1. Sinonasal Inflammatory Disease in the College Health Setting
Mark Friedel, MD, MPH
Director of Rhinology, Endoscopic Sinus and Skullbase Surgery, Advanced ENT

2. Introduction
Our mission is to provide effective, compassionate and responsible medical care and surgical treatment related to ear, nose and throat disorders.

3. Outline Basic Anatomy and Physiology Inflammatory Disease Rhinitis
Sinusitis
Management
Antibiotics Guidelines

4. Nasal Anatomy

5. Intranasal Anatomy Nasal Cavity: Variants
Nasal ala/vestibule extends to Chonae
Septum (medial wall)
Turbinates and lateral
nasal wall
Skull Base – cribriform
plate
Variants
Concha Bullosa
Paradoxical turbinates

6. Blood Supply External Carotid Maxillary branch  Sphenopalatine artery
Kiesselbach’s
plexus
External Carotid
Maxillary branch  Sphenopalatine artery
Internal Carotid
Ophthalmic branch 
Anterior ethmoidal branch
Posterior ethmoidal branch

9. Nasal Endoscopy View

10. Anatomical Variations: Middle Turbinate
Nyquist et al. Middle turbinate preservation in endoscopic transsphenoidal skull base surgery. Skull Base 2010

11. Concha Bullosa

12. Concha Bullosa

13. Paradoxical Middle Turbinate

14. Septal Deformities
Nasal septum
Deviations
Spurs

15. Septoplasty

16. Sinus Anatomy

17. Embryology

18. Sinus Mucosa Ciliated pseudostratified columnar epithelium
Two layers of mucus
Sol layer -- Thick “basement” layer
Gel layer -- Thin, less viscous layer, cilia move to the ostia
Ciliary Dysfunction:
Mucosal changes after Surgery and/or Inflammatory disease
Rare conditions (i.e. Primary Ciliary Dyskinesia)
May lead to recalcitrant sinus disease
Neuroreceptors:
smell (olfactory nerve)
airflow (located in the inferior and middle turbinates)

19. Mucus (gel layer) Direction of mucociliary flow
Mucus (sol layer) Mucous gland
Ciliated cells
Goblet cell
Periosteum Bone

20. Olfactory bulb
Postero-lateral nasal branches
Anterior ethmoidal nerve
Internal and External
nasal branches
Greater and Lesser palatine nerves

21. Maxillary Sinus Earliest sinus to develop and aerate
Biphasic growth
First growth during first 3 years of life
Next growth between 6-12 years
Initially located medial to orbit, then extends lateral
and inferior
Largest of the paranasal sinuses generally
Easiest to access surgically
Posterior wall separates this sinus from the contents of the infratemporal and pterygomaxillary fossae

22. Ethmoidal Sinus Most complex with greatest variability
Ethmoid “labyrinth” or “honey-comb”
Generally non-aerated at birth and then grow and pneumatize until age 12
Pyramid with base located posteriorly
Lateral wall = Lamina papyracea
Medial wall = Middle turbinate
Superior wall = skull base (fovea ethmoidalis)

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26. Sinus Anatomy OSTEOMEATAL COMPLEX:
Small passageway connecting ethmoid and maxillary sinuses with the
nasal passageway
Important clinically, common area of obstruction leading to sinus obstruction and mucous stasis

28. Frontal Sinus
Develops from anterior-superior ethmoid cells in the area of the frontal recess
Starts at age 2
Then more rapidly increases at age 6 to late teens
Last sinus to pneumatize
Most difficult sinus to approach surgically
Drain via frontal outflow/recess (hourglass shape)

29. Frontal Recess Anatomy
Medial wall = middle
turbinate
Lateral wall = lamina papyracea
Posterior wall = anterior face of bulla ethmoidalis (second lamella)
Anterior wall = Agger nasi cell

30. Frontal Recess Anatomy

31. Sphenoid Sinus Undeveloped and non-aerated at birth
Aeration begins generally at age 3 and progresses posteriorly

32. Dehiscent Carotid - 4% of Patients

33. "Nasal sprays are very harmful to your sinuses.
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"Nasal sprays are very harmful to your sinuses.
From now on Iwant you to use this tiny plumber's helper."

