Management of the Patient with Rhinosinusitis

Published on 18/02/2015 by admin

Filed under Allergy and Immunology

Last modified 22/04/2025

Print this page

This article have been viewed 2349 times

Chapter 4 Management of the Patient with Rhinosinusitis

JOHN H. KROUSE, MD, PHD

Introduction

Rhinosinusitis is one of the most common and prevalent illnesses throughout the world. Both acute and chronic forms of rhinosinusitis (RS) have been described, and affect patients of all ages. By a variety of reports, the incidence of RS is increasing, and the number of patients diagnosed around the world with RS continues to climb.¹ Allergy plays a role in the pathogenesis and expression of symptoms among patients with both acute and chronic RS, although the precise relationship between atopy and the presence of sinus disease can be difficult to define. Due to the heterogeneity seen in acute and chronic RS, consensus panels have been convened to provide clarity to the diagnosis of these common conditions, and to develop guidelines for further research and optimal treatment. This chapter will discuss the various types of RS, diagnostic strategies, and treatment options for both acute and chronic rhinosinusitis.

Prevalence and Burden of Rhinosinusitis

From a variety of sources, it has been noted that RS is increasing in prevalence. In the USA alone it is estimated to affect as many as 31 million patients on an annual basis.² It accounts for billions of dollars in expenditure, with significant increases in direct and indirect costs noted over a several year period.³ In addition, 15% of the US population is symptomatic from sinusitis for a period of at least 3 months annually.⁴

While most adults will experience between two and four acute upper respiratory infections annually, less than 2% of these episodes are due to acute bacterial rhinosinusitis (ABRS).⁵ By calculation, there would therefore be an expected 20000000 cases of ABRS in the USA alone on a yearly basis. RS was estimated to account for 9% of pediatric and 21% of adult prescriptions in the USA annually,⁶ with over $3.5 billion USD spent in 1999 funds for the treatment of ABRS alone.⁷

Two recent studies have examined the burden of chronic rhinosinusitis (CRS) on both patient impact and financial cost. Bhattacharyya followed 322 patients with CRS prospectively over a 1-year period.⁸ During that 1-year period, patients received an average of 2.7 courses of oral antibiotics, and used nasal steroids for over 18 weeks. In addition, patients missed an average of 4.8 days of work related to CRS and had mean medical expenses of US$921. In a second study by Murphy et al, over 200 000 patients in a health maintenance organization (HMO) were surveyed during the 1-year period 1994.⁹ Approximately 10% of patients in the HMO were identified with diagnoses of CRS during this one year. Among this patient group, CRS was responsible for an average of 2.0 office visits and 5.1 pharmacy fills per patient during 1994. Extrapolating to the general US population, this study estimated the overall direct cost of CRS in 1994 to be US$4.3 billion.

In addition to the clear economic burden of both acute and chronic RS, both of these diseases exert significant impact on patient symptoms and quality of life. Gliklich and Metson assessed this impact, and noted that RS is associated with a more negative quality of life than other common medical diseases such as chronic obstructive pulmonary disease and lower back pain.¹⁰

Definition of Rhinosinusitis

The term that is currently accepted by the majority of specialists who manage patients with acute and chronic illnesses affecting the paranasal sinuses is rhinosinusitis. While there is still some debate regarding the use of this term, and while there are individuals who prefer the older term sinusitis, rhinosinusitis is the accepted term agreed to by a consensus group of American medical societies, including the American Academy of Allergy, Asthma and Immunology (AAAAI), the American Academy of Otolaryngic Allergy (AAOA), the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS), the American College of Allergy, Asthma and Immunology (ACAAI), and the American Rhinologic Society (ARS).¹¹ The choice of the term rhinosinusitis implies that the physiological condition of the sinuses correlates closely with the concurrent condition of the nose. Nasal disease, i.e. rhinitis, usually precedes the development of sinus disease, and sinusitis is rare without rhinitis.^1,^11,¹² Given the contiguity of the nasal and sinus mucosa and the interdependency of the nose and sinuses, the term rhinosinusitis (RS) appears to be a more representative name for this process, and will be used in the current chapter.

In 1996, a task force of the AAO-HNS reviewed the current state of knowledge in RS, and drafted a definition statement based upon this expert panel. They defined RS as “a condition manifested by an inflammatory response involving the following: the mucous membranes (possibly including the neuroepithelium) of the nasal cavity and the paranasal sinuses, fluids within these cavities, and/or underlying bone.”¹ The key message implied from this definition is that RS is primarily an inflammatory disease, not an infectious disease. Infection is only one type of pathophysiological process that can affect the sinuses. In addition, recognizing the close relationship between the nose and sinuses, a conjoint conference involving the American allergy/immunology and otolaryngology communities concluded that “rhinosinusitis may be a more appropriate term than either rhinitis or sinusitis alone.”¹² Similar definitions have been applied by the European allergy and otolaryngology communities.¹³

In 2003, the Sinus and Allergy Health Partnership (SAHP), a conjoint society made up of representatives from the AAOA, the AAO-HNS, and the ARS, also met to consider the knowledge base around RS, and drafted a similar definition to that offered in 1996. The SAHP defined RS as “a group of disorders characterized by inflammation of the mucosa of the nose and the paranasal sinuses.”¹⁴ The 2004 consensus panel decided to “endorse and adopt” this definition for framing future research strategies and diagnostic and treatment methodologies.¹¹ The members of this panel recognized that inflammatory processes simultaneously affect the nose and sinuses, and that the term rhinosinusitis best describes this concurrent process.

Classification of Rhinosinusitis

It is clear that RS represents a spectrum of diseases rather than a single pathological entity. There are numerous potential sources of inflammation that can target the mucosa of the nose and paranasal sinuses. In addition to the various types of pathophysiological mechanisms that appear to be active in RS, the temporal sequence of symptoms and the degree of chronicity of the process are important factors in determining the nature of the RS and the best method of approaching its treatment.

▪ RS: 1997 Consensus

In the 1997 system, the diagnosis of RS was based purely on patient symptoms. These symptoms were broken down into major and minor factors that were associated with the presence of RS. These major and minor factors are noted in Box 4.1. It is important to note that headache or facial pain are not sufficient symptoms for the diagnosis of RS in the absence of other major or minor factors, primarily nasal in origin. These criteria are useful in assisting the clinician in the consideration of the diagnosis of acute or chronic RS, but do not require the presence of confirmatory findings on either physical examination or radiological imaging to apply a diagnosis. This lack of confirmation was felt to be a weakness in the 1997 document.

The 1997 task force also described the temporal course of RS and divided RS further into five categories, three primary categories: acute rhinosinusitis, recurrent acute rhinosinusitis, and chronic rhinosinusitis; and two derivative categories: subacute rhinosinusitis and acute exacerbations of chronic rhinosinusitis. The three primary groupings are often used to delineate the time course of RS in individual patients and to assist in the development of appropriate treatment modalities (Figure 4.1).

Figure 4.1 Temporal course of rhinosinusitis: acute, recurrent acute, and chronic.

(Adapted with permission from Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997;117:S1–S7.)

