Rhinosinusitis—Overview of Management

computed tomography (CT). Plain skiagram is relatively non-sensitive mode of investigation for CRS and hence its usage for establishing a diagnosis is debatable except to rule out suspected complications and cases of acute sinusitis.² However, it can be used as a screening tool in the beginning where CT scan is not easily accessible or not affordable by the patient. In such a situation, CT scan may be advised if the patient does not respond to medical management of 3 months. The CT scan may be contrast-enhanced but both coronal and axial sections should be preferably obtained. This may be followed by a diagnostic proof puncture. The returning fluid after the wash may give an indication about the nature of the disease and differentiate allergic rhinosinusitis from CRS.

Algorithm 1 Diagnosis of chronic rhinosinusitis (CRS).

a. Rosenfeld RM, Andes D, Bhattacharyya N, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg 2007;137(3 Suppl):S1-31.

b. Pfleiderer AG, Croft CB, Lloyd GA. Antroscopy: its place in clinical practice. A comparison of antroscopic findings with radiographic appearances of the maxillary sinus. Clin Otolaryngol Allied Sci 1986;11:455–61.

As in many chronic ailments, the etiopathogenesis of CRS is far from established.³ A corollary to this statement is the obscure definitive treatment to this malady. Consequently, many options exist in most forms of medicine which claim far reaching success. These may range from a bathe in sulphur springs to special breathing techniques and from long-term medications to extensive open surgical procedures. Therefore, it becomes imperative to point out that no single management protocol can be applicable for management of all cases of CRS. Algorithms 2–5 essentially highlight some relatively well established facts about managing CRS as guiding principles.

Algorithm 2 Medical management in chronic rhinosinusitis (CRS) without nasal polyp.

a. Harvey R, Hannan SA, Badia L, Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev 2007:p.CD006394

b. Sharp HJ, Denman D, Puumala S, Leopold DA. Treatment of acute and chronic rhinosinusitis in the United States, 1999–2002. Arch Otolaryngol Head Neck Surg 2007;133:260–5.

c. Cervin A, Wallwork B. Macrolide therapy of chronic rhinosinusitis. Rhinology, 2007;45:259–67.

d. Lim M, Citardi MJ, Leong JL. Topical antimicrobials in the management of chronic rhinosinusitis: a systematic review. Am J Rhinol 2008;22:381–9.

Algorithm 3 Medical management in chronic rhinosinusitis (CRS) with nasal polyp.

a. Harvey R, Hannan SA, Badia L, Scadding G. Nasal saline irrigations for the symptoms of chronic rhinosinusitis. Cochrane Database Syst Rev 2007;3:CD006394.

b. Mullol J, Obando A, Pujols L, Alobid I. Corticosteroid treatment in chronic rhinosinusitis: the possibilities and the limits. Immunol Allergy Clin North Am 2009;29:657–68.

c. Klimek L, Pfaar O. Aspirin intolerance: does desensitization alter the course of the disease. Immunol Allergy Clin North Am 2009;29:669–75.

Algorithm 4 Surgical management of chronic rhinosinusitis (CRS).

a. Soler ZM, Smith TL. Quality of life outcomes after functional endoscopic sinus surgery. Otolaryngol Clin North Am 2010;43:605–12.

b. Khalid AN, Quraishi SA, Kennedy DW. Long-term quality of life measures after functional endoscopic sinus surgery. Am J Rhinol 2004;18:131–6.

Algorithm 5 Management in chronic rhinosinusitis (CRS) with allergic fungal rhinosinusitis (AFRS).^* ^* Ryan MW, Marple BF. Allergic fungal rhinosinusitis: diagnosis and management. Curr Opin Otolaryngol Head Neck Surg 2007;15:18–22.

Till such time an anatomical cause of CRS is not established, CRS is a medical disease with customized medical management as the mainstay of treatment. Surgery has an important role in resistant cases though this is essentially an adjunctive role. Surgery is also important in the management of complications.

What exactly constitutes optimum medical management is also not well established. An earlier rule of thumb of giving antibiotics for long-term to all patients of CRS is already under question.⁴ The medical management recommended is usually based on the nature of the disease.

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Tags: Chronic Rhinosinusitis - ECAB

Jun 5, 2016 | Posted by admin in OTOLARYNGOLOGY | Comments Off

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