Rhinosinusitis: Diagnosis and Treatment: Edoardo Cervoni, M.D

Edoardo Cervoni, M.D.
RHINOSINUSITIS:
DIAGNOSIS AND
TREATMENT
GP Trainees 27/11/13,
Education Centre RPH 1
Discolosures
• Grant/Research Support: no
disclosure
• Consultant: no disclosure
• Major Shareholder: Locumdoctor4u
Ltd. (Locum and Concierge Medical
Services)
• I will not be discussing “off-label”
uses of medications or investigations
ENT Referrals
i. Most ENT referrals are linked to Audiological and
Otological problems.
ii. Out of 271 consecutive referrals to the RHP ENT

Department triaged in 2011, 58% could be potentially
managed in Primary Care.
CLPCT NHS Survey 2011 – E Cervoni
GP Trainees 27/11/13, 3
Education Centre RPH
ENT Referrals
i. Snoring and sleep apnoea were relatively common reasons of
referrals.
ii. In a rather significant proportion of cases, relevant information,
with specific reference to the physical examination, were missing.
iii. Among the referrals redirected to the GPwSI in ENT, deafness with
wax, epistaxis and blocked nose were the most common
complaints.
CLPCT NHS Survey 2011 – E Cervoni
Conditions referred
Cervoni E - 2011
EPOS 2012
Rhinosinusitis
 Inflammation
Inflammation of
of the
the nose
nose and
and
paranasal
paranasal sinuses
sinuses characeterized
characeterized
by
by the
the presence
presence ofof 22 or
or more
more
symptoms
symptoms of of which
which one
one MUST
MUST bebe
nasal
nasal obsteruction
obsteruction or
or rhinorrhoea
rhinorrhoea
with:
with:
±facial
±facial pain/pressure
pain/pressure
±hypo/anosmia
±hypo/anosmia
Associated with
 Endoscopic signs: and/or  CT abnormal changes:
-- polyps
polyps and/or
and/or -- mucosal
mucosal changes
changes atat the
the level
level
-- purulent
purulent secretion
secretion from
from the
the middle
middle of
of the
the osteo-meatal
osteo-meatal complex
complex or or
meatus
meatus and/or
and/or of
of the
the paranasal
paranasal sinuses
sinuses
-- oedema/mucosal
oedema/mucosal obstruction
obstruction
prevalent
prevalent in
in the
the middle
middle meatus
meatus
CLASSIFICATION
on severity of the symptoms
Rhinosinusitis may be classified into mild, moderate or
severe on the basis of VAS score.
Mild
Mild == VAS
VAS 00 -- 33 Moderate
Moderate == >3
>3 -- 77 Severe
Severe == VAS
VAS >7
>7 -- 10
10
To assess the severity of the symptoms the patient is asked

to answer the following question:
How
How painful
painful are
are the
the symptoms
symptoms of
of your
your sinusitis?
sinusitis?
No pain 10 cm Worst possible

pain
CLASSIFICATION
on duration
12 weeks
ACUTE/RECURRENT CHRONIC
(complete
(complete resolution
resolution of
of the
the symptoms)
symptoms) (incomplete
(incomplete resolution
resolution of
of the
the symptoms)
symptoms)
Acute Rhinosinusitis:
clinical features
Sudden onset of its symptoms of which one must be nasal
obstruction or rhinorrhoea
±facial
pain/pressure
±hypo/anosmia
±hypo/anosmia
And duration <12 weeks
Presence
Presence of of endoscopic
endoscopic signssigns of:of:
••Purulent
Purulent secretion
secretion from
from the
the middle
middle meatus
meatus
••Oedema
Oedema and/or
and/or obstruction
obstruction of
of the
the middle
middle meatus
meatus
Presence
Presence of
of abnormal
abnormal changes
changes to
to CT
CT imaging
imaging
Acute rhinosinusitis:

types
Acute viral (common cold)
Duration
Duration of
of the
the symptoms
symptoms << 10
10 days
days
 Acute post-viral
-- Symptoms
Symptoms oncrease
oncrease after
after 55 days
days
-- Persistence
Persistence of
of the
the symptoms
symptoms after
after 10
10 days,
days, but
but for
for less
less than
than
12
12 weeks
weeks
 Bacterial post-viral
Presence
Presence of
of at
at the
the least
least 33 symptoms
symptoms and/or
and/or signs:
signs:
-Purulent
-Purulent secretion
secretion
-Pain
-Pain with
with unilateral
unilateral preponderance
preponderance
-Fever
-Fever (>38
(>38 C)
C)
-Raised
-Raised ESR
ESR and
and CPR
CPR
-Worsening
-Worsening of
of the symptoms
theEducation
symptoms after
RPHa
after
Centre a phase
phase of
of remission
remission
differential diagnosis
 Viral infection of the upper airways
 Allergic rhinitis
Confirmed
Confirmed positivity
positivity to
to aa common
common allergen
allergen
ItIt is
is characterized
characterized by by rhinorrhoea
rhinorrhoea (which
(which isis not
not
purulent),
purulent), senstion
senstion of
of nasal
nasal obstruction,
obstruction, itchy
itchy nose,
nose,
sneezing
sneezing (spontaneus
(spontaneus regression
regression ofof the
the symptoms
symptoms
or
or following
following treatment)
treatment)
Associated
Associated to
to ophtalmological
ophtalmological symptoms/signs
symptoms/signs
 Odontogenic
Absence
Absence of
of nasal
nasal signs
signs and
and symptoms
symptoms
CHRONIC RHINOSINUSITIS
Sudden appearance of two or more symptoms of which ine
should be nasal obstruction or rhinorrhoea
±facial
pain/pressure
±hypo/anosmia
±hypo/anosmia
Duration >12 weeks
Presence
Presence of of endoscopic
endoscopic signs
signs of:of:
••Nasal
Nasal polyps
polyps
••Muco-purulent
Muco-purulent secretion
secretion from
from the
the middle
middle meatus
meatus
••Oedema
Oedema and/or
and/or obstruction
obstruction of
of the
the middle
middle meatus
meatus
Presence
Presence of
of CT
CT abnormalities
abnormalities
Types of chronic rhinosinusitis
 With nasal polyps
 Without nasal polyps
15
This disequilibrium determines an activation of TH2 immune response.
The response is characterized by the production of cytokines which may
differ depending of the specific nature of the chronic inflammatory
response.
Allergic fungal
rhinosinusitis
Usually unilateral, with occasional purulent secretion
Characterized by high levels of IL-4, IL-5 and IL-13.
The high levels of IL-5 observed on those patients affected by allergic fungal
rhinosinusitis highlights who this condition may be considered
independently from oesinophils dysfunction disease.
Allergic fungal rhinosinusitis
Invasive form
• Acute fulminant
• Chronic: - granulomatous
- invasive
Non-invasive form
• Allergic fungal rhinosinusitis
• Fungal ball
NOTE: surgery must be associated to antibiotic therapy and
corticosteroids aiming to reduce the inflammatory component
and/or infective.
There is scientific evidence to support the use of topical steroids,
antibiotics and antifungal drugs.
Diagnosis is based on CT, MRI and pathology results
Chronic rhinosinusitis:
- Without asthma or allergy
- Whitout asthma, but with allergy
- With asthma and allergy
- With asthma, but without allergy
- With allergy to aspirin
- Allergic fungal
- Cystic fibrosis
DIAGNOSIS
- Anamnesis
- Anterior rhinoscopy
- Nasal endoscopy
- Nasal swab
- CT
- MRI
- Biofilm Research
Little role of plain x-rays
(Skinner et al., 1991)
F.N.* F.P.** A.D.***
Maxillary sinus 3% 20% 77%
Ethimoid 55% - 36%
Sphenoid 43% 1% 52%
Nasal cavity 3% 4% 93%
* False negatives: Rx normal/pathological

** mucosa
*** False positives: Rx pathological/ normal
mucosa Diagnostic accuracy: Education
Rx findings/Intra-
Centre RPH
operative findings in keeping with Rx
DIAGNOSIS
• Extension of the disease
• Presence of bone eroisions
• Presence of anatomical ESTENSIONE DELLA PATOLOGIA
variances with possible

operative challenges
PRESENZA DI INTERRUZIONE DELLE LIMITANTI OSSEE
PRESENZA DI ANOMALIE ANATOMICHE
Osteitis
Does
Does not
not offer
offer details
details of
of bone
bone structures
structures
Overestimes
Overestimes presence
presence of
of mucosal
mucosal abnormalities
abnormalities
Excellent
Excellent visualization
visualization of
of soft
soft tissues.
tissues.
Helpful
Helpful to
to assess
assess neoplastic
neoplastic pathology
pathology
Helpful
Helpful to
to assess
assess the
the extension
extension of
of inflammatory
inflammatory processes.
processes.
DIAGNOSIS
European guidelines
for the treatment of
rhinosinusitis and nasal
polyps
“EVIDENCE BASED MEDICINE”
Categories
Ia Evidence
Evidence from
from meta-analysis
meta-analysis of
of randomised
randomised controlled
controlled trials
trials
Ib Evidence
Evidence from
from at
at least
least one
one randomised
randomised controlled
controlled trials
trials
IIa Evidence
Evidence from
from at
at least
least one
one controlled
controlled study
study without
without randomisation
randomisation
IIb Evidence
Evidence from
from at
at least
least one
one other
other type
type of
of quasi-experimental
quasi-experimental study
study
III Evidence
Evidence from
from non-experimental
non-experimental descriptive
descriptive studies,
studies, such
such asas
comparative
comparative studies,
studies, correlation
correlation studies,
studies, and
and case-control
case-control studies
studies
IV Evidence
Evidence from
from expert
expert committee
committee reports
reports or
or opinions
opinions or
or clinical
clinical
experience
experience of
of respected
respected authorities,
authorities, or
or both
both
Shekelle et al., BMJ 1999
Acute rhinosinusitis: therapy
Acute rhinosinusitis: therapy
Antibiotic thereapy is indicated