Acute Rhinosinusitis

Acute rhinosinusitis (ARS) is a very common condition, and generally has a sudden onset of symptoms, often following a viral upper respiratory infection. It is defined as lasting from 1 day to 4 weeks. It is important to distinguish between a viral upper respiratory infection, which is very common, and an acute bacterial rhinosinusitis. The most robust method of distinguishing these two conditions is the temporal course of the illness. Viral symptoms generally peak within 3 or 4 days of onset and then decline in severity. By contrast, acute bacterial RS generally worsens after 5 days and persists longer than 10 days.¹⁵ In addition, certain physical signs are suggestive of a diagnosis of acute bacterial RS. Facial erythema or swelling are associated with bacterial disease, although they are uncommon. Maxillary tooth pain is correlated well with the presence of bacterial disease, and when accompanied with fever often confirms the presence of acute bacterial RS.¹⁶

Recurrent Acute Rhinosinusitis

Many patients may experience episodes of acute bacterial RS that last 7–10 days and respond rapidly to treatment, yet seem to have frequent recurrent episodes with a similar pattern. Between symptomatic episodes, these patients may be clear of any symptoms of nasal or sinus disease. The frequent recurrent nature of these episodes suggests a separate categorization of disease, which has been called recurrent acute RS. While there are not strict criteria for the diagnosis of this process, some authors have suggested that patients should experience at least four episodes of acute RS within a year, and that intervening periods without symptoms should be at least 8 weeks.^1,¹⁷ It is not clear whether recurrent acute RS is a distinct pathophysiological entity, reflecting a unique underlying process, or if it simply reflects random variation in the frequency of disease.

Chronic Rhinosinusitis

Chronic rhinosinusitis (CRS) is in many ways a distinct pathophysiological process that reflects the chronic inflammatory nature of the disease. It is not simply acute disease that has not resolved or has progressed into chronic disease. From a temporal standpoint, CRS is generally classified as persistent sinonasal symptoms for at least 12 weeks,^11,¹⁸ although some systems suggest that 8 weeks may be adequate to classify the disease as CRS.¹⁹ CRS likely has numerous mechanisms involved in its pathogenesis, and is probably best considered as a syndrome rather than a unique pathophysiological entity. Recent classification systems make clear distinctions between CRS with the presence of nasal polyps (CRSwNP) and CRS without the presence of nasal polyps (CRSsNP).^11,¹³

▪ RS: 2004 Consensus

The 2004 consensus document broadens the criteria necessary for the diagnosis of RS. While the document is designed to promulgate diagnostic criteria for research studies and clinical trials, it is practical to include some element of objective evidence into diagnostic practices when managing the patient with presumed RS. This document sets out specific criteria for the diagnosis of various forms of RS based on patient symptoms, the pattern of those symptoms, and the presence of objective documentation. It describes specific definitions for patient care. These consensus criteria are noted in Table 4.1.

TABLE 4.1 Rhinosinusitis consensus definitions for patient care. (Source: Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing definitions for clinical research and patient care. Otolaryngol Head Neck Surg 2004;131:S1–S62)

The 2004 criteria categorize RS into four distinct categories. These categories each have individual diagnostic criteria and definitions.

Anatomy of the Paranasal Sinuses

The sinuses are paired air-containing cavities present within the bony framework of the face. There are four sets of sinuses on each side of the face: ethmoid, maxillary, frontal, and sphenoid. These chambers connect to the nasal cavity through small ostia and recesses. Normal health of the sinuses depends on their unimpeded ventilation through these ostia, so that airflow can occur into the sinuses and mucus can be cleared from the sinuses into the nose. For that reason, normal configuration and patency of the sinus ostia is a critical factor in the likelihood of the sinuses to become diseased.

The ethmoid and maxillary sinuses can be seen in rudimentary form even in fetal life. The ethmoid and maxillary sinuses are the first sinuses to develop, and are visible on radiographic studies in early childhood. The frontal and sphenoid sinuses, however, do not develop significantly until later childhood, reaching their maximum dimension in adolescence or early adulthood. For that reason, ethmoid sinus disease is seen in young children while frontal and sphenoid sinusitis are noted only much later in life.

Ethmoid Sinuses

The ethmoid bones form the structure for much of the nose and the superior sinuses. They are paired bones bounded in the midline by the perpendicular plate. The superior border of the ethmoid bones is the anterior skull base, and the lateral border is the lamina papyrecea, a thin bony plate that separates the ethmoid sinuses from the orbits. The lamina papyrecea forms a barrier between the ethmoid sinuses and the eyes bilaterally. It is very thin and infection in the ethmoid sinuses can extend into the orbits through this thin bone, resulting in orbital cellulitis or abscess formation.

The anatomy of the ethmoid sinuses is variable. They can be best viewed as a group of discrete cells separated into anatomic regions by a series of bony partitions. These cells can be grouped into two units: the anterior ethmoid cells, which are numerous and smaller in size, and the posterior ethmoid cells, which are less numerous and larger.

The anterior ethmoid cells are contiguous with the nose through an important anatomic region known as the ostiomeatal complex. This area is of primary importance in the normal functioning of the anterior paranasal sinuses. When the ostiomeatal complex is narrowed or occluded, the ethmoid sinuses can easily become diseased, resulting in a higher incidence of acute and chronic rhinosinusitis. The posterior ethmoid sinuses communicate with the nose more posteriorly, and an area known as the sphenoethmoidal recess.

Maxillary Sinuses

The maxillary bones are paired bilaterally and form the mid portion of the anterior face. The nasal cavity opens into the maxillary bone bilaterally at the level of the nostrils. In addition, the orbital processes of the maxillary sinuses make up a portion of the orbital floor.

Contained within the maxillary bones are the maxillary sinuses. These sinuses are the largest of the four sets of sinuses, and are surrounded by bony walls. The maxillary sinus communicates with the nose through an opening in the lateral wall known as the maxillary ostium. The ostium is located on the medial wall of the maxillary sinus, toward its superior border.

Sphenoid Sinuses

Housed within the sphenoid bone in the center of the skull are the paired bilateral sphenoid sinuses. As noted with the posterior ethmoid sinuses, these sinuses also communicate with the nasal cavity bilaterally in the sphenoethmoidal recesses. The ostium of the sphenoid sinus is located in the superior portion of the anterior wall of the sphenoid bone.

Frontal Sinuses

The superior portion of the face is composed of the frontal bone, which forms the contour of the forehead as well as the anterior wall of the cranium. Within this bone the frontal sinuses develop as bilateral pneumatized spaces. The frontal sinuses are of variable size, and are absent in up to 10% of patients. The ostia of the frontal sinuses are found inferiorly, and communicate with the nose through a funnel-shaped channel known as the frontal recess.

Facial trauma can significantly affect the bony framework of the sinuses and interfere with normal ostial patency. Facial fractures can alter the dimensions of the sinuses and can lead to increased status of mucus due to this ostial occlusion. Long-term effects of trauma can be seen through the development of expansile cystic masses known as mucoceles secondary to rests of epithelium that do not communicate adequately with the nose.

