Medical management of chronic rhinosinusitis

Chronic rhinosinusitis: phenotypes and endotypes

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is a broad classification of airway inflammation that affects a significant portion of the population. The current model of delineating patients suffering from CRS is dated and is no longer as simple as the presence of polyps or no polyps. Continued advances in the endotype descriptions of CRS have allowed for new phenotypic descriptions that aid in driving management and research efforts.

RECENT FINDINGS

Geographic differences exist between patient presentations, which require a molecular evaluation of the driving forces. Increased understanding of these differences allows for patient-specific treatment decisions.

SUMMARY

New descriptions of CRS phenotypes allow for more targeted therapy for patients, particularly to those with difficult to control disease. The previously broad classification of CRS with or without nasal polyps is no longer sufficient at driving these treatment decisions.

Rhinology

Osteomas are the most common benign sinonasal lesion with the frontal sinus the most common location. On sinus MRI, dried secretions show as hyperintense on T1, hypointense on T2, and polyps show hypointense on T1, hyperintense on T2. Rhinoscleroma is caused by Klebsiella rhinoscleromatis with histopathology showing Mikulicz cells (macrophages containing pathogen) and Russell bodies (plasma cells).

Clinical characteristics and expression of thymic stromal lymphopoetin in eosinophilic and non-eosinophilic chronic rhinosinusitis

OBJECTIVE

To evaluate the differences in clinical features and expression of cytokine thymic stromal lymphopoetin (TSLP) and its receptors in patients with eosinophilic and non-eosinophilic chronic rhinosinusitis (ECRS and NECRS).

METHOD

36 ECRS patients and 50 NECRS patients were evaluated for symptoms, nasal sinus computed tomography scanning, nasal endoscopy, skin prick test (SPT) positivity, and total IgE. Expression of TSLP and receptors in ethmoid sinus mucosa from the ECRS and NECRS groups were investigated by using immunohistochemical staining.

RESULTS

ECRS patients demonstrated significantly higher scores of cough and hyposmia. 66.7% of ECRS patients also demonstrated nasal polyps, compared to 50% of NECRS patients, with significantly higher polyp endoscopy scores. 80.6% of ECRS patients demonstrated SPT positivity, compared to 14% of NECRS patients. The overall expression of TSLP, TSLP receptors and IL-7R was significantly greater in eosinophils in the mucosa of ECRS patients than in NECRS patients. The expression of TSLP and receptors in SPT-positive ECRS patients was significantly greater than in SPT-negative patients, with a significant correlation noted between the expression of TSLP and nasal polyp scores.

CONCLUSION

The clinical manifestations of ECRS are likely to be influenced by atopic status of an individual and TSLP-mediated eosinophil infiltration of the rhinosinusoidal mucosa.

Efficacy of medical therapy in treatment of chronic rhinosinusitis

Uncomplicated chronic rhinosinusitis (CRS) is generally treated with medical therapy initially and surgery is contemplated only after medical therapy has failed. However, there is considerable variation in the medical treatment regimens used and studies defining their efficacy are few. The aim of this study was to determine the proportion of patients treated medically who responded sufficiently well so that surgery was not required. Subgroup analysis to identify clinical features that predicted a favorable response to medical therapy was also performed. Eighty patients referred to the Otorhinolaryngology Clinic at North Shore Hospital were treated with a standardized medical therapy protocol (oral prednisone for 3 weeks, oral antibiotics and ongoing saline lavage and intranasal budesonide spray). Symptom scores were collected before and after medical therapy. Clinical features such as presence of polyps, asthma, and aspirin hypersensitivity were recorded. Failure of medical therapy was defined as the persistence of significant CRS symptoms, and those patients who failed medical therapy were offered surgery. Follow-up data were available for 72 (90%) patients. Of this group, 52.5%, (95% CI, 42.7%, 62.2%) failed to respond adequately to medical therapy and were offered surgery. The remaining patients (37.5%) were successfully treated with medical therapy and did not require surgery at the time of follow-up. The premedical therapy symptom scores were significantly higher than the postmedical therapy symptom scores (p < 0.01). The symptom scores of those patients postmedical therapy who proceeded to have surgery were significantly higher than the group who responded well to maximum medical therapy (MMT) and did not require surgery (p < 0.0001). There were no significant differences in the proportion of patients with asthma, aspirin sensitivity, or polyps between the groups failing or not failing MMT. In approximately one-third of patients with CRS, medical therapy improved symptoms sufficiently so that surgical therapy was avoided. Patients with more severe symptoms tended not to respond as well as those with less severe symptoms. Long-term follow-up is required for the group of responders to determine how many will eventually relapse.

