Knowledge week contents
Contributing Author: Nick Jones
Sinusitis occurs with concomitant rhinitis; hence the term rhinosinusitis. Rhinosinusitis may be allergic, non-allergic or infective, sometimes resulting from immune deficiency (innate or acquired). Mixed forms also occur.
Diagnosis of rhinosinusitis
This is primarily a clinical diagnosis and made on the history and examination.
Signs and Symptoms
Major symptoms - two or more of:
• Nasal congestion or obstruction
• Nasal discharge (anterior or posterior)
• Facial pain or pressure
• Olfactory disturbance
AND either
Endoscopic signs - one or more of:
• Polyps, oedema or mucopurulent discharge
OR
Computerised Tomography (CT) signs
• Significant mucosal changes
Acute rhinosinusitis is usually viral. Antibiotics are only indicated for bacterial superinfection when the symptoms are severe. Analgesia and steam inhalation offer symptomatic relief. Topical nasal corticosteroids with oral antibiotics give a more rapid resolution of symptoms.
Chronic rhinosinusitis may be predominantly eosinophilic or neutrophilic.
Sinus X-rays rarely help. CT scans should be reserved for failed medical therapy or features of atypical infection or malignancy i.e. unilateral symptoms, blood-stained discharge, eye displacement.
Aetiology
Investigation of underlying causes:
• Allergy (skin prick tests/specific IgE)
• Immune deficiency, chronic infection (immunoglobulins subclasses/histology, culture)
• Vasculitis/granulomatous/autoimmune (FBC, CRP, ACE, ANCA, biopsy)
• Aspirin sensitivity (inhaled or nasal lysine-aspirin challenge, oral aspirin challenge)
• Allergic fungal sinusitis (skin prick tests, aspergillus-specific IgG and IgE, CT changes, histology)
Treatment
Initial therapy is medical to reduce symptoms. Surgery is reserved for treatment failure. A randomised prospective study of patients with polypoid or non-polypoid chronic rhinosinusitis demonstrated that there was no difference between patients who received medical treatment (topical corticosteroid, nasal douching and long term erythromycin) compared to those who underwent endoscopic sinus surgery combined with topical nasal steroids [1].
Systemic steroids help control symptoms and a short course minimizes side effects. A dose of 40–70 mg (depending on body mass) of prednisolone with breakfast for 4–7 days is recommended.
Check there are no contraindications (diabetes, cardiac disease, gastric or duodenal ulcers, osteoporosis, etc.). Patients should be warned of the potential side effects.
The most potent topical steroid is betamethasone drops taken in the nostril up position but they should only be given for two months at a time and no more than 4 months in any 12 month period because of their systemic absorption. Antihistamines only help if there is allergy. Leukotriene inhibitors help a minority with coexisting asthma and/or aspirin sensitivity. There is some evidence that three months of a macrolide antibiotic can help in nasal polyposis [2]. Douching has been shown to provide symptomatic benefit [3-8].
Nasal Polyps
Nasal polyps occur when the oedematous lining of the nasal cavity becomes dependent. Nasal polyps are not associated with allergy but can be associated with asthma, aspirin sensitivity, cystic fibrosis, allergic fungal sinusitis (AFS).
Symptoms of nasal polyps
• Nasal obstruction
• Rhinorrhoea
• Hyposmia / anosmia, decreased taste
• Post nasal catarrh
• Secondary bacterial infection may occur when polyps block the sinus ostia.
Diagnosis
• Larger polyps distinguishable from the inferior turbinate by their lack of sensitivity, mobility, and yellowish grey colour.
• Smaller polyps may only be visible on nasendoscopy.
• Unilateral polyps may be a sign of malignancy and should always be subject to ENT referral.
