Rhinosinusitis: spoelen, sprayen of snijden? · Headache/facial pressure in sinusitis. Neus-, keel-...

Neus-, keel- en oorheelkundeHoofd- en halschirurgie

Rhinosinusitis:spoelen, sprayen of snijden?

Prof. Dr. Philippe Gevaert

Dienst Neus-, keel- en oorheelkunde


Wat is er nieuw sinds EPOS 2005?

Nieuwe defintie en classificatie

Update literatuur en behandelingen

Nieuwe en bruikbare schema’s voor

• acute rhinosinusitis volwassenenkinderen

• chronicsche rhinosinusitis volwassenenkinderen

• nasale polyposis

(Aangeven nood aan nieuwe studies)Rhinology, suppl 20, 2007

Neus‐, keel‐ en oorheelkundeHoofd‐ en halschirurgieNeus-, keel- en oorheelkundeHoofd- en halschirurgie

Definitions and classification for General PracticeBased on symptoms:Two or more symptoms, one of which should be either

• nasal blockage/obstruction/congestion or• nasal discharge: anterior/post nasal drip;• ± facial pain/pressure,• ± reduction or loss of smell

Examination: anterior rhinoscopyX-ray/CT not recommended

* DURATIONACUTE / intermittent < 12 weeks

complete resolution of symptomsCHRONIC / persistent > 12 weeks

incomplete resolution of symptoms

Special attention to questions on allergic symptoms


Definitions and classification (ENT)Based on symptoms:Two or more symptoms, one of which should be either

• nasal blockage/obstruction/congestion or• nasal discharge: anterior/post nasal drip;• ± facial pain/pressure,• ± reduction or loss of smell

AND EITHER

• endoscopic findings of polypsmucopurulent dischargeedema or obstruction

OR

• CT scan abnormality: mucosal changes within ostiomeatal complex or sinus cavity


Definitions and classification

* SEVERITY Visual Analogue Scale (VAS)

mild 0-3moderate 3-7severe 7-10

* DURATION

ACUTE / intermittent < 12 weekscomplete resolution of symptoms

CHRONIC / persistent > 12 weeksincomplete resolution of symptoms

CLASSIFICATION OF RHINOSINUSITIS


Headache/facial pressure in sinusitis


Nasal Endoscopy


http://www.entusa.com/Nasal Photos/nasal_polyp.jpg


Mucopurulente secreties en polypoïde mucosa in het linker ethmoïd na sinus chirurgie

Linker neusholte

Korst met sterk vermoeden van surinfectie door staphylococcus aureus in de linker middenste neusgang


Rechter middenste neusgang met korsten en purulente secreties door een extramucosale mycosis

Rechter middenste neusgang met purulente secreties achter de processus uncinatus (de middelste neusschelp is gemedialiseerd)


RX sinuses: - Waters, Caldwell an Hirtz

- poor sensitivity and specificity

- NOT RECOMMENDED!

Imaging of sinsuses


Imaging of sinsusesMRI: only recommended in tumor diagnosis

CT sinuses: current standard imaging (50mGy)

Cave! radiation damage of lens (500-2000mGy)

- Acute rhinosinusitis: only if signs for complications!!

- Chronic sinusitis: only after 4w-12w treatment!


Septal deviation

Dental sinusitis

Chronic Sinusitis

Nasal polyps


Infections induces changes in sinus mucosa

Ventilationand Drainage

Inflammationand Remodeling

B

MT

MS

ITThe ostiomeatal complexB Bulla ethmoidalisIT inferior turbinateMT middle turbinateMS maxillary sinus


Common cold induces changes in sinus mucosa

Virus ICAM-1

T helper 1 polarisation * CD4+ CTL* NK activity* Ig

IL-1β , IL-6, TNF-αIL-8, MCP-1IFN-γ

CD8+ CTLsNKcellsneutrophil monocyte recruitment and activation

Elimination of rhinovirusT helper 1 polarisation * CD4+ T helper cells

* NK activity* Immunoglobulins

IL-1β , IL-6, TNF-αINFgamma, IL-8

CD8+ T cytotxic cellsNatural Killer cellsNeutrophils monocyte recruitment and activation

Elimination of rhinovirus


MicrobiologyNormal sinuses: Free of growth

Acute rhinosinusitis:2/3 Viral1/3 Bacterial (St Pneumoniae,H Influenzae, M Catharralis)

Chronic rhinosinusitis:>>Anaerobes: Propionibacterium, Bacteriodes, PeptococcusAerobes:Staphylococcus, Corynebacterium, PseudomonasFungi (» aspergillus fumigatus)

Dentogene sinusitis: ?


