CHRONIC RHINOSINUSITIS

What is chronic rhinosinusitis?

Chronic inflammation of the nasal or sinus cavities for more than 12 weeks can be termed chronic Rhinosinusitis (CRS). It is classically defined to be present when at least two of the following symptoms occur for > 12 weeks: 1. nasal discharge 2. Facial/dental pain, 3. Nasal blockage 4. Hyposmia (decreased smell)

CRS has three distinct categories, namely:

-CRS with nasal polyp

-CRS without nasal polyp

-Allergic fungal rhinosinusitis

CRS without nasal polyposis: Most common type where there is swelling and irritation of the lining of the sinus cavities due to factors such as allergies/infections.

CRS with nasal polyposis: Growth of pale abnormal grape-like tissue inside of the nasal cavities is termed nasal polyp. These polyps tend to cause physical obstruction to the sinus drainage pathway and cause recurring inflammation of the sinus lining and fluid accumulation.

Endoscopic image showing pale polypoidal tissue in the right nasal cavity

Allergic Fungal Rhinosinusitis: Strong allergic reaction of nasal sinuses to fungal spores causes the production of thick nasal mucous and cadre of sinusitis symptoms and are thence classified under this category.

Etiology

Bacterial- streptococcus, pneumococcus, Hemophilus

Viral- rhinovirus

Allergic- dust mite/mold

Structural causes- DNS, polyp

Ciliary dysfunction

Immunodeficiencies

Associated comorbidities & disorders- cystic fibrosis, AIDS, Bronchial asthma

What cardinal symptoms can denote the presence of CRS?

1. Nasal discharge- purulent/mucopurulent yellowish or greenish in color

2. fullness and pressure-like pain over the face and/or Dental region

3. fever may be inciting factor or may be present on and off continuously

4. nasal block and difficulty breathing

5. decreased sense of smell

6. headache

7. earache/ block sensation in the ear

8. Halitosis/ toothache

9. Cough, fatigue

Four episodes of sinusitis in one year can be termed a recurrent sinusitis

Evaluation of Chronic Rhinosinusitis

Coronal CT scan image showing ethmoidal polyposis and opacification of the right maxillary sinus and air-fluid shadow of the left maxillary sinus

Coronal CT image showing CRS with polyposis

Gomori methenamine silver staining showing fungal elements, diagnostic of AFRS

Sagittal Image showing CRS without polyposis showing mucosal inflammation of maxillary sinus wall

Management of Chronic Rhinosinusitis

Lifestyle and supportive modifications

1. Smoking cessation

2. Avoidance of allergic triggers and their identification

3. Nasal hygiene and regular nasal douching

Medical management

1. Nasal topical steroid sprays such as Fluticasone furoate for 8-12 weeks duration

2. Nasal saline irrigation- high volume regular douching acts as a good adjunct

3. Antihistamines can be given orally

4. Decongestant help with the relief of symptoms

5. Oral steroids are not routinely indicated

Surgical Management

Balloon Sinuplasty is a system used for creating microfracture in the bone near the sinus Ostia to facilitate drainage from the sinus spaces

Functional Endoscopic Sinus surgery has now become the routine modality of treatment where there is absolute relief of obstruction, restoration of drainage pathways and mucociliary clearance, and ventilation of sinus spaces. It is a minimally invasive surgical procedure that exteriorizes the sinus air cells and opens the sinus Ostia using endoscopic direct vision. Unlike open sinus surgery, FESS preserved normal structures, removes obstructions only, and restores the function of the sinus spaces with quick recovery. With the advent of Intraoperative navigational systems, FESS has become a more routine surgery for targeted sinus disease eradication and treatment increasing thereby the effectiveness of subsequent anti-allergy medications and supportive therapy thereby preventing any future possibilities of recurrence.