34. Sinonasal Function Filtering, Humidifying and Warming inspired air
Assisting in regulation of intranasal pressure
Increase surface area of olfactory membranes
Lightening of the skull
Improve head balance and assist in flotation
Absorbing shock to the head
Resonance to voice
Contributing to facial growth
Evolutionary remains of useless air space

35. Breathing Air The nose conditions 10,000 to 20,000 L of inspired
air daily
The air contains billions of infectious, allergenic, irritative, and toxic materials
This air must be filtered, neutralized and eliminated
Inhaled particles or microorganisms are trapped by nasal hairs and mucus layer
Through mucociliary clearance gradually filtered posteriorly through nasal cavity into nasopharynx, esophagus and into GI tract

36. RHINITIS Symptoms: Non-Allergic Rhinitis Allergic Rhinitis
Nasal congestion/obstruction, irritation, facial pressure, non-purulent rhinorrhea, sneezing
Generally not severe headache, fever, pain
Non-Allergic Rhinitis
Vasomotor Rhinitis
Rhinitis Medicomentosum
Allergic Rhinitis

37. NON-ALLERGIC RHINITIS
May be caused by drugs such as:
Beta blockers
Methyldopa related
Reserpine
Oral contraceptives
Nasal sprays (OTC) (afrin, neosynephrine,etc)
Decongestants
SMOKING!!

38. NON-ALLERGIC RHINITIS
May also be caused by certain conditions such
as:
Pregnancy
Hypothyroidism
Temperature related
Recumbency rhinitis
Vasculitis/Inflammatory conditions (i.e. sarcoid, SLE,
etc)
Paradoxical nasal obstruction (Nasal cycle)
Atrophic Rhinitis
Non-airflow rhinitis (Adenoid hypertrophy, choanal
atresia)

39. ALLERGIC RHINITIS IgE mediated hypersensitivity of mucous
membranes to antigenic substance
Incidence: 10-20% population
Types:
Seasonal
Perennial
Perennial with seasonal exacerbations

40. ALLERGIC RHINITIS Signs: Symptoms: Itching sensation
Paroxysms of sneezing
Watery discharge (not purulent)
Alternating nasal obstruction
Associated allergic symptoms (eye, skin,
ear, chest)
Signs:
Pale, bluish edema of mucosa
and turbinates
Excessive secretions
Polyps may be present

42. RHINITIS: TREATMENT Avoidance of exposure  Oral steroids
(allergic patients)
Nasal saline irrigations
Humidification
Emollients (i.e.
Ponaris)
Mast cell stabilizers
(cromolyn)
Immunotherapy
Nasal strips (i.e.
breathe rite strips®)
Topical Nasal Steroids  Surgery
Oral/topical decongestants
Conservative use
Oral or Topical antihistamines
Turbinate reduction or steroid injections
Septoplasty
Concha Bullosa resection

43. TREATMENT Vasomotor Rhinitis may respond to anticholinergic agents
Ipratropium Bromide Nasal sprays
.03% or .06% formulation
Particularly when main complaint is persistent rhinorrhea
Rhinitis Medicomentosum
Very challenging
Steroid taper and nasal steroid as bridge to cessation of
use of decongestant
Address underlying issues
? structural (perforation, deviated septum, etc)

44. Rhinosinusitis Rhinosinusitis affects 1 in 8 adults annually each
year in the U.S.
31 million adults will be Dx with sinusitis
5.8 billion dollars spent on Dx and treatment
More than 1 in 5 antibiotics are ordered for sinusitis
5th most common reason to write for antibiotic
76 million days of inactivity, lost work

45. Rhinosinusitis Often preceded by rhinitis Typically viral or bacterial
Fungal less common
Causes edema and obstruction of the sinus
outflow
Stasis of mucous and purulent fluids leads to symptoms
ARS typically improves within 7-10 days
By 15 days, 90% are cured or improved

46. Rhinosinusitis Other sources:
Odontogenic source (i.e. infection, extractions, etc.)
Adenoiditis and hypertrophy
Ciliary Dysfunction
Facial trauma
Iatrogenic (surgery, NG tubes, etc.)