The sinus chambers are lined with a ciliated pseudostratified columnar respiratory-type epithelium. This mucosa is similar histologically to that seen in the nose and the lower respiratory tract (Figure 4.2). This histological similarity is one reason that inflammatory respiratory diseases commonly affect more than one portion of the respiratory tract simultaneously. This epithelium secretes mucus, which is swept from the interior of the sinuses to the ostia and into the nose by fine cilia on the surface of the mucosal cells. This mucus blanket traps particles in the nose and sinuses, and transports these particles posteriorly into the nasopharynx, where they then can be swallowed. Particulate matter that can affect the nasal and sinus mucosa includes bacteria, viruses, irritants, and allergens.

Figure 4.2 Appearance of the normal respiratory epithelium of the nose and paranasal sinuses.

(Reproduced with permission from Minshall E, Ghaffar O, Cameron L, et al. Assessment by nasal biopsy of long-term use of mometasone furoate aqueous nasal spray in the treatment of perennial rhinitis. Otolaryngol Head Neck Surg 1998;118:648–654.)

Physiology of the Sinuses in Health and Disease

In healthy sinuses, mucus is secreted by goblet cells within the epithelium and transported to the ostia of the sinuses for clearance into the nose. This process for the transport of mucus within the nose and sinuses is known as mucociliary clearance. Through active action of the cilia, mucus is easily moved from the periphery of the sinuses toward the ostia. This mucociliary clearance is generally rapid and efficient, and prevents the accumulation of mucus and particulate debris within the sinus chambers. It is essential for normal sinus health and function (Figure 4.3). Mucociliary clearance patterns within the sinuses are genetically directed to maintain the flow of mucus from the sinuses through the sinus ostium and into the nose itself.²⁰

Figure 4.3 The sinuses in health and disease. The left side of the illustration demonstrates the normal state, with ventilated sinuses and freedom from edema and obstruction. The right side of the illustration demonstrates acute rhinosinusitis, with mucosal edema, ostial obstruction, and retention of mucopurulent secretions in the maxillary antrum.

By contrast, when normal mucociliary clearance is inhibited, either through local physiological changes or through anatomic obstruction, the sinuses become diseased. It is clear that ventilation of the sinuses and drainage of mucus out of the sinuses maintains the normal physiology of the sinuses. Disruptions to this normal ventilation and drainage is a central factor in the pathogenesis of acute and chronic rhinosinusitis.²¹ Many factors can adversely influence the clearance of mucus from the sinuses, and thereby result in acute and chronic changes. Mucociliary clearance can be directly affected by ciliostatic agents, such as tobacco smoke and viral infections. Both irritants such as smoke and viral disease disrupt the cilial layer in the sinuses, resulting in cilial loss and impaired cilial motility. With impairment of the normal clearance mechanisms of the sinus mucosa, mucus stasis occurs and bacterial colonization can begin. As bacteria colonize the sinuses, they can proliferate within the mucus layer and can cause localized acute inflammation. This inflammation will cause tissue edema and ostiomeatal narrowing, which can result in additional injury to the mucosa. In addition, any structural obstruction to the ostia or significant decrease in their diameter will further impair mucociliary clearance and lead to increased bacterial growth. In response to the increased presence of bacteria, normal host mechanisms will recruit neutrophils and other inflammatory cells into the sinuses, resulting in increased local inflammation and secondary injury to the mucosa. An illustration of this inflammatory cycle is displayed in Figure 4.4.

Figure 4.4 The cycle of respiratory injury in rhinosinusitis. Numerous interactive factors contribute to the development of acute and chronic sinus disease.

The consequence of this cyclical inflammation is the creation of conditions that support the development of both acute and chronic rhinosinusitis. As also demonstrated in Figure 4.3, in contrast to the normal physiology of the healthy sinuses, in diseased sinuses conditions exist that favor the proliferation of bacteria and the development of symptoms. In diseased sinuses pressure is created from tissue edema, resulting in contact between the mucous membranes of the nose, turbinates, and sinuses. This contact stimulates nerve fibers resulting in localized pain. In addition, bacteria multiply within the chambers of the sinuses, resulting in additional pain as mucosal swelling increases. In addition, fever is common in response to the presence of infection and the host response generated by the infection. It is clear from this model that normal mucociliary clearance is essential in the normal physiological functioning of the sinuses.

Pathophysiology of Acute and Chronic Rhinosinusitis

▪ Acute (Presumed Viral) Rhinosinusitis

Most upper respiratory infections are viral, and are therefore self-limited. These viral infections can be classified as viral rhinosinusitis, but are often referred to as resulting in a common cold. A range of viruses can affect the nose and sinuses, including rhinovirus, adenovirus, and influenza virus. While rhinovirus does not generally cause injury to the nasal epithelium itself, both adenovirus and influenza virus can cause significant mucosal injury.^22,²³ Viral infections of the nose and sinuses cause an upregulation of a variety of acute inflammatory mediators, including bradykinin, histamine, and interleukins 1, 6, and 8. In addition, viral infections trigger a suppression of the normal immune functions of effector cells such as macrophages and neutrophils.²⁴ As a consequence of this immunosuppressive effect, the mucosa of the nose and sinuses is more easily infected secondarily by bacteria following viral infections.

The symptoms of viral rhinosinusitis are triggered by activation of the parasympathetic nervous system and various inflammatory pathways that lead to the symptoms experienced during the common cold: fever, myalgias, rhinorrhea, and pharyngitis. While the more acute symptoms related to viral infections can be resolved within 5 days, some symptoms such as nasal congestion and cough may persist for several weeks following the acute onset of the infection. While most of the acute symptoms of the viral upper respiratory infection will resolve by days 7–10, when symptoms worsen after the first 5–7 days, or when symptoms such as fever and purulent rhinorrhea persist for longer than 7–10 days, the likelihood of the patient having an acute bacterial rhinosinusitis are significantly increased (Figure 4.5).⁵

Figure 4.5 The time course of symptoms in viral rhinosinusitis. Note that while acute symptoms such as fever and sore throat resolve within 7 days, cough and nasal congestion can persist, even in the absence of bacterial infection.

(Reproduced with permission from Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:S1–S45.)

▪ Acute Bacterial Rhinosinusitis

As noted here, persistent or worsening upper respiratory symptoms suggest the diagnosis of acute bacterial rhinosinusitis (ABRS). Patients with ABRS will usually present with symptoms of fever, purulent rhinorrhea, nasal congestion, cough, anosmia, and related aural symptoms such as fullness and blockage. ABRS is a bacterial infection of the nose and paranasal sinus mucosa that often is preceded by a viral upper respiratory infection. As mucociliary clearance mechanisms are disrupted by viral infection and the subsequent immune-mediated events that occur from viral disease, the mucosa of the nose and sinuses is increasingly sensitive to infection by bacterial organisms. Ostial obstruction and ciliary dysfunction lead to bacterial proliferation with acute changes of active bacterial infection.

ABRS generally occurs in adults and children as a result of infections due to one of three organisms: Streptococcus pneumoniae, Haemophilus influenzae, or Moraxella catarrhalis.⁵ The latter organism is primarily seen as a pathogen in children, while the other two organisms can be recovered in patients with ABRS across the lifespan. While the nasopharynx is commonly colonized with these organisms, they do not generally become pathogenic without injury or infection to the normal respiratory epithelium. S. pneumoniae is the most common organism recovered in cases of ABRS, with prevalence rates of 20–43%.⁵ H. influenzae follows this organism closely in frequency of species recovered, with prevalence rates of 22–35%.⁵ By contrast, M. catarrhalis is seen in 2–10% of adults with ABRS, but in 15–20% of children with ABRS.⁵ Other pathogens are less commonly seen, and include other streptococcal species, anaerobic organisms, and Staphylococcus aureus (Figure 4.6).