• Test children with nasal polyps for cystic fibrosis
Treatment
Patients should have a trial of medical treatment prior to surgery unless histology is required. Smaller polyps may respond to topical corticosteroid, initially betnesol. Larger polyps may respond to a
medical polypectomy (Prednisolone 0.5mg/kg each morning for five to ten days plus Betnesol 2 drops per nostril tds in the ‘nostril up’ position for five days, then twice daily until the bottle runs out. Maintenance therapy with fluticasone (drops, spray) or mometasone (spray) is recommended as these have lower bioavailability, unlike betnesol.
Other treatment modalities
• Leukotriene receptor antagonists
• Macrolide antibiotics can reduce nasal polyps when used over several weeks or months, possibly via anti-inflammatory activity.
• Azelastine: open studies suggest that this may have some benefit in nasal polyposis [9].
• Surgery will remove the obstructing tissue, but does not control the symptoms of rhinitis. Poor olfactory function may not be reversed by surgery. A randomised prospective study showed that medical treatment is superior to surgery when effects on the lower respiratory tract are considered [1].
References
1. Ragab SM, Lund VJ, Scadding G. Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomised, controlled trial. Laryngoscope 2004; 114:923-30. [Link to abstract]
2. Yamada T, Fujieda S, Mori S, Yamamoto H, Saito H. Macrolide treatment decreased the size of nasal polyps and IL-8 levels in nasal lavage. Am J Rhinol 2000; 14:143-8. [Link to abstract]
3. Tomooka LT, Murphy C, Davidson TM. Clinical study and literature review of nasal irrigation. Laryngoscope 2000; 110:1189-93. [Link to abstract]
4. Brown CL, Graham SM. Nasal irrigations: good or bad? Curr Opin Otolaryngol Head Neck Surg 2004; 12:9-13. [Link to abstract]
5. Taccariello M, Parikh A, Darby Y, Scadding G. Nasal douching as a valuable adjunct in the management of chronic rhinosinusitis. Rhinology 1999; 37:29-32. [Link to abstract]
6. Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R. Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. J Fam Pract 2002; 51:1049-55. [Link to abstract]
7. Heatley DG, McConnell KE, Kille TL, Leverson GE. Nasal irrigation for the alleviation of sinonasal symptoms. Otolaryngol Head Neck Surg 2001;125:44-8. [Link to abstract]
8. Shoseyov D, Bibi H, Shai P, Shoseyov N, Shazberg G, Hurvitz H. Treatment with hypertonic saline versus normal saline nasal wash of pediatric chronic sinusitis. J Allergy Clin Immunol 1998; 101:602-5. [Link to abstract]
9. Gehanno P, Deschamps E, Garay E, Baehre M, Garay RP. Vasomotor rhinitis: clinical efficacy of azelastine nasal spray in comparison with placebo. ORL J Otorhinolaryngol Relat Spec 2001; 63:76-81. [Link to abstract]
Knowledge week contents
Contributing Author: Nick Jones
Sinusitis occurs with concomitant rhinitis; hence the term rhinosinusitis. Rhinosinusitis may be allergic, non-allergic or infective, sometimes resulting from immune deficiency (innate or acquired). Mixed forms also occur.
Diagnosis of rhinosinusitis
This is primarily a clinical diagnosis and made on the history and examination.
Signs and Symptoms
Major symptoms - two or more of:
• Nasal congestion or obstruction
• Nasal discharge (anterior or posterior)
• Facial pain or pressure
• Olfactory disturbance
AND either
Endoscopic signs - one or more of:
• Polyps, oedema or mucopurulent discharge
OR
Computerised Tomography (CT) signs
• Significant mucosal changes
Acute rhinosinusitis is usually viral. Antibiotics are only indicated for bacterial superinfection when the symptoms are severe. Analgesia and steam inhalation offer symptomatic relief. Topical nasal corticosteroids with oral antibiotics give a more rapid resolution of symptoms.
Chronic rhinosinusitis may be predominantly eosinophilic or neutrophilic.
Sinus X-rays rarely help. CT scans should be reserved for failed medical therapy or features of atypical infection or malignancy i.e. unilateral symptoms, blood-stained discharge, eye displacement.