47. SIGNS AND SYMPTOMS PRIMARY SYMPTOMS: Facial Pain/Pressure/Fullness
Frontal, maxillary, mid-facial, upper teeth, retro-orbital, crown of the head
temporal, parietal and occipital headaches are not frequently associated with sinusitis
Presence in the absence of purulent drainage is insufficient for Dx
Nasal congestion and/or Obstruction
Described as blockage, congestion, obstruction, fullness
Rhinorrhea/Drainage
Anterior or postnasal drainage
Purulent, cloudy
Color does not necessarily determine viral vs. bacterial infection

48. SIGNS AND SYMPTOMS Secondary Symptoms: Fever Hyposmia/Anosmia Malaise
Cough
Sore throat
Halitosis
Generalized Headache

49. Classifications
Rosenfeld RM, et al 2015

50. Classifications
Viral Rhinosinusitis
Rosenfeld RM, et al 2015

51. ACUTE SINUSITIS Less than one month duration
Purulent drainage, congestion/obstruction, significant sinus pain and pressure
Isolated acute infection without recurrent “sinus
symptoms”
Most commonly secondary to upper respiratory viral infection or other inflammatory condition
Associated with perennial rhinitis with inflammation
obstruction of the ostia/drainage passages of the sinuses
primarily neutrophilic inflammation with a small amount of
eosinophils

52. COMMON BACTERIA in ABRS
 70%
Streptococcus pneumoniae
Haemophilus influenza
Moraxella catarrhalis
Others:
Staphylococcus aureus
Sterptococcus pyogenes
Gram-negative bacilli

53. CHRONIC SINUSITIS Greater than three months duration
multiple treatments or infections within one year
multiple year history of recurrent infections or episodes of sinus pain and pressure
symptoms that coincide with changes in altitude or
weather
chronic nasal congestion and drainage
Neutrophilic inflammation associated with obstruction and
inflammation of sinus ostia

54. COMMON BACTERIA in CRS Can Differ from those involved in ABRS
Staphylococcus aureus
methicillin-susceptible S aureus [MSSA]
methicillin-resistant S aureus [MRSA] strains
Coagulase-negative staphylococci
H influenzae
M catarrhalis
S pneumoniae
Streptococcus intermedius
Pseudomonas aeruginosa
Nocardia species
Anaerobic bacteria (Peptostreptococcus, Prevotella, Porphyromonas, Bacteroides, Fusobacterium species)

55. CHRONIC RHINOSINUSITIS (CRS) WITH POLYPS
Associated with eosiniphilic inflammation with some association with interleukin 4 and 5 and IgE mediated response
Patients with genetic mucociliary transport diseases such as cystic fibrosis or patients who have significant acquired changes of the mucosa following surgery may also have neutrophilic inflammation

56. Nasal Endoscopy polyp Purulent discharge
Nyquist, et al Surgical management of rhinosinusitis in endoscopic-endonasal skull-base surgery, Int Forum All Rhino 2015

58. ALLERGIC FUNGAL SINUSITIS (AFRS)
Non-invasive
local fungal hyphae in the mucin
allergic response to the fungus
polyps with thick grey to brownish “greasy” mucin drainage

59. ALLERGIC FUNGAL SINUSITIS (AFRS)
Invasive
Microscopic invasion of fungus in the
mucosa
Necrotic black tissue with nonpainful debridement is an emergent life threatening fungal infection
Immunocompromised patients (DM, HIV,
pancytopenia, etc.)