Figure 4.6 Routine microbiology of acute bacterial rhinosinusitis.

(Adapted from Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:S1–S45.)

Of major concern for the treatment of all pathogenic organisms in ABRS is the emergence of bacterial resistance. Resistance is increasing to most antibiotics worldwide, and can be a significant barrier to successful treatment. Resistance and strategies to approach resistance in ABRS are discussed in the section on treatment.

▪ Chronic Rhinosinusitis

In contrast to ABRS, chronic rhinosinusitis (CRS) is a more variable disease, and is not as well characterized. Issues in precisely defining CRS have limited broad-scale research into this disease, and have impaired understanding of the pathophysiological etiology of this common disease. It is probably best to conceptualize CRS as a syndrome rather than as a distinct pathological entity. This model will allow consideration of the various potential mechanisms that may be active in an individual who presents with symptoms suggestive of CRS (Figure 4.7).

Figure 4.7 The syndrome of chronic rhinosinusitis. Numerous factors can potentially contribute to the etiology of chronic rhinosinusitis. These factors may act synergistically in the development of chronic inflammation in the nose and sinuses.

As noted earlier CRS is generally characterized by rhinorrhea, nasal congestion, nasal obstruction, and pain and pressure within the sinuses that persists for longer than 12 weeks in duration. Histopathologically, CRS is distinguished by basement membrane thickening, submucosal fibrosis and edema, goblet cell hyperplasia, and chronic and persistent inflammation.¹⁴ CRS is associated with partial occlusion and obstruction of the sinus ostia, which leads to stasis of mucus and secondary bacterial colonization. It is also associated with chronic changes to the nasal and sinus mucosa, resulting in chronic hyperplasia and the development of polypoid disease within the nose and sinuses.²⁵

In patients who have both CRS and IgE-mediated inhalant allergy, a cellular infiltrate is seen within the sinuses. This infiltrate is characterized by the presence of eosinophils and both T and B lymphocytes.^26,²⁷ In addition, there is a higher concentration of IL-4, IL-5, and IL-13 in the mucosa of sinuses among patients with both allergic disease and CRS than in normal control subjects.²⁸ The presence of inflammatory chemokines in patients with CRS is associated with the accumulation of inflammatory cells, such as eosinophils, which have often been described as the primary cell involved in the pathogenesis of CRS.^29,³⁰

The subepithelial layer of the sinus mucosa consists of bundles of collagen fibers and ground substance.³¹ With ongoing injury to the mucous membrane of the upper respiratory tract, there is edema of the stroma, resulting in cellular infiltration by eosinophils and other inflammatory cells.³² Eosinophils are activated by a number of mediators in the pathogenesis of CRS, with the release of toxic proteins such as eosinophilic cationic protein (ECP) and major basic protein (MBP).^33,³⁴ These and other cellular mediators trigger significant chronic change in the mucosa of the sinuses.

In another model of CRS, Schubert discusses the role of T-cell-mediated inflammation triggered by nonspecific bacterial exotoxins.³⁵ This model has been described as the superantigen hypothesis, and suggests that bacterial exotoxins may exert immune-mediated mucosal damage through activating inflammation through an alternative pathway. These exotoxins, which have been primarily reported with Staph. aureus, bind to a portion of the alpha chain of the human leukocyte antigen major histocompatibility complex II (HLA-II) molecule, at a separate site from the antigen-specific region of the molecule. T-cell mediators are upregulated, including IL-4, IL-5, IL-13, and interferon gamma (IFN-γ), and progressive inflammation can be triggered. In this superantigen model, persistent stimulation from exotoxins can incite chronic changes in the respiratory mucosa, and may be responsible for diseases such as chronic rhinosinusitis, allergic fungal rhinosinusitis, and asthma. Other researchers have also supported the role of superantigen-mediated inflammation in CRS.^36,³⁷

Another potential mechanism involved in the pathogenesis of CRS is the role of biofilms. Biofilms are colonies of bacteria and other microbes that cluster together in a state of decreased metabolic activity, yet actively communicate in maintaining the stability and persistence of the colony. They have been found in a variety of chronic and persistent infectious conditions, including dental plaque, indwelling catheters, and implantable medical devices such as heart valves and joint replacements. Bacterial biofilms have been found in numerous patients with CRS over the past few years, yet appear to be rare in the sinus mucosa of individuals without CRS.^38,³⁹ Biofilms are able to persist because they form a community of organisms that is extremely resistant to antibiotic treatment, and chronic infection is a common sequela of the presence of these colonies. Since biofilms are extremely resistant to treatment with current medical therapies, surgical debridement of these biofilms is often necessary to eradicate the bacteria and bring the infection under control. The extent to which biofilms are responsible for ongoing inflammation in CRS, as opposed to their role as opportunistic pathogens, is yet to be appreciated.

▪ Allergic Fungal Rhinosinusitis

Allergic fungal rhinosinusitis (AFRS) is in essence a type of chronic rhinosinusitis, although the specific pathophysiology is better understood. In AFRS, the primary pathophysiological mechanism appears to be a very robust immune response to the presence of one or more families of fungi within the sinuses. AFRS represents an IgE-mediated hypersensitivity response to the presence of fungi in the nose and sinuses, rather than an invasive, infectious process.

In the development of AFRS, an atopic host is exposed to one of several types of dematiaceous fungi through normal nasal respiration, which provides the basis for the IgE-mediated immune response. The type of response is not different from that noted in other allergic nasal conditions (see Chapter 3), although the significant degree of polypoid change and ostial occlusion associated with this inflammatory response provokes additional pathophysiological changes. Due to ostial occlusion, fungal proliferation occurs, as does an ongoing robust allergic response to these fungal organisms. Allergic mucin is produced, and the net result of these inflammatory changes is an expansile inflammatory mass that can cause bony remodeling and impingement upon intracranial and intraorbital structures.

Patients with AFRS usually present with unilateral disease, and generally experience significant unilateral nasal obstruction. As the disease progresses, they can have significant functional symptoms, including diplopia, visual loss, and facial dysmorphism. They will often have marked nasal crusting and mucopurulent rhinorrhea, although pain is uncommon even in advanced disease. It is important to note that AFRS is a disease of the immunocompetent host; it is not a fungal infection in an immunocompromised individual. The immune system functions quite well in patients with AFRS, and it is in fact hypersensitivity to commonly present antigens that is the hallmark of the disease.

Diagnosis of the Patient with Rhinosinusitis

As in most areas in medicine, the most important element of the diagnostic process in evaluating the patient with suspected rhinosinusitis is the history. The 1997 guidelines have been reviewed above, and form a foundation for reaching a presumptive diagnosis of acute or chronic RS. These 1997 guidelines again suggest a list of major and minor factors that would suggest to the clinician the diagnosis of RS. These factors are reproduced in Table 4.1.