Aetiology
Investigation of underlying causes:
• Allergy (skin prick tests/specific IgE)
• Immune deficiency, chronic infection (immunoglobulins subclasses/histology, culture)
• Vasculitis/granulomatous/autoimmune (FBC, CRP, ACE, ANCA, biopsy)
• Aspirin sensitivity (inhaled or nasal lysine-aspirin challenge, oral aspirin challenge)
• Allergic fungal sinusitis (skin prick tests, aspergillus-specific IgG and IgE, CT changes, histology)
Treatment
Initial therapy is medical to reduce symptoms. Surgery is reserved for treatment failure. A randomised prospective study of patients with polypoid or non-polypoid chronic rhinosinusitis demonstrated that there was no difference between patients who received medical treatment (topical corticosteroid, nasal douching and long term erythromycin) compared to those who underwent endoscopic sinus surgery combined with topical nasal steroids [1].
Systemic steroids help control symptoms and a short course minimizes side effects. A dose of 40–70 mg (depending on body mass) of prednisolone with breakfast for 4–7 days is recommended.
Check there are no contraindications (diabetes, cardiac disease, gastric or duodenal ulcers, osteoporosis, etc.). Patients should be warned of the potential side effects.
The most potent topical steroid is betamethasone drops taken in the nostril up position but they should only be given for two months at a time and no more than 4 months in any 12 month period because of their systemic absorption. Antihistamines only help if there is allergy. Leukotriene inhibitors help a minority with coexisting asthma and/or aspirin sensitivity. There is some evidence that three months of a macrolide antibiotic can help in nasal polyposis [2]. Douching has been shown to provide symptomatic benefit [3-8].
Nasal Polyps
Nasal polyps occur when the oedematous lining of the nasal cavity becomes dependent. Nasal polyps are not associated with allergy but can be associated with asthma, aspirin sensitivity, cystic fibrosis, allergic fungal sinusitis (AFS).
Symptoms of nasal polyps
• Nasal obstruction
• Rhinorrhoea
• Hyposmia / anosmia, decreased taste
• Post nasal catarrh
• Secondary bacterial infection may occur when polyps block the sinus ostia.
Diagnosis
• Larger polyps distinguishable from the inferior turbinate by their lack of sensitivity, mobility, and yellowish grey colour.
• Smaller polyps may only be visible on nasendoscopy.
• Unilateral polyps may be a sign of malignancy and should always be subject to ENT referral.
• Test children with nasal polyps for cystic fibrosis
Treatment
Patients should have a trial of medical treatment prior to surgery unless histology is required. Smaller polyps may respond to topical corticosteroid, initially betnesol. Larger polyps may respond to a
medical polypectomy (Prednisolone 0.5mg/kg each morning for five to ten days plus Betnesol 2 drops per nostril tds in the ‘nostril up’ position for five days, then twice daily until the bottle runs out. Maintenance therapy with fluticasone (drops, spray) or mometasone (spray) is recommended as these have lower bioavailability, unlike betnesol.
Other treatment modalities
• Leukotriene receptor antagonists
• Macrolide antibiotics can reduce nasal polyps when used over several weeks or months, possibly via anti-inflammatory activity.
• Azelastine: open studies suggest that this may have some benefit in nasal polyposis [9].
• Surgery will remove the obstructing tissue, but does not control the symptoms of rhinitis. Poor olfactory function may not be reversed by surgery. A randomised prospective study showed that medical treatment is superior to surgery when effects on the lower respiratory tract are considered [1].
