Evidence-based Medical Management of Chronic Rhinosinusitis
Summary
This chapter reviews the current medical therapy available for treating chronic rhinosinusitis (CRS). Because this disease is multifactorial, more severe cases are best managed in a multidisciplinary approach with a respiratory physician, allergist, and rhinologist. Although the disease can be diagnosed on history and examination alone, initial assessment should be thorough enough to determine specific etiologies. The primary assessment should include testing for allergy (skin prick test or radioallergosorbent test). In more severe and difficult cases, testing should include screening for immunodeficiency (immunoglobulin subclass levels), autoimmune disease/vasculitis (antineutrophil cytoplasmic autoantibody, antinuclear antibodies, angiotensin-converting enzyme, complete blood count, and erythrocyte sedimentation rate), neoplasia (biopsy, computed tomography [CT], and magnetic resonance imaging [MRI]), and allergic fungal sinusitis (biopsy, CT, and MRI).
Medical management of CRS can be commenced while awaiting further investigations. The physician should aim to maximize sinus drainage at the ostiomeatal complex (OMC). This can be achieved by nasal douching, topical corticosteroids, and consideration of long-term macrolide antibiotics.
Surgical management should be employed only when medical therapy is unsuccessful. With modern equipment and techniques, good surgical results can be achieved with minimal morbidity.
Introduction
CRS is an inflammatory process of the mucosa of the nasal cavity and paranasal sinuses. It is one of the most common chronic health problems in the Western world and affects 11% of the adult population in Europe.1 It has a significant impact on quality of life,2,3 which has been shown to greatly improve with treatment.4
CRS with and without nasal polyps (CRSwNP and CRSsNP, respectively) is often described as one disease entity because it is difficult to differentiate between them based on inflammatory markers, suggesting they may represent a spectrum of the same disease process. Indeed, a T helper 1 (Th1) or Th2 inflammation has been described in CRSwNP and CRSsNP. However, in Europe and the United States, CRSwNP shows generally more Th2 cells, with interleukin-5 (IL-5) as the major cytokine, resulting in increased eosinophil survival and an eosinophilic type of inflammation, which may be associated with immunoglobulin E (IgE) formation. In contrast, the predominant T-effector cell in Asian patients with polyps is the Th17 cell, with IL-17 being the key cytokine, resulting in a predominance of neutrophils. Asian and European/American patients also show a marked difference in the prevalence of comorbid asthma, with this disease being rare in Chinese and Thai patients.
Multiple factors and processes play a widely debated role in the etiology of CRS, which thus accounts for the myriad of treatment options trialed. Mucociliary dysfunction, allergic rhinitis, nonallergic rhinitis, asthma, immunodeficiency, superinfection by bacteria (namely, Staphylococcus aureus), fungi, and aspirin sensitivity have all been postulated but with relatively little evidence to support any one definitively. However, following the current evolution in phenotyping, more personalized treatments based on the underlying inflammation will most likely be considered in the future.
Tips and Tricks
Severe, recurrent CRS should be managed by a multidisciplinary team approach involving a respiratory physician, allergist, and rhinologist.
Definition
The diagnosis of CRS is based largely on patient symptoms, with confirmation of clinical signs using nasal endoscopy. CT and MRI can be abnormal in up to one-third of the normal population, so they should not be routinely used for diagnosis but instead reserved for those cases with acute complications, diagnostic uncertainty, or failed medical therapy.
The European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS)5 defines CRS as inflammation of the nose and paranasal sinuses characterized by symptoms and signs as highlighted in Table 17.1.
Management Algorithm
An algorithm for the management of CRSwNP and CRSsNP has been proposed by EPOS ( Figs. 17.1 and 17.2 ).5
Tips and Tricks
Initial assessment of patients with CRS must include allergy testing and in severe cases autoimmune immunoglobulin deficiency screening.
Current Medical Management Options
With so many proposed etiologic factors in the development of CRS, it is no surprise that therapeutic options are so extensive. However, when high-level evidence is employed to critically assess these medical options, relatively few can be recommended for CRS at the current time. Treatment options are discussed below, with levels of evidence of efficacy summarized in Tables 17.2 and 17.3.