The 2004 guidelines for the diagnosis of RS suggest that confirmation of patient symptoms is essential in reaching a diagnosis of acute or chronic RS. Confirmation for the diagnosis of RS involves physical examination methods such as anterior rhinoscopy, endoscopic examination of the nose and middle meatus, and radiological imaging.

Anterior rhinoscopy

The anterior portion of the nose is easily accessible to examination using simple instruments found in most physicians’ offices. A nasal speculum with either a flashlight or a headlight/mirror for illumination can demonstrate the appearance of the anterior nasal septum, the presence of rhinorrhea, and the condition of the nasal mucosa. In most patients the most anterior portion of the middle turbinates can also be visualized in this manner. In addition, a standard otoscope with a large tip can also demonstrate these areas well in most patients. In addition, most current otoscopes have a magnifying lens, which can allow the clinician to examine the nasal interior and nasal mucosa closely and with good acumen. In patients suspected of significant nasal disease, anterior rhinoscopy should be completed in both the nondecongested and the decongested state. Topical application of phenylephrine, oxymetazoline, or xylometazoline in the office can result in a rapid and thorough reduction in the blood flow to the nasal turbinates, increasing the clinician’s ability to visualize the nose and appreciate any abnormalities that may be present.

In patients with allergic fungal rhinosinusitis (AFRS), specific findings are often noted on nasal examination. The hallmark of AFRS is the presence of allergic mucin, a thickened, oily, yellowish mucous secretion that has sometimes been described as “axle grease.” This mucin is composed of thickened mucus and remnants of fungal organisms. The presence of this type of mucoid secretion in the setting of nasal polyps, especially in cases of unilateral disease, suggests a diagnosis of AFRS.

Nasal endoscopy

A thorough examination of the nasal cavity is not complete without a nasal endoscopic examination. Both flexible and rigid fiberoptic endoscopes are available for visualization of the nose, the areas of the sinus ostia, and the nasopharynx. Nasal endoscopic exam should be conducted with the nose well decongested. In addition, a mild topical anesthetic such as xylocaine or tetracaine can be instilled into the nose to improve patient tolerance. The nasal endoscope is attached to an external light source, which provides excellent illumination of the nasal cavity. Nasal endoscopy is useful for evaluating the posterior and superior portions of the nasal cavity. In addition, it is valuable in examining the middle meatus, which is the area in which both the anterior ethmoid and maxillary sinuses communicate with the nose. Nasal endoscopic examination is easy to perform with good patient acceptance and offers significant advantages in improving the visualization of the interior of the nose.

Imaging studies

The primary methodology that should be used to image the sinuses is the computed tomographic (CT) scan of the sinuses. CT scanning is rapid and safe, and newer methods have very low exposure to radiation. CT scans allow illustration of the ethmoid sinuses, which can be difficult to visualize on standard plane radiographs, as well as demonstrating the fine anatomy of the sinus ostia as they communicate with the nose. CT scans in the coronal plane are the most valuable for rapidly evaluating the sinuses, as they bring the sinus ostia into visualization most readily. Axial scans can also be useful in evaluating for neoplastic changes in the nose and sinuses, as well as in surgical planning.

CT scanning has essentially supplanted the use of plain films of the sinuses. Standard views of the sinuses done on plain film radiographic machines do not offer the degree of precision and accuracy given by CT scans. In circumstances in which the clinician wishes to know if there is an air–fluid level in the maxillary sinus, such as for confirmation of an acute maxillary sinusitis, a single Waters’ view of the sinuses can be useful. In evaluating the patient for CRS, however, plain films offer little or no benefit.

MRI scanning of the sinuses is also used in certain circumstances, such as in evaluating for neoplastic changes in the nose and sinuses and in differentiating soft tissue from mucus when necessary. In the routine evaluation of the sinuses, however, they are overly sensitive to minor changes. As such, MRI scan will generate significant numbers of falsely positive findings that do not bear relationship to patient symptoms or signs. In addition, the use of MRI scanning is more costly than CT scanning, and the information gained from MRI does not warrant the expense for routine use.

Allergy testing

In patients suspected of having significant inhalant allergy concurrent with CRS, allergy testing using either in vitro or in vivo techniques can be useful. Since there is a higher prevalence of allergy among patients with CRS than among matched controls without CRS, it would appear that allergy plays a role in at least the expression of symptoms among these patients. Methods of allergy testing are discussed in Chapter 2.

Treatment of the Patient with Rhinosinusitis

▪ Acute (Presumed Viral) Rhinosinusitis

As was noted earlier, most cases of acute rhinosinusitis are caused by self-limiting viral infections. Most individuals will experience from two to four such viral upper respiratory infections annually. Since these infections are self-limited, and since they are due to viruses, treatment for patients with acute viral rhinosinusitis is symptomatic. These patients usually complain of nasal congestion, facial pain or pressure, and low-grade fever. In addition, these symptoms are often accompanied with myalgias. The color or character of the mucopurulent discharge noted by patients is not of use in differentiating viral from bacterial forms of ARS. There is no role for the use of antiviral medications in this group of patients.

Patients with presumed viral ARS should be treated with medications to reduce their acute symptoms. Systemic analgesics and antipyretics such as acetaminophen or ibuprofen are frequently prescribed in both adults and children with viral upper respiratory infections. Salicylates should be avoided in suspected viral infections in children due to an association with Reye’s syndrome. In addition, topical and systemic decongestants can be of use on a short-term basis to reduce the nasal blockage that usually accompanies these infections. Oxymetazoline or phenylephrine can be used topically as nasal sprays to reduce congestion and improve nasal airflow. These agents work as topical vasoconstrictors, and rapidly decrease vascular inflow to the nasal turbinates, reducing turbinate bulk and improving nasal ventilation. These agents do have the potential for rebound congestion, and should only be used for brief periods of time lasting 3–4 days at the maximum. Systemic decongestants such as pseudoephedrine and phenylephrine can also be recommended for patient use, although they are not as efficacious in reducing nasal congestion and are often accompanied by significant side effects such as nervousness, palpitations, and insomnia.

Alternative treatments are often recommended for treating viral upper respiratory infections as well, and can be beneficial in reducing the symptoms of the disease. Nasal saline sprays have been routinely recommended for cleansing the nose, and are often used with success in reducing some of the rhinorrhea that is common in these illnesses. Steam inhalation and the use of vaporizers and humidifiers can also be of some symptomatic relief. Herbal remedies and other complementary therapies are also used, but have variable efficacy in the relief of symptoms.

▪ Acute (Presumed Bacterial) Rhinosinusitis

Acute upper respiratory infections lasting longer than 7–10 days, or infections that initially improve yet worsen again after the fifth day, are more likely to be caused by bacterial organisms than are the remainder of acute episodes of RS. These presumed bacterial infections are referred to as acute bacterial rhinosinusitis (ABRS). In this group of patients, generally a more aggressive therapeutic approach is necessary to bring about resolution of symptoms.

ABRS is a common disease, and affects a large number of both children and adults. The symptoms are similar to those experienced in viral upper respiratory infections, but often are more severe, with higher fever, increased facial pain and pressure, and increased mucopurulent rhinorrhea. In those patients with ABRS, bacterial infection of the mucosa of the nose and sinuses drives the presence and severity of symptoms, and can progress to involve the soft tissues surrounding the nose and sinuses in severe cases and without appropriate treatment. In addition to supportive and symptomatic treatment, as was discussed for viral RS above, antibiotics are indicated in the treatment of ABRS where the suspicion is high that bacterial infection is the cause of the rhinosinusitis.