References
1. Ragab SM, Lund VJ, Scadding G. Evaluation of the medical and surgical treatment of chronic rhinosinusitis: a prospective, randomised, controlled trial. Laryngoscope 2004; 114:923-30. [Link to abstract]
2. Yamada T, Fujieda S, Mori S, Yamamoto H, Saito H. Macrolide treatment decreased the size of nasal polyps and IL-8 levels in nasal lavage. Am J Rhinol 2000; 14:143-8. [Link to abstract]
3. Tomooka LT, Murphy C, Davidson TM. Clinical study and literature review of nasal irrigation. Laryngoscope 2000; 110:1189-93. [Link to abstract]
4. Brown CL, Graham SM. Nasal irrigations: good or bad? Curr Opin Otolaryngol Head Neck Surg 2004; 12:9-13. [Link to abstract]
5. Taccariello M, Parikh A, Darby Y, Scadding G. Nasal douching as a valuable adjunct in the management of chronic rhinosinusitis. Rhinology 1999; 37:29-32. [Link to abstract]
6. Rabago D, Zgierska A, Mundt M, Barrett B, Bobula J, Maberry R. Efficacy of daily hypertonic saline nasal irrigation among patients with sinusitis: a randomized controlled trial. J Fam Pract 2002; 51:1049-55. [Link to abstract]
7. Heatley DG, McConnell KE, Kille TL, Leverson GE. Nasal irrigation for the alleviation of sinonasal symptoms. Otolaryngol Head Neck Surg 2001;125:44-8. [Link to abstract]
8. Shoseyov D, Bibi H, Shai P, Shoseyov N, Shazberg G, Hurvitz H. Treatment with hypertonic saline versus normal saline nasal wash of pediatric chronic sinusitis. J Allergy Clin Immunol 1998; 101:602-5. [Link to abstract]
9. Gehanno P, Deschamps E, Garay E, Baehre M, Garay RP. Vasomotor rhinitis: clinical efficacy of azelastine nasal spray in comparison with placebo. ORL J Otorhinolaryngol Relat Spec 2001; 63:76-81. [Link to abstract]
Knowledge week contents
An extensive literature search was conducted on rhinitis for the period 1st May 2006 to 30th April 2007. The full evidence update report is available here.
The following results were extracted for rhinosinusitis and nasal polyps:
Systematic reviews:
(1) Dalziel K, Stein K, Round A, Garside R, Royle P. Endoscopic sinus surgery for the excision of nasal polyps: A systematic review of safety and effectiveness. American Journal of Rhinology. 2006;20:506-519. [Link to abstract]
(2) Finnish-Office-for-Health-Care-Technology-Assessment-. Antibiotics for acute maxillary sinusitis in adults (project) (Brief record). Finnish-Office-for-Health-Care-Technology-Assessment. 2006.
(3) Guo R, Canter P, Ernst E. Herbal medicines for the treatment of rhinosinusitis: a systematic review. Otolaryngology - Head and Neck Surgery 2006;135:496-506. [Link to abstract]
(4) Harvey RJ, Lund VJ. Biofilms and chronic rhinosinusitis: systematic review of evidence, current concepts and directions for research. Rhinology 2007;45:3-13. [Link to abstract]
(5) Khalil HS, Nunez DA Functional endoscopic sinus surgery for chronic rhinosinusitis Cochrane Database of Systematic Reviews: Reviews 2006 Issue 3 John Wiley & Sons , Ltd Chichester, UK DOI : 10 1002 /14651858 CD004458 pub2. 2006. [Link to full text]
(6) Patiar S, Reece P. Oral steroids for nasal polyps. Patiar S, Reece P Oral steroids for nasal polyps Cochrane Database of Systematic Reviews: Reviews 2007 Issue 1 John Wiley & Sons , Ltd Chichester, UK DOI : 10 1002 /14651858 CD005232 pub2. 2007. [Link to full text]
(7) Zalmanovici A, Yaphe J. Steroids for acute sinusitis. Zalmanovici A, Yaphe J Steroids for acute sinusitis. Cochrane Database of Systematic Reviews: Reviews 2007 Issue 2 John Wiley & Sons , Ltd Chichester, UK DOI : 10 1002 /14651858 CD005149 pub2. 2007. [Link to full text]