Common cold/ Acute viral rhinosinusitis

Occurence in adults: up to 4 times a year

URTI: symptoms < 10 days

Symptomatic treatment only: • Decongestants

• Pain relief

• Saline drops

Can lead to post-viral inflammation of nose and sinuses

Belgian Guidelines for Acute Rhinosinusitis


Acute post-viral Rhinosinusitis (ARS)

• ↑ symptoms after 5 days or

• persistent symptoms after 10 days

• less than 12 weeks

Symptoms: • Nasal obstruction/congestion and/or

• Facial pain/pressure

Accompanied by:

• Nasal discharge and/or

• Reduction or loss of smell

Definition:



Acute post-viral Rhinosinusitis (ARS)

• once or more than once in defined time period (episodes per year)

• complete resolution between symptoms

Appearance: • Mild

• Severe

Occurence:

• Fever > 38,3°C

• Localized pain over the sinuses

May lead to complications !!Streptococcus pneumoniae,Haemophilus influenzaeand Moraxella catarrhalis


Strength of evidence for treatment of Acute RhinosinusitisTherapy Level Recommendation Relevance

antibiotic Ia (49 studies) A yes: after 5 –10 days,or in severe cases

topical steroid 1b (1 study) A yes

addition of topical steroid to antibiotic

Ib (5 studies) A yes

oral steroid no evidence (1 study)

D no

addition of oral antihistamine in allergic patients

Ib (1 study) B no

nasal douche no evidence (3 studies)

D no

decongestion no evidence(3 studies)

D yesas symtomatic relief

mucolytics no evidence (3 studies)

D no


Dolor et al. JAMA Oct 2002

DBPC trial in 95 patients with acute sinusitis (with history of CRS)

All received 2x/d xylometazoline spray (3days) and

2 x 250mg/d cefuroxime (10 days)

47 patients 200µg (two puffs) Fluticasone or 48 patients placebo spray


J Allergy Clin Immunol. 2005 Dec;116(6):1289-95. Number of patients = 981


*P<0.001 vs placebo.Gross et al. J Allergy Clin Immunol. 2007; 119 (Suppl S):S64. Pe

rcen

t cha

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in p

atie

nt-r

epor

ted

cong

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n sy

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core

from

bas

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e Days

**

**

* * **

* * * * * *

Percent Change in Congestion Symptom Score (Patient-Reported)

Nasal GCS and nasal congestion


Management of Acute Rhinosinusitis


Acute Rhinosinusitis in de huisartspraktijk90 %patiënten: 1. bij neusverstopping: xylo- of oxymethazoline (max 7 d),

nasaal corticoid 2x/dag2. bij pijn: paracetamol: 500 mg 4 à 6 x per dag3. warme damp en/of neusspoeling met fysiologisch water

<10% patiënten: AMOXICILLINE 3 x 1 gr/dag gedurende 7-14 dIndien geen verbetering binnen de 3 dagen:Amoxi vervangen door Amoxicilline-Clav

alternatief bij allergie: chinolones (ciproxine, avelox, proflox, tavanic, tarivid à 0,5-1g/d)

Zeer uitzonderlijk: orale corticosteroiden (medrol 32mg ged 5 dagen)Nooit: sinus punctie


Chronic Rhinosinusitis with and without nasal polyps

Chronic Rhinosinusitis Nasal Polyps

CRS NPThe spectrum of sinus disease

- Eosinophils +


Facial pain/pressure

Facial congestion/fullness

Nasal obstruction/blockage

Nasal discharge/purulence/postnasal drip

Hyposmia/anosmia

Blood eosinophils

Asthma

Aspirin hypersensitivity

Chronic Sinusitis

Yes

Yes

Yes

Yes

Rarely

No

Rarely

Rarely

Nasal Polyposis

Rarely

Yes

Yes

Yes

Yes

Often

Often

Typical

Diagnose: symptomatologie


Diagnose: nasale endoscopie en CT-scan

Chronische rhinosinusitis

Neuspoliepen


Nasal Polyps:eosinophilsTh2 inflammation

Cystic Fibrosis:neutrophilsTh1 inflammation

Eotaxin

IL-5

ECP

AlbuminIgE

Cells and cytokines during sinonasal inflammation

Pathogen?