As was discussed earlier, the primary pathogens responsible for ABRS are S. pneumoniae and H. influenzae. Other organisms are present in ABRS, including both Staph. aureus and M. catarrhalis, although these organisms are somewhat less common (Figure 4.6). For that reason, when antibiotics are prescribed for treating ABRS, consideration must be given to the microbiology of the disease and the most prevalent organisms.

An additional factor that must be considered in choosing antibiotics for the treatment of ABRS is the patterns of resistance that continue to develop. Penicillin resistance among S. pneumoniae varies around the world, but is generally present in at least 25–30% of specimens cultured. In addition, macrolide resistance to this organism parallels penicillin resistance, and is generally at least 30% in most areas. Further, beta-lactamase producing strains of H. influenzae are also quite common, again in excess of 30% of specimens cultured, and essentially all specimens of M. catarrhalis are beta-lactamase producing. Beta-lactam drugs such as penicillins and cephalosporins are therefore inactive in treating these resistant strains. Antibiotic selection must therefore take into account knowledge of the local resistance rates for these common pathogens, and physicians must monitor the effectiveness of antibiotics prescribed to insure response to therapy.⁵

Another important factor to be considered when selecting an antibiotic is prior recent use of antibiotic therapy, especially when that antibiotic has been used to treat a recent respiratory infection. Recent antibiotic use can select out for resistant organisms, and can increase the likelihood that the antibiotic chosen will be ineffective. This observation has been noted with both macrolides and beta-lactam drugs. It is therefore important for the physician to obtain a carefully history of recent drug use prior to prescribing an antibiotic for an individual adult or child.

While symptomatic medications are used to reduce the pain, fever, and congestion often associated with ABRS, antibiotics are prescribed to eradicate bacteria from the site of infection. By clearing the bacterial burden, antibiotic therapy assists the sinuses in returning to a healthy physiological state, decreases the length of symptoms, allows patients to return to activity more rapidly, and lessens the likelihood of the patient developing a complication of sinusitis such as meningitis. These severe complications, however, are uncommon.⁵

Based upon a consideration of microbial resistance patterns and the common prevalent pathogens seen in ABRS, the Sinus and Allergy Health Partnership in 2004 published a specific series of recommendations on types of antibiotic medications to be used in the treatment of ABRS. These guidelines are illustrated in Figure 4.8. Amoxicillin, with or without clavulanate, remains a common yet effective treatment for adults and children with ABRS. The addition of clavulate will be of assistance in treating beta-lactamase-producing strains of H. influenzae, which is a common pathogen in children with ABRS. Amoxicillin alone continues to have efficacy in most patients with ABRS, although doses often must be increased to overcome intermediate resistance. The 2004 SAHP guidelines suggest a daily dose of 4 g in adults (2 g orally twice daily), and 90 mg/kg/day in children, given in divided twice-daily doses. Cephalosporin medications are alternative drugs for treating ABRS, and later generation agents have good stability in the presence of beta-lactamase-producing organisms. They are often less effective, however, against S. pneumoniae. Recommended cephalosporins include cefuroxime, cefpodoxime, and cefdinir. In patients with allergies to beta-lactam drugs, alternate agents can be chosen. These include trimethoprim/sulfamethoxazole, doxycycline, and macrolide medications such as clarithromycin and azithromycin.

Figure 4.8 Guidelines in the selection of antibiotics for acute bacterial rhinosinusitis.

(Adapted from Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg 2004;130:S1–S45.)

It is mandatory for clinicians treating patients with ABRS to assess the patient’s response to initial therapy in 72 hours. Due to resistance patterns and individual variability in response to treatment, the initially prescribed antibiotic may be ineffective, and the patient’s symptoms may continue to worsen on therapy. In those cases in which initial antibiotic therapy is ineffective, or in patients who have had recent antibiotic therapy within the prior 6 weeks, second-line antibiotics are often prescribed. If a patient has had amoxicillin alone and has responded poorly to therapy, amoxicillin with clavulanate can be considered as the second course of therapy. In patients who fail to respond to amoxicillin with clavulanate, fluoroquinolones such as moxifloxacin, gatifloxicin, and levofloxacin can be excellent choices for antibiotic therapy. They have excellent activity against all common pathogens in ABRS, and are generally well tolerated. Fluoroquinolones are not approved for use in children under the age of 18 in the USA, although in severe infections they have sometimes been used with caution.

Antibiotic therapy in ABRS is generally continued for 7–10 days. Recent changes in antibiotic delivery and in dosing patterns have suggested that shorter courses of therapy may be practical in ABRS, as short as 3 days with certain medications. These shorter treatment courses have become more commonly employed, although standard therapy generally considers longer courses of antibiotic treatment.

In addition to treatment with antibiotics, topical nasal corticosteroid sprays can provide additional benefit in the management of the patient with ABRS. Studies have demonstrated more rapid symptom reduction among patients using topical steroid sprays than those treated with antibiotics alone. Doses of these agents are generally higher than would be used in the treatment of allergic rhinitis, and the drugs are delivered twice daily rather than once daily. Agents that have shown benefit as adjuvants to antibiotic treatment of ABRS include fluticasone propionate and mometasone furoate.^40,⁴¹

There is no role for surgical treatment in the management of routine cases of ABRS. In those rare cases in which ABRS extends into adjacent areas such as the orbit and intracranial cavity, surgical drainage and evacuation are indicated, especially when a discrete abscess is noted or when changes are noted in vision or mental status. Prompt referral to an otolaryngologist is essential in patients with orbital swelling or changes in vision or mental status.

▪ Chronic Rhinosinusitis, with and without Nasal Polyps

As has been discussed previously, chronic rhinosinusitis (CRS) is pathophysiologically a distinct condition from ABRS, not simply the chronic progression of acute bacterial disease. For that reason, treatment of CRSwNP and CRSsNP is much different than the treatment of ABRS. The most appropriate treatment of CRS continues to be unclear in the absence of a uniform agreement concerning its pathogenesis. Most experts will agree, however, that the primary treatment of CRS remains medical therapy, with surgery reserved for patients who fail aggressive, appropriate and maximal medical management.⁴² Maximal medical management of CRS usually involves the use of broad-spectrum antibiotics to control the acute bacterial component of the patient’s symptoms, as well as topical intranasal corticosteroid sprays, and oral and topical decongestants,^14,⁴² although prospective clinical trials have not been conducted to evaluate these treatment approaches. Appropriate medical therapy, however, appears to control nasal and sinus symptoms in about 80% of patients with CRS.⁴³

CRS is essentially an inflammatory disease, whose inflammation can be triggered or exacerbated by a variety of factors. It is important, therefore, to address the causes of CRS in order to decrease the burden of disease and return the patient to a maximal state of health and sinus function. Since it is often difficult to keep the underlying inflammation under good control, especially in severe cases of CRSwP such as Samter’s triad, a comprehensive medical (and sometimes surgical) strategy is necessary in approaching the patient with CRS.