60. Fungal Sinusitis
Nyquist, et al Surgical management of rhinosinusitis in endoscopic-endonasal skull-base surgery, Int Forum All Rhino 2015

61. Intra-operative Allergic Fungal Sinusitis

62. Complications of Rhinosinusitis
Orbital cellulitis or abscess
Meningitis
Brain abscess
Cavernous Sinus thrombosis
Subdural empyema
Pulmonary disease exacerbations (i.e. intractable asthma)

63. Adult Sinusitis Guidelines OTO HNS Academy 2015
Rosenfeld RM, et al 2015

64. Rosenfeld RM, et al 2015

65. Adult Sinusitis Guideline
OTO HNS Academy
Strong recommendations:
Distinguish presumed ABRS from ARS caused by viral upper respiratory infections and noninfectious conditions and
Confirm a clinical diagnosis of CRS with objective documentation of sinonasal inflammation, which may be accomplished using anterior rhinoscopy, nasal endoscopy, or computed tomography.
Rosenfeld RM, et al 2015

66. Adult Sinusitis Guideline
OTO HNS Academy
Recommendations:
should either offer watchful waiting (without antibiotics) or prescribe initial antibiotic therapy for adults with uncomplicated ABRS;
should prescribe amoxicillin with or without clavulanate as first-line therapy for 5 to 10 days (if a decision is made to treat ABRS with an antibiotic)
should reassess the patient to confirm ABRS, exclude other causes of illness, and detect complications if the patient worsens or fails to improve with the initial management option by 7 days after diagnosis or worsens during the initial management;
Rosenfeld RM, et al 2015

67. Adult Sinusitis Guideline
OTO HNS Academy
Recommendations:
Distinguish CRS and recurrent ARS from isolated episodes of ABRS and other causes of sinonasal symptoms;
Assess the patient with CRS or recurrent ARS for multiple chronic conditions that would modify management, such as asthma, cystic fibrosis, immunocompromised state, and ciliary dyskinesia;
Confirm the presence or absence of nasal polyps in a patient
with CRS
Recommend saline nasal irrigation, topical intranasal corticosteroids, or both for symptom relief of CRS.
Rosenfeld RM, et al 2015

68. Adult Sinusitis Guideline
OTO HNS Academy
Options (limited data, provider discretion):
recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation for symptomatic relief of viral rhinosinusitis;
recommend analgesics, topical intranasal steroids, and/or nasal saline irrigation) for symptomatic relief of ABRS;
obtain testing for allergy and immune function in
evaluating a patient with CRS or recurrent ARS.
Rosenfeld RM, et al 2015

69. Adult Sinusitis Guideline
OTO HNS Academy
Recommendation AGAINST:
should not obtain radiographic imaging for patients who meet diagnostic criteria for ARS, unless a complication or alternative diagnosis is suspected
should not prescribe topical or systemic
antifungal therapy for patients with CRS
Rosenfeld RM, et al 2015

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72. ABRS NON-SURGICAL TREATMENT
Nasal corticosteroids
Nasal saline irrigations
Analgesics
Mucolytics
Antihistamines
in ARS, dehydrating. Not indicated
Decongestants
Conservative use
3 days max for intranasal
Oral steroid taper
An option
Not typically necessary
Reviews suggest improve symptoms vs placebo, but not compared to Abx alone
Venekamp et al 2015
Mucocilia may take up to 4-6 weeks to resume normal function
CT of sinuses only if indicated (suspect complication)