only when strictly required
(confirmed bacterial infection,
fever and severe pain)
Acute rhinosinusitis: length of antibiotic therapy
Short treatments appear to have the same effectiveness of longer antibiotic
courses
Acute rhinosinusitis: type of antibiotic treatmen
Acute rhinosinusitis: topical steroid therapy
Acute rhinosinusitis: combined therapy
(steroid and oral antibiotic)
Corticosteroids when combined with

oral antibiotics appear to be
particularly effective in producing a
prompt improvement of the
symptoms – evidenca IA
Duration of treatment 3-5 days
Acute rhinosinusitis: complications
Between 3,7% and 20%
Can be:
• Orbital (60-75%) ,
• Intracranial (15-20%)
• Bones (5-10%).
Sinusites account for 10% of the intra-cranial complications, and up to 90% of the
orbital complications.
treatment summary
Chronic rhinosinusitis without nasal
polyposis
topical steroids
Only 2 recent papers have reported a significant benefit of topical steroids versus
placebo.
Anatomical factors and type of device to affect effectiveness of the treatment.
polyposis
topical steroids
polyposis
topical steroids
polyposis
topical steroids
polyposis
topical antibiotics
There is no evidence of benefits resulting from topical antibiotic therapy.
polyposis
oral antibiotics
There is no evidence of benefits from antibiotic therapy < 4 weeks(short term), if
there is no evidence of infection on the basis of microbiology results.
Macrolids are the only class of antibiotics to have shown some benefits (Ib)
Chronic rhinosinusitis with nasal polyposis
topical steroids
Rinosinusite cronica con poliposi nasale
terapia corticosteroidea sistemica
Chronic rhinosinusitis with nasal polyposis
topical steroids
51
Rinosinusite cronica con poliposi nasale
terapia antibiotica sistemica
Non ci sono evidenze sulla terapia antibiotica topica
When surgery?
Experience
Common sense Knowledge of

the pathology
WHY SURGERY?
Remove paranasal obstruction

Improve ventilation and drainage of sinuses
Reduce number of exacerbations
Reduce complications
Improve quality of life
PROBABILITY OF SUCCESS OF
ENDOSCOPIC SURGERY
Poor paranasal sinuses ventilation

Recurring sinusitis
Sinusitis affwecting only one sinus
Maximal “Fungus ball”
Mucocele
Antral polyp
Orbital/intra-cranial complications
PROBABILITY OF SUCCESS OF
ENDOSCOPIC SURGERY
Rhinosinusitis with macropolyposis
Rhinosinusitis with asthma

Intermediate ASA-Syndrome
Cystic Fibrosis
Minimal Kartagener’s S.
Congenital disorders

Rhinosinusitis: Diagnosis and Treatment: Edoardo Cervoni, M.D

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Edoardo Cervoni, M.D.

ii. Out of 271 consecutive referrals to the RHP ENT

CLPCT NHS Survey 2011 – E Cervoni

To assess the severity of the symptoms the patient is asked

No pain 10 cm Worst possible

Duration >12 weeks

 Without nasal polyps

Usually unilateral, with occasional purulent secretion

Characterized by high levels of IL-4, IL-5 and IL-13.

F.N.* F.P.** A.D.***

Maxillary sinus 3% 20% 77%

Ethimoid 55% - 36%

Sphenoid 43% 1% 52%

Nasal cavity 3% 4% 93%

* False negatives: Rx normal/pathological

• Presence of bone eroisions

• Presence of anatomical ESTENSIONE DELLA PATOLOGIA

variances with possible

PRESENZA DI INTERRUZIONE DELLE LIMITANTI OSSEE

Antibiotic thereapy is indicated

Corticosteroids when combined with

Duration of treatment 3-5 days

Common sense Knowledge of

Remove paranasal obstruction

Poor paranasal sinuses ventilation

Rhinosinusitis with macropolyposis

Rhinosinusitis with asthma

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F.N.* F.P. A.D.*