In the patient with CRS, both anatomic and physiological factors must be considered in managing the disease. Anatomic issues often require surgical intervention to normalize ventilation and drainage patterns of the diseased sinuses. Obstruction of the sinus ostia increases the burden of disease, and inhibits the normal physiological mechanisms in the sinus mucosa from their normal function. Sinus surgery will be addressed later in this section. Since various inflammatory triggers can be important in the pathogenesis and symptomatic expression of CRS, relevant sources of inflammation must be treated to maximize patient outcomes. Each of these areas will be discussed.

Infection

In most patients with CRS, infection plays a central role in exacerbations of disease. While infection may not be the primary source underlying the presence of CRS, it is clear that as the burden of bacterial disease increases the patient becomes increasingly symptomatic. During episodes of acute exacerbation, various bacterial organisms can be recovered from the sinuses, and increase the amount of nasal and sinus inflammation that is present. These organisms are much broader than those seen in ABRS, and include an increased number of gram-negative species, including pathogens such as Pseudomonas aeruginosa. Many patients with CRS have received several courses of antibiotics over a short period of time, so resistance among these organisms is often elevated.

While antibiotic therapy is usually prescribed in the face of these acute exacerbations, and while clinical experience suggests benefit in the antibiotic therapy of these exacerbations, there is relatively little clinical data supporting their use. Empirically, agents such as amoxicillin/clavulanate and fluoroquinolones such as moxifloxicin are often prescribed. Guidelines for the treatment of CRS suggest that antibiotic therapy should be continued for longer than the 7–10 days usually employed in the treatment of ABRS. In fact, it is common for clinicians to treat CRS with 4- to 6-week courses of these antibiotics. The ideal length of treatment course for these patients is not known.

In patients who have had several courses of antibiotics without improvement, one consideration is the presence of an unusual or resistant organism. In those cases, endoscopically guided cultures of the middle meatus can be useful. Culture and sensitivity data from this technique can then be used to guide selection of an appropriate antibiotic. Again, this antibiotic should be considered for use for a period of at least 4 weeks.

The clinician should remember that since infection is often not the primary pathology in patients with CRS, antibiotic therapy may be poorly effective in managing these patients without adjuvant medical or surgical therapy. Even patients who may have an excellent short-term response to antibiotic therapy may have frequent exacerbations of their CRS and remain symptomatic for extended periods of time. Treatment of these patients will therefore usually involve the use of adjuvant oral and topical medications.

In addition, there is some evidence that at least in some patients with CRS, the infection may not just involve the mucosa and fluid spaces of the sinuses, it may extend to involve the bony walls of the sinuses themselves. In this case, CRS may be persistent as a result of osteitis. In cases with presumed osteitis, surgical therapy can be useful in removing the dead and diseased bone, and thereby removing this source of chronic, recurrent infection.

Mucosal edema

Patients with CRS uniformly have significant edema of the mucosa of the nose and paranasal sinuses. This edema interferes with the normal mucociliary clearance mechanisms of the nose and sinuses, and contributes to mucus stasis and ostial obstruction. Treatment of this mucosal edema is essential in maximizing the patient’s response to therapy.

Topical nasal corticosteroid sprays are commonly recommended for treating patients with CRS, and are usually given at twice-daily doses. These agents can reduce edema and inflammation at the level of the middle meatus, and are often recommended for ongoing use, even between episodes of acute exacerbation. In addition, oral corticosteroid medications are frequently prescribed for use in patients during periods of symptomatic exacerbation. Steroids have shown benefit in these periods, even in patients with concurrent bacterial disease. Management of the mucosal edema present in these patients can be very useful in decreasing the burden of symptoms and in maximizing mucociliary function.

Allergy

Allergy can play a significant role in the expression of symptoms among patients with CRS, and can contribute to the pathogenesis of CRS through interacting with other inflammatory mechanisms. Allergy has been shown to be a predictor of the severity of symptoms among patients with CRS, and the treatment of the allergic component of the disease among atopic individuals can be of benefit. Allergy management should include treatment of the patient’s rhinitis with appropriate pharmacotherapy and immunotherapy. A further discussion of allergic rhinitis and its treatment can be found in Chapter 3.

Surgical Treatment

In patients with evidence of significant obstruction of the sinus ostia, or in patients with severe sinonasal polyposis, surgical treatment of the sinuses can be useful. The goals of surgery are to remove the burden of any obstructive tissue, to eliminate any sources of chronic infection, such as diseased bone, and to improve ostial patency, thereby maximizing mucociliary function and ventilation and drainage of the sinuses. Surgery of the sinuses is best conceptualized as a tool in the comprehensive management of patients with CRS, and is most useful when done along with careful preoperative and postoperative medical therapy.

Sinus surgery has been performed for many years, initially to treat severe cases of acute rhinosinusitis and those with extrasinus complications. In addition, surgical removal of nasal polyps has been performed for centuries. As instrumentation has advanced over the past several decades, surgeons are better able to visualize the inside of the nose and sinuses, and surgical devices have improved the precision and safety of sinus surgery. In addition, imaging modalities such as CT scanning have allowed better evaluation of the interior of the sinuses and the bony framework in which they are housed. Because of these developments, sinus surgeons are able to affect more targeted change in addressing localized abnormalities in the nose and sinuses, with improved outcomes and excellent safety.

The primary type of sinus surgery currently performed for CRS is known as functional endoscopic sinus surgery, or FESS. This technique is a minimally invasive, endonasal approach to the sinuses in which the surgeon uses fine fiberoptic endoscopes to visualize the interior of the nasal cavity and paranasal sinuses. The approach in FESS is truly functional, in that the goal of surgery is not to radically remove bone and mucosa, but rather to target the surgery to diseased tissue and to restore normal physiological function to the extent possible. In FESS, primary surgical attention is directed toward the ostia of the sinuses and to any disease that may be impinging on those ostia. Under endoscopic guidance, the surgeon can make changes to the anatomy and structure of these areas, and can remove obstructive tissue such as polyps in the nose and sinuses.

FESS can be a very effective modality in the patient with significant CRS, especially among those patients with significant sinonasal polyposis. It can also be of benefit as an adjuvant in the medical management of CRS. The primary indication for consideration of sinus surgery is the failure of aggressive, comprehensive medical management. This comprehensive management usually includes the extended use of an appropriate antibiotic along with adjuvant medical therapy including topical and systemic corticosteroids. It is also indicated in severe sinonasal polyposis and for any complication of rhinosinusitis.

Treatment Recommendations for the Patient with CRS

In order to maximize the reduction in patient symptoms from CRS, a comprehensive strategy for medical management is essential. Since patients with CRS often present to the clinician at the time of an acute exacerbation of CRS, and since bacterial proliferation often triggers these symptomatic exacerbations, antibiotic treatment is usually indicated in the initial treatment. If the patient has significant nasal congestion at the time of this acute exacerbation, a short term course of an oral corticosteroid such as prednisone can be useful. Steroid treatment can rapidly improve patient symptoms of congestion and pressure, and through improving edema and encouraging drainage can allow antibiotic therapy to be more rapid and efficacious in reducing symptoms. In addition to the use of these two oral medications, topical treatment can be effective as well. Nasal saline sprays and irrigations can cleanse the nasal mucosa and rinse thickened mucopurulent secretions out of the nose. In addition, topical nasal corticosteroids can be useful in their local anti-inflammatory effects, and can be continued for extended periods of time after the acute exacerbation is brought under control.