73. Systematic reviews indicated in untreated immunocompetent,
Antibiotics in ABRS
First Line Tx [w/o risk factors for resistance]:
Watchful waiting
Systematic reviews indicated in untreated immunocompetent,
70-80% improve within 2 weeks OR
Amoxicillin (+/- Clavulanate) 500 mg TID or 875mg BID x 5-10 days
Clavulanate improved coverage for resistant H.Flu and Moraxella
Patients with significant risk factors for resistance:
High dose Augmentin 875mg - 2g/125mg BID
Risk factors include:
Increased local resistance rates
>65 yrs
Recent hospitalization
Recent antibiotic use within prior month
Immunocompromised
Multiple comorbidities (DM, hepatic/renal disease)
Signs of severe infection (fever >102, complications)
Chow AW et al, 2012

74. Antibiotic Management
Rosenfeld RM, et al 2015

75. Antibiotics in ABRS Patients w/ PCN allergy or alternative for PCN:
Doxycycline (100 mg orally twice daily or 200 mg orally daily) is a reasonable alternative for first-line therapy
For PCN allergic patients who can tolerate cephalosporins,
clindamycin 150 mg or 300 mg every six hours
plus a third-generation oral cephalosporin
cefixime 400 mg daily
cefpodoxime 200 mg twice daily

76. Antibiotics in ABRS Alternatives for Augmentin non-responders
Fluoroquinolone
levofloxacin 500 mg orally or moxifloxacin 400 mg orally once daily
should be reserved for those who have no alternative treatment options
Potential for serious adverse effects associated with
fluoroquinolones may outweigh the benefits for patients with ABRS
Resistance higher for
Macrolides (clarithromycin or azithromycin)
trimethoprim-sulfamethoxazole
second- or third-generation cephalosporins alone
Not recommended for empiric therapy because of high rates of resistance of S. pneumoniae (and of H. influenzae for trimethoprim-sulfamethoxazole)
(Accessed on May 26, 2016)

77. Antibiotics in ABRS Duration: Initial 5-10 days
Evidence suggests response and relapse rates may be similar between short and long course
Meta-analysis is inconsistent
Most opt for 10 day course
Falagas ME, 2009

78. Antibiotics in ABRS Treatment Failure: Second Line Tx:
Worsening or failure to improve within 7 days
Reassessment necessary to confirm Dx
Imaging optional – concern for complication or question of correct diagnosis
Second Line Tx:
Broad Spectrum coverage
If improvement w/in 7 d, continue for total course of 10d
Amoxicillin-clavulanate 2 g/125 mg extended-release tablets
orally twice daily
Levofloxacin 500 mg orally once daily
Moxifloxacin 400 mg orally once daily
Doxycycline 100 mg orally twice daily or 200 mg orally daily

79. Antibiotics in ABRS Relapse after initial treatments:
Within 2 weeks, if had initial good response, can dose same medication for longer
If relapse is more severe, consider alternate Abx choice for resistance

80. Antibiotics in ABRS Failure of 1st and 2nd line therapy:
Refer to Otolaryngology
Endoscopic-guided cultures indicated
Consider CT imaging
Non-contrast for most uncomplicated resistant ABRS
Contrast if concern for complication (i.e. orbital
cellulitis/abscess, intracranial involvement)
Consider ordering CT with surgical navigation protocol
May save on additional imaging
Hold on ordering imaging if sending for consultation

81. CRS: NON-SURGICAL TREATMENT
Chronic or recurrent sinusitis without polyps
Nasal steroids – long-term treatment
Nasal saline irrigation – long-term treatment
Antibiotics as indicated typically from 3-6 weeks or
longer
Culture guided
Medication Irrigations (off-label)
Otolaryngologist evaluation
CT sinuses
Allergy workup may be indicated

82. CRSwNP: NON-SURGICAL TREATMENT Chronic rhinosinusitis with polyps
Otolaryngologist evaluation
Nasal steroids – long-term treatment
Nasal saline irrigation – long-term treatment
Systemic Steroids (variable dosing)
Main treatment option
Primarily an inflammatory disease process
Antibiotics as indicated typically from 3-6 weeks or longer
Culture guided
Medicated Irrigations (off-label use steroids, Abx)
Usually in post-op patients
Allergy testing/Immunotherapy