Randomised controlled trials:
(1) Basibuyuk T, Ozaydin E, Cengizlier R. Nasal cytology in the diagnosis and treatment of sinusitis in atopic and nonatopic children. The Journal of Otolaryngology 2006;35:255-260. [Link to abstract]
(2) Bavbek S, Dursun AB, Dursun E, Eryilmaz A, Misirligil Z. Safety of meloxicam in aspirin-hypersensitive patients with asthma and/or nasal polyps. A challenge-proven study. International Archives of Allergy and Immunology 2007;142:64-69. [Link to abstract]
(3) Benítez P, Alobid I, de HJ et al. A short course of oral prednisone followed by intranasal budesonide is an effective treatment of severe nasal polyps. The Laryngoscope 2006;116:770-775. [Link to abstract]
(4) Beule AG, Wilhelmi F, Kühnel TS, Hansen E, Lackner KJ, Hosemann W. Propofol versus sevoflurane: bleeding in endoscopic sinus surgery. Otolaryngology Head and Neck Surgery 2007;136:45-50. [Link to abstract]
(5) Bugten V, Nordgård S, Skogvoll E, Steinsvåg S. Effects of nonabsorbable packing in middle meatus after sinus surgery. The Laryngoscope 2006;116:83-88. [Link to abstract]
(6) Bugten V, Nordgård S, Steinsvåg S. The effects of debridement after endoscopic sinus surgery. The Laryngoscope 2006;116:2037-2043. [Link to abstract]
(7) Chan KO, Gervais M, Tsaparas Y, Genoway KA, Manarey C, Javer AR. Effectiveness of intraoperative mitomycin C in maintaining the patency of a frontal sinusotomy: a preliminary report of a double-blind randomized placebo-controlled trial. American journal of rhinology. 2006;20:295-299. [Link to abstract]
(8) Corradini C, Del NM, Buonomo A et al. Amphotericin B and lysine acetylsalicylate in the combined treatment of nasal polyposis associated with mycotic infection. Journal of Investigational Allergology & Clinical Immunology 2006;16:188-193. [Link to abstract]
(9) De S, Lemiengre M, Van M et al. Predicting prognosis and effect of antibiotic treatment in rhinosinusitis. Annals of Family Medicine. 2006;4:486-493. [Link to full text]
(10) El H, Abou H, Zaher SR. Management of clinically diagnosed subacute rhinosinusitis in children under the age of two years: a randomized, controlled study. The Journal of Laryngology and Otology 2006;120:845-848. [Link to abstract]
(11) Franklin J, Wright E. Randomized, controlled, study of absorbable nasal packing on outcomes of surgical treatment of rhinosinusitis with polyposis. American Journal of Rhinology 2007;21:214-217. [Link to abstract]
(12) Friese KH, Zabalotnyi DI. Homeopathy in acute rhinosinusitis : A double-blind, placebo controlled study shows the effeciency and tolerability of a homeopathic combination remedy. HNO 2007;55:271-277. [Link to abstract here]
(13) Gevaert P, Lang LD, Lackner A et al. Nasal IL-5 levels determine the response to anti-IL-5 treatment in patients with nasal polyps. The Journal of Allergy and Clinical Immunology 2006;118:1133-1141. [Link to abstract]
(14) Hissaria P, Smith W, Wormald P et al. Short course of systemic corticosteroids in sinonasal polyposis: a double-blind, randomized, placebo-controlled trial with evaluation of outcome measures. The Journal of Allergy and Clinical Immunology 2006;118:128-133. [Link to abstract]
(15) Johansson L, Oberg D, Melen I, Bende M. Do topical nasal decongestants affect polyps? ACTA OTO LARYNGOL 2006;126:288-290. [Link to abstract]
(16) Kemppainen T, Kokki H, Tuomilehto H, Seppä J, Nuutinen J. Acetaminophen is highly effective in pain treatment after endoscopic sinus surgery. The Laryngoscope 2006;116:2125-2128. [Link to abstract]