Topical Corticosteroids
Topical intranasal corticosteroids are the most common treatment for CRS. They act by suppressing inflammation at multiple points along the inflammatory cascade ( Fig. 17.3 ).6 They target the inflammatory response underlying nasal congestion, blockage, and facial pain, promote OMC drainage, and occasionally improve the sense of smell. They can be used in both spray and droplet form, with delivery in the head- dependent position being optimal for the latter ( Fig. 17.4 ).
EPOS has provided evidence-based guidelines from meta-analysis of randomized, controlled clinical studies for the treatment of CRS with intranasal corticosteroids for moderate cases and combining this with antibiotics for severe cases (see Figs. 17.1 and 17.2 ). A recent systematic review of intranasal corticosteroids in CRSwNP has also confirmed a benefit in treatment, showing a significant reduction in polyp size of 0.43 when using a standardized polyp size scoring system.7 In patients with CRSsNP, modest but definite improvements in disease extent and patient symptoms with intranasal corticosteroids have been demonstrated.8,9 Intranasal corticosteroids also have a beneficial effect after surgery in significantly reducing both the number and the size of recurrent polyps when compared with placebo.10
Intranasal Corticosteroid Drops
By changing the formulation of nasal corticosteroids into drops, the dose delivered to the middle and upper meatus, where polyps originate, may be increased. Two randomized, placebo-controlled trials have demonstrated that corticosteroid nasal drops reduced polyp size and symptoms significantly compared with placebo.11,12 Fluticasone nasal drops (400 µg) taken once daily also reduced the need for surgery in patients with CRS and nasal polyposis refractory to intranasal corticosteroid spray.13
Systemic Corticosteroids
Topical corticosteroid therapy is not always effective. This is often due to the level of inflammation, preventing adequate access in the nose for the topical steroids to be administered correctly. This can be overcome by the use of systemic corticosteroids to control the disease as a short-term measure. Based on clinical experience, systemic corticosteroids remain important for the treatment of CRSwNP. This treatment has been shown to be comparable to surgery,14 providing some improvement in both symptoms and polyp size.15 The period of symptom relief in CRSwNP is limited, with complete recurrence after 3 months,16 making the use of repeated systemic corticosteroid courses a viable option if used up to two to three times yearly. However, there is no evidence so far that the natural course of the disease may be influenced by short- or long-term, low-dose treatment regimens; furthermore, the use of oral corticosteroids is limited by the long-term adverse effects of suppression of the hypothalamic-pituitary-adrenal axis, which include osteoporosis, cataract formation, glaucoma, and growth retardation in children. Topical therapy can be used to maintain the patient between courses. There are no data showing the efficacy of oral corticosteroids in CRSsNP.
Tips and Tricks
Short-term courses of oral corticosteroids can be given two to three times yearly.
Short-term Antibiotics
Bacteria can be isolated from middle meatal swabs taken from patients with CRS. The most common pathogens are Haemophilus influenzae, Streptococcus pneumoniae, S. aureus, Moraxella catarrhalis, and Pseudomonas aeruginosa (in cystic fibrosis). Clinically, the use of short-term antibiotics should be reserved for acute exacerbations of CRS. These can be considered like cases of acute rhinosinusitis and treated similarly. In these circumstances, several trials have shown that oral antibiotics have an effect on the symptomatology of these acute exacerbations,17 preferably via a culture-directed therapy.18,19 However, none of these studies were double-blind and placebo- controlled. Higher level evidence has been gathered showing combination therapy with oral antibiotics and topical corticosteroid treatment can be beneficial. A recent systematic review of the literature suggests that topical antibiotic therapy may have a role in acute exacerbations of CRS, albeit with a low level of evidence (III).20 Topical antibiotics, however, should not be considered first-line, but remain an option for refractory cases where traditional topical steroids and oral antibiotics are ineffective.
Nasal Irrigation
Nasal douching is a safe, inexpensive treatment with many potential beneficial physiologic effects observed. Improvement in mucus clearance, enhanced ciliary beat activity, removal of antigen, biofilm, or inflammatory mediators, and a protective role on sinonasal mucosa have all been proposed. A reduction in nasal symptoms and increased quality of life have been demonstrated,21 and a Cochrane systematic review has shown that, although nasal saline douching is not as effective as an intranasal steroid, there is a beneficial effect, and it should be included as an adjunct for symptoms of CRS.22 Recently it has been suggested to do saline irrigation with 2 mg local corticosteroids in 200 mL saline to better reach the sinus.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
