Transcript Etiologies

Medical Management
of the
Chronic Rhinosinusitis
Bastaninejad, Shahin, MD, ORL & HNS, TUMS
Amiralam Hospital
Presentation Outlines
•
•
•
•
Definition
Diagnosis
Etiologies
Medical Treatments
–
–
–
–
General measures
CRSNPCRSNP+
Recurrent CRS post FESS operation
• Accessory evaluations
– Allergy W/U
– Immunologic W/U
Definition
• Chronic rhinosinusitis is a
disorders characterized by:
group
of
– inflammation of the mucosa of the nose and
paranasal sinuses for at least 12 consecutive
weeks’ duration
• Importance:
– CRS is a common disorder affecting
approximately 13% of the population in the
United States annually
– in USA, one in five antibiotic prescriptions are
for patients with sinusitis symptoms! (acute
and chronic)
Presentation Outlines
•
•
•
•
Definition
Diagnosis
Etiologies
Medical Treatments
–
–
–
–
General measures
CRSNPCRSNP+
Recurrent CRS post FESS operation
• Accessory evaluations
– Allergy W/U
– Immunologic W/U
Diagnosis
the use of symptoms
to define CRS is not
as effective as for
ABRS
2007
Diagnosis
1) Continuous symptoms/physical findings
for more than 12wks
2) One of these signs must be present:
– Discolored drainage or nasal polyp
– Edema of the middle meatus
– General or localized edema in other areas
– Imaging confirmation (CT-Scan)
History &
Physical
examination
Endoscopy
(edema and
discolored
secretions)
CT-Scan*
Presentation Outlines
•
•
•
•
Definition
Diagnosis
Etiologies
Medical Treatments
–
–
–
–
General measures
CRSNPCRSNP+
Recurrent CRS post FESS operation
• Accessory evaluations
– Allergy W/U
– Immunologic W/U
Etiology
• The potential causes of CRS may be
numerous,
disparate,
and
frequently
overlapping
• A unified, accepted understanding of the
etiology of CRS is still being sought
Allergy
Bacterials
Major
debatable
CRS
etiologies
Anatomic Variations
Fungi
Allergy
• The concordance of allergy and CRS
ranges from 25% to 50%, with pediatric
studies reporting the higher association
• In the subpopulation of patients with CRS
symptomatic enough to require surgery,
allergy is present in 41% to 84% of
patients
• Perennial hypersensitivity Predominates
(especially house dust mite)
• Allergic patients with CRS responded
more poorly to medical management than
allergic patients who did not have CRS
• Impact of allergic rhinitis on surgical
results in endoscopic sinus surgery 
success rate will be diminished about 10%
(90%80%)
• The etiologic association between allergic
rhinitis, and CRS is less clear yet (despite
ABRS)
Bacterial Infection
• The role of bacteria in the pathogenesis
of CRS, remains elusive, But:
–
–
–
–
mostly of mixed
Staphylococcus aureus
infections, with a
Coagulase-negative staphylococcus median of 3 different
bacteries
Anaerobic
Gram-negative bacteria.
• Despite
the
uncertainties
surrounding
the
etiologic factors associated with CRS, antibiotic
therapy has served as a mainstay of treatment
• Why their contribution is elusive?
• Relative abundance of eosinophils and the
paucity of neutrophilic inflammation in
tissue samples of the most cases of CRS
• This
inflammatory
response
independent of infection
may
be
Probable Mechanisms
• Chronic infection
• Osteitis
• Bacterial allergy
• Superantigen (usually from SA)
• Biofilms
The exact role of bacteria
in CRS remains unclear
Osteitis
• It is conceivable that bacteria may cause
bone
pathology
by
increasing
the
inflammatory mediators (LT,PG,…)
• Impacts of Biofilms in this scenario is
evaluated (they release soluble bacterial
virulence
pathology)
factors
that
generate
local
Biofilms
• Bacterial biofilms are defined as “an
assemblage of microbial cells enclosed in
a self-produced polymeric matrix that is
irreversibly associated with an inert or
living surface
• Biofilm formation is probably more likely
with
gram-negative
Pseudomonas species
rods
such
as
Fungi (mechanism)
• Chronic Invasive Fungal Sinusitis
• Allergic Fungal Sinusitis (charactristics:
eosinophilic mucin containing noninvasive fungal
hyphae, nasal polyposis, characteristic radiographic
findings, immunocompetence, and allergy)
• Fungal balls obstruction
• Immune Complex (non-IgE inflammation)
• At the current time, it appears that multiple
conditions
may
play
a
direct
or
contributory role in the pathogenesis of
CRS
• Current literature supports the important
role that bacteria and/or fungi, appear to
play in the pathogenesis of CRS
Anatomic Variants
• May predispose to earlier obstruction of