(17) Kroflic B, Coer A, Baudoin T, Kalogjera L. Topical furosemide versus oral steroid in preoperative management of nasal polyposis. European Archives of Otorhinolaryngology 2006;263:767-771. [Link to abstract]
(18) Meltzer E, Bachert C, Staudinger H. Treating acute rhinosinusitis: comparing efficacy and safety of mometasone furoate nasal spray, amoxicillin, and placebo. The Journal of Allergy and Clinical Immunology 2005;116:1289-1295. [link to abstract]
(19) Pfaar O, Landis BN, Frasnelli J, Hüttenbrink KB, Hummel T. Mechanical obstruction of the olfactory cleft reveals differences between orthonasal and retronasal olfactory functions. Chemical Senses 2006;31:27-31. [Link to full text]
(20) Pinto JM, Elwany S, Baroody FM, Naclerio RM. Effects of saline sprays on symptoms after endoscopic sinus surgery. American Journal of Rhinology 2006;20:191-196. [Link to abstract]
(21) Polonovski JM, El MM. [Treatment of acute maxillary sinusitis in adults. Comparison of cefpodoxime-proxetil and amoxicillin-clavulanic acid]. Presse médicale 2006;35:33-38. [Link to abstract]
(22) Poole M, Anon J, Paglia M, Xiang J, Khashab M, Kahn J. A trial of high-dose, short-course levofloxacin for the treatment of acute bacterial sinusitis. Otolaryngology Head and Neck Surgery 2006;134:10-17. [Link to abstract]
(23) Ragab S, Scadding GK, Lund VJ, Saleh H. Treatment of chronic rhinosinusitis and its effects on asthma. The European Respiratory Journal 2006;28:68-74. [Link to abstract]
(24) Ragab SM, Lund VJ, Saleh HA, Scadding G. Nasal nitric oxide in objective evaluation of chronic rhinosinusitis therapy. Allergy 2006;61:717-724. [Link to abstract]
(25) Raghavan U, Jones NS. A prospective randomized blinded cross-over trial using nasal drops in patients with nasal polyposis: an evaluation of effectiveness and comfort level of two head positions. American Journal of Rhinology 2006;20:397-400.[Link to abstract]
(26) Ratau NP, Snyman JR, Swanepoel C. Short-course, low-dose oral betamethasone as an adjunct in the treatment of acute infective sinusitis: A comparative study with placebo. CLIN DRUG INVEST 2004;24:577-582. [Link to full text]
(27) Stjärne P, Mösges R, Jorissen M et al. A randomized controlled trial of mometasone furoate nasal spray for the treatment of nasal polyposis. Archives of Otolaryngology Head & Neck Surgery. 2006;132:179-185. [Link to abstract]
(28) Upchurch J, Rosemore M, Tosiello R, Kowalsky S, Echols R. Randomized double-blind study comparing 7- and 10-day regimens of faropenem medoxomil with a 10-day cefuroxime axetil regimen for treatment of acute bacterial sinusitis. Otolaryngology Head and Neck Surgery 2006;135:511-517. [Link to abstract]
(29) Vauterin T, Vander P, V, Jorissen M. Long term effects of cutting forceps in endoscopic sinus surgery. Rhinology. 2006;44:123-127. [link to abstract]
(30) Wallwork B, Coman W, Mackay S, Greiff L, Cervin A. A double-blind, randomized, placebo-controlled trial of macrolide in the treatment of chronic rhinosinusitis. Laryngoscope 2006;116:189-193. [Link to full text]
(31) Zabolotnyi DI, Kneis KC, Richardson A et al. Efficacy of a Complex Homeopathic Medication (Sinfrontal) in Patients with Acute Maxillary Sinusitis: A Prospective, Randomized, Double- Blind, Placebo-Controlled, Multicenter Clinical Trial. EXPLOR J SCI HEAL. 2007;3:98-109. [Link to abstract]
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