CHRONIC RHINOSINUSITISSTATE OF THE ART Gary Kroukamp Definition

CHRONIC RHINOSINUSITISSTATE OF THE ART Gary Kroukamp

Definition: � >3 months of symptoms of sinusitis

Case Study: 55 yo man 3 episodes of acute sinusitis since last winter Treated with antibiotics Resolution of acute sx continues to have pressure “sinus” headache, nasal congestion, poor smell, and intermittent rhinorrhea.

Chronic Rhinosinusitis? l History Duration Allergic Symptoms? Smoker? l l Presenting symptoms Examination

The Dairy and Wheat Myth! Milk mucous sensation Inhaled vs Ingested allergen

Common Presenting Symptoms nasal obstruction l postnasal drip l facial pain & headache l rhinorrhoea S hyposmia / anosmia l 94% 92% 90% 61%

Physical examination: l l l Purulent rhinorrhoea Polyps Complications?

Scope Pus Polyps Oedema

Pathophysiology: Obstruction of osteomeatal complex � Impaired mucociliary clearance � Biofilm � Superantigen � Inflammatory Cascade �

Anatomical variants: deviated nasal septum � concha bullosa � ethmoid bulla � � other middle turbinate anomalies Agger nasi cells Haller cells

Underlying diseases: l l asthma cystic fibrosis ciliary dysmotility immuno-compromised: l l l chemotherapy transplant immuno-deficiency

CT scan? Sinusitis or not? � Surgical Planning �

Normal CT

Abnormal CT

Really Abnormal CT

Objectives for treatment: Improve Symptoms � Treat Infection � Resume normal sinus physiology � Prevent complications �

Microbiology: � Anaerobes Staphylococcus aureus � Streptococcus � Haemophilus Influenzae � Moraxella catarrhalis �

Treatment options: � Antibiotics l sufficient duration Oral Steroids � Nasal Steroids � Saline � Anti –leucotrienes (Singulair) – not shown to be effective �

Antibiotics: S S Controversial- none approved in Canada as indication for CRS If there is pus! Amoxicillin-clavulanic acid - Augmentin � Fluoroquinolones - Moxifloxacin � Macrolides - Ketek �

Steroids? � � � Oral short course IL-5 & IL-13 Reduce tissue inflammation, oedema

Nasal Steroids Treatment mainstay! Compliance! 3 months! Chronic use…

Future Research The magic bullet! Anti-inflammatory biological Anti-interleukin

Referral Failure of treatment � Complications �

“Sinus headache” � � Headache is complicated Multifactorial! Sinus headache/pain does NOT mean sinusitis MUST have proper evaluation

FESS – Functional Endoscopic Sinus Surgery Patient selection crucial! – Don’t operate for headache! Abnormal CT Restore sinus function Improve ventilation and drainage Open the ostium Remove the obstructed honeycomb (ethmoids) Clear obstruction

FESS – Surgical Aims Restore sinus function Improve ventilation and drainage Open the ostium Remove the obstructed honeycomb (ethmoids) Clear obstruction

Evidence/Validation? Impact of Functional Endoscopic Sinus Surgery on Symptoms and Quality of Life in Chronic Rhinosinusitis†Michael Damm MD, Gero Quante MD, Markus Jungehuelsing MD, Eberhard Stennert MD – Laryngoscope Jan 2009 Recalcitrant Rhinosinusitis, the diagnosis and treatment and evaluation of results – Rhinology 2010 EPOS - http: //www. ep 3 os. org/EPOS 2007. pdf