IL-8

MPO

Pathogens

TGFβ ↑INFγ ↑

Chronic rhinosinusitis:remodelling

Th1 inflammation

Pathogens


Chronic Rhinosinusitis

prevalence of 14,7% in the normal population

year Antibiotic prescript.1985 5,8 Mil1992 13 Mil

year loss of working days1985 50 Mil1992 73 Mil

Th1 type Inflammation with • increased IFNγ ↑• increased TGFβ and remodeling


Nasal polyposis

Prevalence app. 2-4%

Adult onset Asthma in app. 40%Aspirin sens. & asthma in 15%

Mixed cellular infiltrate with prominent eosinophilia in 90%

Inflammation with • local IgE production• increased IL-5, eotaxin,

cys-LTs and ECP


Strength of evidence for treatment of CRS / NP

Intervention Chronic rhinosinusitis Nasal polyps

Corticosteroids Topical A ← A ←

Systemic / C ←

Antibiotics Oral short term < 2w C DOral long term >12w C ← C ←

Antimycotics Topical / Systemic D DAntihistamines D BAnti-leucotriens / C ←

Nasal saline douche C ← D ←

Decongestants D DAllergen avoidance D D

Adapted from EAACI Position Paper on Rhinosinusitis and Nasal Polyps, 2007


Behandeling chronische sinusitis

≠Behandeling

acute sinusitis


No evidence for short term antibiotic treatments for CRS


Management of Chronic Rhinosinusitis: primary care


Rhinology, 42, 57-62, 2004


2009


Nasale douching / spoeling met zoutwater1 liter flessenwater (kamertemperatuur/ ideaal 37°C)+ 9 gram zeezout (keukenzout)= 2 koffielepels of 1 soeplepelGoed mengenBeide neusgaten spoelen boven lavabo

2 x dag met 250ml met20ml spuit of neuskannetje of spoelsystemen

spoelen en snuitenNasale Corticosteroiden: 2x2/d, minstens 8 weken (dan evt CT scan)

Chronic Rhinosinusitis in de huisartspraktijk


Management of Chronic Rhinosinusitis: ENT’s


Long term antibiotic treatment in CRS

• DBPC study in 90 patients: • 3m low-dose erythromycin, nasal douche,

nasal GCS vs. sinus surgery• 50% Improvement of symptoms• no difference vs sinus surgery


• Nasal douching/Saline

• Nasal Corticosteroids: 2x2/d

• Antibiotics: long-term Macrolides ?!?!?!

Clarithromycine 500mg/d(3 months) • FESS (functionele endoscopische sinus chirurgie)

Chronic Rhinosinusitis bij de NKO-arts


Surgical Management of rhinosinusitis•Endoscopic sinus surgery (2 decades):

> 85% symptomatic improvement

Classical instruments Microdebrider / shaver


The challenge of managing Nasal Polyposis

Adapted from EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: 583-601

Medication Recommendation:Topical corticosteroids AOral corticoteroids CAntibiotics short term DAntibiotic long term CAntimycotics DAntihistamines BAntileucotrienes CNasal saline DDecongestants DAllergen avoidance D


Surgical Management of Nasal Polyps

3 randomized controlled studies:- Symptomatic improvement: 78%- Improvement of nasal obstruction: 92- Improvement of anosmia: 60%- Recurrences of nasal polyposis: 25 - 45% !!

Endoscopic sinus surgery gives the best chance for complete resolution of bilateral nasal polyposis.

Systematic review of endoscopic sinus surgery for nasal polyps Kim Dalziel et al, Health technology Assessment, 2003


Lund V, et al. Arch Otolaryngol Head Neck Surg 1994; 124: 513-8

Significant change in Nasal Polyp score

Significant % change PNIF

DBPC in severe bilat nasal polyps9/29: placebo10/29: FP (2 x 200 μg/d)10/29: BD (2 X 200 μg/d)

Nasal corticosteroid spray in nasal polyposis

No significant ↓ in number of patients requiring polypectomy !!


Nasal corticosteroid DROPS in nasal polyps

double-blind, placebo-controlled study with nasal GCS dropsAfter 12-weeks: ↓ nasal blockage, ↓ peak nasal inspiratory flow

↓ polyp volume (CT score)↓ need for sinus surgery

Aukema, Mulder, Fokkens; JACI 2005


Management of Nasal Polyposis


Management of Nasal Polyposis

• Nasal douche with saline • Nasal corticosteroids

• GCS sprays: 2x/d, symptoms↓, no resolution of NP• GCS drops: symptoms↓, surgery↓↓, not available in Belgium

• Oral corticoids: effective but fast recurrencelong term side effects

• Antibiotics:• Antibiotic ointment• Long-term antibiotics: macrolides 500mg/d ged 3m

doxycycline 100 mg/d ged 1mCombinations?

• Endoscopic sinus surgery: only chance for cure!!in NP: recurrences


Revised GINA 2006: Sinusitis treatment

Sinusitis treatment mayimprove asthmaEVIDENCE B→Saline

Long term antibioticsShort term antibioticsOral GCSNasal GCS

Refractory sinusitis/polyps→ Endoscopic sinus surgery

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