In patients who fail to respond to comprehensive medical management, a CT scan can be useful in assessing the extent of the patient’s sinonasal disease, and to see if there is any significant structural abnormality or ostial occlusion. CT scans are of assistance in following the course of the disease in CRS, and are useful in planning for surgery if it is considered to be necessary. The failure of aggressive medical management would be the primary reason to consider surgical intervention. In addition, surgery would be of benefit in patients with significant polypoid disease of the nose and sinuses.

Once patients with acute exacerbations of CRS have been appropriately treated and their disease is under reasonable control, it is important to continue medical intervention for an extended period of time since CRS is a chronic inflammatory disease that is rarely cured with a single intervention. A model for the management of CRS can be seen in asthma, as asthma is a chronic inflammatory disease of the lower respiratory tract. Many of the pathophysiological changes seen in asthma have similar parallels in the sinuses of patients with CRS. For that reason, long-term use of anti-inflammatory medications is useful. Patients with CRS can benefit from ongoing therapy with topical nasal corticosteroid medications to suppress the inflammation of the nasal and sinus mucosa. This benefit is especially apparent in CRSwNP, as most types of nasal polyps are sensitive to treatment with topical corticosteroids. Topical therapy may need to continue indefinitely in order to control the inflammation and decrease the frequency of acute exacerbations of CRS. In addition, some clinicians have used leukotriene receptor antagonists and inhibitors such as montelukast and zileuton in the management of patients with CRSwNP. While prospective studies have not confirmed the efficacy of these agents in CRS, some retrospective reviews have suggested some positive effect.

In addition, as was noted earlier, in patients with CRS who are atopic and also have significant allergic rhinitis, management of allergy is important in decreasing the burden of chronic inflammation. While the use of oral antihistamines is not of benefit alone in the management of CRS, they can be helpful in reducing allergic symptoms that can increase the burden of sinus disease among these patients. In addition, immunotherapy can also be of benefit in these patients through reducing the burden of sinonasal inflammation caused by allergic hypersensitivity.

▪ Allergic Fungal Rhinosinusitis

Management of the patient with allergic fungal rhinosinusitis (AFRS) is similar to the approach used with patients in treating CRS with nasal polyps. The primary goal of treatment for AFRS is the elimination of the burden of disease, and as such, surgical therapy is indicated in all patients with AFRS. In contrast to other forms of CRS, surgical intervention is considered an indispensable component of the management of patients with AFRS. Surgical therapy is used as an initial portion of the treatment plan among these patients. The goal of surgical therapy is to eliminate as fully as possible the polypoid disease and underlying fungal material in the nose and sinuses, and to widely open and ventilate the involved sinuses. While external surgical approaches were commonly used in the past, in most cases patients with AFRS can be managed well with intranasal FESS procedures.

In addition, to surgical therapy, aggressive medical management is essential in the treatment of patients with AFRS. Oral corticosteroid medications are used prior to surgery and for weeks to months after surgery to suppress and control the severe underlying inflammation present in the mucosa of these patients. Prednisone at 1 mg/kg/day is commonly prescribed 1 week prior to surgery, with tapering doses being used after surgery based on the endoscopic appearance of the nasal and sinus mucosa. Topical nasal steroid sprays are also used generously, usually on a twice-daily basis.

Data have also suggested that immunotherapy for fungal antigens can be useful in decreasing the inflammation present in these patients.^44,⁴⁵ A series of studies by Mabry and colleagues have shown improved control among patients treated with immunotherapy for fungal antigens that persist for a significant period of time following treatment. These patients required less medication over the course of their treatment, and had significantly improved quality of life with immunotherapy.

Adjuvant medical therapy may also be of benefit in patients with AFRS. Leukotriene-modifying agents have been used in patients with nasal polyps, both with and without fungal hypersensitivity. Results have been encouraging, although additional study is necessary to clarify their use in AFRS. In addition, one treatment that would theoretically be of benefit in these patients is the use of the monoclonal antibody anti-IgE (omalizumab). Studies to date have not been conducted, but since AFRS is strongly associated with high IgE levels to specific fungi, there could be theoretical benefit in decreasing IgE levels using this approach. Again, studies have not been conducted to explore this potential method of treatment.

Conclusion

Rhinosinusitis is a common disease that affects a substantial portion of the adult and pediatric population. It has various forms and etiologies, and response to therapy depends upon the type of RS and its underlying pathology. Diagnostic criteria and classification systems for RS have not been uniformly accepted, which can make treatment confusing. One algorithm that can be used in the diagnosis and treatment of the patient with rhinosinusitis is found in Figure 4.9.

Figure 4.9 An algorithm for the diagnosis and management of patients with sinonasal symptoms. GERD = gastroesophageal reflux disease.

(Reproduced with permission from Slavin RG, Spector SL, Bernstein IL, et al. The diagnosis and management of sinusitis: a practice parameter update. J Allergy Clin Immunol 2005;116:S1–S47.)

The primary management strategy for both ABRS and CRS remains medical. For AFRS, medical therapy is also critically important, but is generally used after approprate surgical treatment has eliminated the burden of the disease within the nose and sinuses. Appropriate medical therapy would include both anti-inflammatory and anti-infective regimens as indicated. Future treatment strategies will be based on prospective evidence-based guidelines, and should enhance patient care. At present, an understanding of potential pathophysiological mechanisms involved in RS and an awareness of and a facility with a range of treatment options will offer the best potential for clinicians to provide efficacious therapies for these common diseases.

REFERENCES

1 Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg. 1997;117:S1-S7.

2 International Rhinosinusitis Advisory Board. Infectious rhinosinusitis in adults: classification, etiology and management. Ear Nose Throat J. 1997;76:5-22.

3 Anand VK. Epidemiology and economic impact of rhinosinusitis. Ann Otol Rhinol Laryngol. 2004;193:S3-S5.

4 Reilly JS. The sinusitis cycle. Otolaryngol Head Neck Surg. 1990;103:856-862.

5 Anon JB, Jacobs MR, Poole MD, et al. Antimicrobial treatment guidelines for acute bacterial rhinosinusitis. Otolaryngol Head Neck Surg. 2004;130:S1-S45.

6 Scott Levin Prescription Audit from Verispan, L.L.C. January–December 2002.

7 Ray NF, Baraniuk JN, Tharner M, et al. Healthcare expenditures for sinusitis in 1996: contributions of asthma, rhinitis, and other airway disorders. J Allergy Clin Immunol. 1999;103:408-414.

8 Bhattacharyya N. The economic burden and symptom manifestations of chronic rhinosinusitis. Am J Rhinol. 2003;17:27-32.

9 Murphy MP, Fishman P, Short SO, et al. Health care utilization and cost among adults with chronic rhinosinusitis enrolled in a health maintenance organization. Otolaryngol Head Neck Surg. 2002;127:367-376.

10 Gliklich RE, Metson R. The health impact of chronic sinusitis in patients seeking otolaryngologic care. Otolaryngol Head Neck Surg. 1995;113:104-109.