the sinuses, allowing for the development
of CRS, although strong evidence is
lacking
Presentation Outlines
•
•
•
•
Definition
Diagnosis
Etiologies
Medical Treatments
–
–
–
–
General measures
CRSNPCRSNP+
Recurrent CRS post FESS operation
• Accessory evaluations
– Allergy W/U
– Immunologic W/U
Steroids
• Topical (INCS): Four of the five clinical
trials
demonstrated
significant
improvement in symptoms
• Although systemic steroids are widely
used, no RCTs have investigated their use
in CRS without polyposis
Antibiotics
• There is a lack of RCT in the literature regarding
to this topic, however, no difference between
antibiotics was noted
• But nowadays, Macrolids are in particular
attention because in addition to
effects,
macrolides
antiinflammatory
corticosteroids
have
effects
antibacterial
some
akin
to
interesting
those
of
• Also macrolides can possibly decrease biofilm
formation and overall bacterial virulence
• Regimens (3mo duration):
– Erythromycin Ethylsuccinate: 400 q6h up
to 2wk, then 400 BD up to 10wk
– Clarithromycin: 500 q12h up to 2wk, then
500 daily up to 10wk
Nasal douching
• At least four RCTs have shown
improvement in symptoms, quality of life
and endoscopy and imaging findings
• Nasal saline irrigation has been shown to
potentially provide more benefit than nasal
saline spray in patients with CRS
• A 2007 Cochrane review concluded that
nasal saline appears to have benefits as
an adjunctive treatment for CRS
Antifungal agents
• To date no convincing evidence of their
efficacy over and above saline douching
has been provided
Decongestants
• No RCTs have been performed in
CRS
Mucolytics
• There is little evidence in the literature for
the use of mucolytics such as bromhexine
Antihistamines
• There is no evidence to support the use of
antihistamines in CRS, and they are not
recommended
Bacterial lysates
• These entities have included 5 bacterial
lysates
(Enterococcus
faecalis
autolysate,
Klebsiella
pneumoniae, Streptococcus pneumoniae, Streptococcus pyogenes,
and Haemophilus influenza).
• In a multicenter RCT in 284 patients who
had CRS, the use of a mixed bacteria
lysate
reduced
significantly
symptom
scores
Immunomodulators and
immunostimulants
• G-CSF
and
Gama-IFN
significant improvement
not
show
Proton Pump inhibitors
• The importance of GERD as a cause of
CRS is unknown, but it may be more
important in the pediatric population than
in adults
• No RTCs have shown benefit
• GERD may be more of a comorbid state
than a cause of CRS
Leukoteriene modifiers
• Montelukast (10mg once a day), a
leukotriene receptor antagonist, has been
shown in a few open studies to benefit
CRS patients with nasal polyposis
Aspirin Desensitization Therapy
• Aspirin desensitization is shown to reduce
the number of episodes of sinusitis and to
decrease polyp recurrence and the need
for additional surgery
Conclusion
• To date, however, because of the paucity
of properly conducted trials, no absolute
recommendation for a ‘correct regimen’
can be given
CRS without nasal polyps
•
•
•
•
•
INCS for 3-6mo
Nasal Douching with N/S
Macrolide for 3mo
Mucolytics
On failures, perform culture guided
therapy
• If failed again  Proceed with FESS
operation
CRS with nasal polyps
• INCS for undisclosed time!
• Nasal Douching with N/S
• Macrolide administration for 3mo
• Oral corticosteroids for 10 days (20-40mg)
• Montelukast
Recurrence of CRS post FESS
surgery
• Under 8 wk  Endoscopy:
– Nl. INCS
– Abn.
• Technical  CT scan
• Nontechnical (infection) Cx
• After 8 wk  Endoscopy:
– Nl. CT scan
– Abn.
• Technical  CT
• Nontechnical (infection) Cx
AECRS
• Antibiotics that cover both the common
ABRS and CRS organisms are effective in
reducing the exacerbation of AECRS
• Aggressive anti-inflammatory agents such
as systemic steroids may also be
necessary
Presentation Outlines
•
•
•
•
Definition
Diagnosis
Etiologies
Medical Treatments
–
–
–
–
General measures
CRSNPCRSNP+
Recurrent CRS post FESS operation
• Accessory evaluations
– Allergy W/U
– Immunologic W/U
Accessory evaluations
• Allergy studies
patients:
may
be
ordered
for
– who fail to improve
– who have symptoms consistent with both
allergy and CRS at the beginning
• Allergy skin prick testing is considered the
study of choice
• For
patients
aggressive
who
continue
medical
and
to
fail
surgical
management, immunodeficiency may be
present:
– Selective IgA deficiency
– Common variable immunodeficiency
– Hypogammaglobulinemia
– Also HIV