83. Allergic Fungal Sinusitis (AFRS)
TREATMENT
Otolaryngologist evaluation and management
Most common organism – Aspergillus fumigates
Antifungal Tx not demonstrated to improve over placebo
Nasal steroids – long-term treatment
Nasal saline irrigation – long-term treatment
Allergy workup and treatment
Antibiotics if mixed infection
Systemic Steroids – variable dosing
CT sinuses indicated for surgical planning
Surgery – for persistent symptomatic or chronic disease treatment of choice.
Must remove fungal mucin/debris or symptoms will recur

84. Intra-operative Allergic Fungal Sinusitis

85. SURGICAL TREATMENT Balloon Dilation In-office or outpatient surgery
Limited indications
Can be used in hybrid with traditional FESS
Functional Endoscopic Sinus Surgery
First line approach for most CRS
Image guidance
Open sinus procedures
Rarely indicated currently. Technologic improvement provides excellent visualization and access endoscopically
Caldwell Luc, Trephination, Frontal sinus
osteoplastic flap, cranialization

86. Image-guided Endoscopic Sinus Surgery

87. Conclusions AVRS expect to resolve within 10 days
AVRS which fails to improve after ≥10 days of symptomatic management are more likely to have ABRS and should be managed as ABRS
Symptomatic management of ARS aims to relieve symptoms of nasal obstruction and rhinorrhea
OTC Analgesics and saline nasal irrigation
Intranasal glucocorticoids
Urgent, early referral for patients with symptoms that are concerning for complicated ABRS or have evidence of complications on imaging
ABRS may be a self-limited disease
Watchful waiting for immunocompetent patients with ABRS who have good follow- up
Start antibiotic therapy for patients who do not have good follow-up

88. macrolides, Bactrim or oral second- or third-generation cephalosporins
Conclusions
Antibiotics in those managed with observation who have worsening symptoms, especially after 10 days
Initial empiric treatment with amoxicillin (+/--clavulanate) rather than
macrolides, Bactrim or oral second- or third-generation cephalosporins
PCN allergy: Doxycycline or combo clinda/3rd generation cephalosporin
Patients with risk factors for resistance
consider high-dose amoxicillin-clavulanate (875 to 2 g/125 mg extended-
release tablets orally twice daily)
Reserve fluoroquinolone – high risk option
Recurrence within 2 weeks of response to initial treatment
usually represents inadequate eradication of infection
Extend tx course
Imaging generally not indicated for ABRS
Consider referral first to ENT for non-responders

89. References:
Nyquist et al. Middle turbinate preservation in endoscopic transsphenoidal skull base
surgery. Skull Base 2010
Rosenfeld, RM, et al. Clinical Practice Guideline (Update): Adult Sinusitis. Otolaryngology–Head and Neck Surgery. Vol 152, Issue 2_suppl, pp. S1 - S39. April
Chow AW, Benninger MS, Brook I, Brozek JL, Goldstein EJ, Hicks LA, Pankey GA, Seleznick M, Volturo G, Wald ER, File TM Jr . IDSA clinical practice guideline for acute bacterial rhinosinusitis in children and adults. Infectious Diseases Society of America. Clin Infect Dis. 2012;54(8):e72.
Falagas ME, Karageorgopoulos DE, Grammatikos AP, Matthaiou DK. Effectiveness and safety of short vs. long duration of antibiotic therapy for acute bacterial sinusitis: a meta- analysis of randomized trials. Br J Clin Pharmacol. 2009;67(2):161. Epub 2008 Sep 19.
Venekamp RP, et al. Systemic corticosteroid therapy for acute sinusitis. JAMA Mar;313(12):
Venekamp RP, Thompson MJ, Hayward G, Heneghan CJ, Del Mar CB, Perera R, Glasziou PP, Rovers MM. Systemic corticosteroids for acute sinusitis. Cochrane Database Syst Rev

90. Thank You!