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Chronic RhinoSinusitis- State of the Art
Gary Kroukamp
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Definition: >3 months of symptoms of sinusitis
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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.
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Chronic Rhinosinusitis?
History Duration Allergic Symptoms? Smoker? Presenting symptoms Examination
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The Dairy and Wheat Myth!
Milk mucous sensation Inhaled vs Ingested allergen
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Common Presenting Symptoms
nasal obstruction 94% postnasal drip % facial pain & headache 90% rhinorrhoea 61% hyposmia / anosmia
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Physical examination:
Purulent rhinorrhoea Polyps Complications?
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Scope Pus Polyps Oedema
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Pathophysiology: Obstruction of osteomeatal complex
Impaired mucociliary clearance Biofilm Superantigen Inflammatory Cascade
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Anatomical variants: deviated nasal septum concha bullosa
ethmoid bulla other middle turbinate anomalies Agger nasi cells Haller cells
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Underlying diseases: asthma cystic fibrosis ciliary dysmotility
immuno-compromised: chemotherapy transplant immuno-deficiency
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CT scan? Sinusitis or not? Surgical Planning
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Normal CT
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Abnormal CT
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Really Abnormal CT
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Objectives for treatment:
Improve Symptoms Treat Infection Resume normal sinus physiology Prevent complications
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Microbiology: Anaerobes Staphylococcus aureus Streptococcus
Haemophilus Influenzae Moraxella catarrhalis
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Treatment options: Antibiotics Oral Steroids Nasal Steroids Saline
sufficient duration Oral Steroids Nasal Steroids Saline Anti –leucotrienes (Singulair) – not shown to be effective
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Antibiotics: Controversial- none approved in Canada as indication for CRS If there is pus! Amoxicillin-clavulanic acid - Augmentin Fluoroquinolones - Moxifloxacin Macrolides - Ketek
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Steroids? Oral short course IL-5 & IL-13
Reduce tissue inflammation, oedema
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Nasal Steroids Treatment mainstay! Compliance! 3 months! Chronic use…
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Future Research The magic bullet! Anti-inflammatory biological
Anti-interleukin
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Referral Failure of treatment Complications
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“Sinus headache” Headache is complicated Multifactorial!
Sinus headache/pain does NOT mean sinusitis MUST have proper evaluation
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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
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FESS – Surgical Aims Restore sinus function
Improve ventilation and drainage Open the ostium Remove the obstructed honeycomb (ethmoids) Clear obstruction
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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 -
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