients belonging to
this group.
• These patients classically manifest with fever, headache, photophobia, proptosis,
ophthalmoplegia and loss of vision.
• Cranial nerve palsies involving III, IV, VI, V1, and V2 are common.
• First ocular sign: color blindness (red-green; blue- yellow)
 Intracranial Complications Bony complication
• Less common due to antibiotics (3.7- • Pott’s puffy tumor
10%)
- Osteomyelitis of frontal bone
• Co-exist with orbital cx
- Edematous swelling of soft tissue
• Mortality 15-43%
overlying the infected frontal bone
- Doughy, fluctuant, swelling over
Complications the forehead
• Meningitis
• Encephalitis
• Cavernous sinus thrombosis
• Extra-dural abscess
• Subdural abscess
• intracranial abscess
MANAGEMENT OF RS

Medical therapy

 Surgery
 ARS CRS

Antibiotic  Amoxicillin  Macrolides have been prescribed for longer

500 mg 8-hourly for five to terms -> for its anti-inflammatory
seven days properties

 Amoxicillin/clavulanate  Azithromycin, clarithromycin and

625 mg 8-hourly for five to erythromycin at low doses (insufficient
seven days strong evidence)

 Cefuroxime axetil  Antibiotics should not be used routinely in

250 - 500 mg PO q12hr x 5 - 10 days chronic rhinosinusitis.

 Clarithromycin 250 - 500 mg PO

q12hr x 7 - 14 days

 Ciprofloxacin (Use with caution)

500 - 750 mg PO q12hr x 7 - 14 days

Duration : 3 to 7 days, *efficacious as a

longer one (six to 10 days)
 ARS
INTRANASAL  Mometasone furoate
CORTICOSTEROIDS 50 mcg/ dose
aqueous nasal spray
- 2 sprays in each nostril twice
daily (total 400 mcg/day)
Duration : 14 – 21 Days
CRS
 Nasal polyposis
- 2 sprays in each nostril twice daily
(total 400 mcg/day), reduced to 2
sprays each nostril once daily
when symptoms are adequately
controlled
Duration : 16 and 52 weeks ->
reduction in polyp size, improvement
of symptoms
 ARS CRS

ORAL CORTICOSTEROIDS  Tab Prednisolone 30 mg/day for -Short-term oral steroids (25mg/day
seven days for two weeks)

 Not to give in ABRS ->  Reduction of nasal polyp size and

exacerbation hyposmia

 Caused transient suppression of

adrenal function and increase bone
turnover

 Short-term oral corticosteroids

should ONLY be given in chronic
rhinosinusitis at
Otorhinolaryngology centre.
 ARS CRS

Nasal Saline Irrigation  facilitates mechanical removal of mucus, infective agents and
inflammatory mediators

 It also decreases crusting in the nasal cavity and increases mucociliary

clearance
Anti-histamine  should be prescribed in rhinosinusitis with associated symptoms
suggestive of allergic rhinitis
(sneezing, nasal itchiness, nasal obstruction and rhinorhoea)
Analgesics  paracetamol or non-steroidal anti-inflammatory drugs
 symptomatic relief
Decongestants  MCC improves significantly with Oxymetazoline after 20 minutes
 symptomatic relief in VRS but however, their ability to prevent ABRS is
unproven
 Topical decongestants should not be prescribed for more than two
weeks due to rebound phenomenon
 Oral decongestants should be cautiously prescribed (diabetes mellitus,
cardiovascular diseases, glaucoma and benign prostate hyperplasia)

Mucolytics & Antiviral Agents no evidence to support the use in RS

 SURGICAL INTERVENTIONS
Functional endoscopic sinus surgery (FESS)
• most common surgical treatment in CRS
• less invasive , minimal postoperative discomfort
• Aim to enlarge the drainage pathways resulting in improvement of ventilation
and restoration of nasal cavity and paranasal sinuses physiological function.
• More beneficial for patients with CRSwNP, reduces nasal obstruction, loss of
smell and polyp size , postnasal drip and headache compared with medical
treatment
• A CT scan before FESS is mandatory to identify the patient's ethmoid anatomy
and its relationship to the skull base and orbit.
 INDICATIONS FOR SURGERY

• Rhinosinusitis causing intracranial / intraorbital complications (ARS)

• Continued chronic and/or recurrent sinusitis despite appropriate medical (CRS)

• Nasal polyps causing obstruction of most or all of nasal lumen

• Recurrent sinusitis secondary to nasal polyposis

• Correction of anatomic variations predisposing to chronic and/or recurrent rhinosinusitis

• Sinus mucocele or pyocele

• Fungal rhinosinusitis
 INDICATIONS FOR REFERRAL - ARS

EARLY ~ Within 2 weeks URGENT ~ Within 24 hours

• persistent symptoms despite optimal • periorbital edema/erythema

therapy • displaced globe
• frequent recurrence (≥4 per year) • double vision
• restricted eye movement
• suspected malignancy
• reduced vision
• immunodeficiency • severe frontal headache
• forehead swelling
• neurological manifestation
• septicaemia
 INDICATIONS FOR REFERRAL -
CRS
EARLY ~ Within 2 weeks URGENT ~ Within 24 hours

• failed a course of optimal medical therapy
• >3 sinus infection per year
• suspected fungal infections, granulomatous
disease or malignancy
• immunodeficiency
• Severe pain or swelling of the sinus areas
(lower threshold for immunocompromised
patients e.g. uncontrolled diabetes, end
stage renal failure, HIV)
 KEY RECOMMENDATIONS
1. Anterior rhinoscopy should be performed as part of clinical assessment of suspected acute
rhinosinusitis in primary care setting.

2. Nasal endoscopy should be performed to diagnose rhinosinusitis at otorhinolaringology centre.

3. Nasal swab should not be performed in rhinosinusitis.

4. In otorhinolaryngology centres, culture and susceptibility test may be considered in patients

who do not respond to antibiotic treatment after 72 hours in acute rhinosinusitis.

5. Endoscopically-directed middle meatal culture may be used to obtain specimen for culture and
susceptibility tests in diagnosing unresolved bacterial rhinosinusitis by otorhinolaryngologists
 KEY RECOMMENDATIONS
6. Antibiotic may be prescribed in acute bacterial rhinosinusitis after weighing benefits against
potential side effects.
- Antibiotic should not be used routinely in chronic rhinosinusitis.

7. Intranasal corticosteroids:
- should be considered for 2 - 3 weeks in acute rhinosinusitis
- should be given for 16 - 52 weeks in chronic rhinosinusitis

8. Saline irrigation should be used as an adjunct therapy in patients with rhinosinusitis.

9. Surgery should be considered in acute rhinosinusitis with orbital or intracranial complications.