Chronic RhinoSinusitis- State 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? History Duration Allergic Symptoms? Smoker? Presenting symptoms Examination
The Dairy and Wheat Myth! Milk mucous sensation Inhaled vs Ingested allergen
Common Presenting Symptoms nasal obstruction 94% postnasal drip 92% facial pain & headache 90% rhinorrhoea 61% hyposmia / anosmia
Physical examination: 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: asthma cystic fibrosis ciliary dysmotility immuno-compromised: 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 Oral Steroids Nasal Steroids Saline sufficient duration Oral Steroids Nasal Steroids Saline Anti –leucotrienes (Singulair) – not shown to be effective
Antibiotics: 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.ep3os.org/EPOS2007.pdf