BSACI guidelines for the management of rhinosinusitis and nasal polyposis

This guidance for the management of patients with rhinosinusitis and nasal polyposis has been prepared by the Standards of Care Committee (SOCC) of the British Society for Allergy and Clinical Immunology (BSACI). The recommendations are based on evidence and expert opinion and are evidence graded. These guidelines are for the benefit of both adult physicians and paediatricians treating allergic conditions. Rhinosinusitis implies inflammation of the nose and sinuses which may or may not have an infective component and includes nasal polyposis. Acute rhinosinusitis lasts up to 12 weeks and resolves completely. Chronic rhinosinusitis persists over 12 weeks and may involve acute exacerbations. Rhinosinusitis is common, affecting around 15% of the population and causes significant reduction in quality of life. The diagnosis is based largely on symptoms with confirmation by nasendoscopy. Computerized tomography scans and magnetic resonance imaging are abnormal in approximately one third of the population so are not recommended for routine diagnosis but should be reserved for those with acute complications, diagnostic uncertainty or failed medical therapy. Underlying conditions such as immune deficiency, Wegener's granulomatosis, Churg-Strauss syndrome, aspirin hypersensitivity and allergic fungal sinusitis may present as rhinosinusitis. There are few good quality trials in this area but the available evidence suggests that treatment is primarily medical, involving douching, corticosteroids, antibiotics, anti-leukotrienes, and anti-histamines. Endoscopic sinus surgery should be considered for complications, anatomical variations causing local obstruction, allergic fungal disease or patients who remain very symptomatic despite medical treatment. Further well conducted trials in clearly defined patient groups are needed to improve management.

Drug management in chronic rhinosinusitis: identification of the needs

Chronic rhinosinusitis (CRS) is a group of multifactorial diseases characterized by inflammation of the mucosa of the nose and paranasal sinuses with a history of at least 12 weeks of persistent symptoms despite maximal medical therapy. The precise role played by infection and immunoglobin E (IgE)-mediated hypersensitivity remains unclear. Diagnosis of CRS is based upon medical history, nasal endoscopy and computed tomography scan of the sinuses. The CRS with polyps visible in the middle meatus must be distinguished from the CRS without polyps. Based on the current knowledge about the pathogenesis of CRS, it is admitted that an optimal medical treatment must consider all favorizing factors and control efficaciously the inflammation process. In case of failure of medical treatment, endoscopic sinus surgery should be proposed. However, some well-validated data and scientific evidences are missing, even for the most frequently used medications. After a review of the actual definitions and classifications, a short description of the current knowledge about pathogenesis of CRS is provided in order to justify the actual therapeutic rationales and identify the needs for an effective treatment of CRS.

Potential New Avenues of Treatment for Chronic Rhinosinusitis: an Anti-inflammatory Approach

Chronic rhinosinusitis is a complex disease process, one that is characterized by much more than just infection. Until its pathophysiology is understood fully, truly definitive therapy may remain elusive. As this underlying inflammatory process begins to unravel, however, new avenues of therapy will begin to emerge. This article discusses some of these new therapies and provides some clues as to where future avenues may go.

Alternative medical treatment strategies for chronic hyperplastic eosinophilic sinusitis

PURPOSE OF REVIEW

Chronic rhinosinusitis (CRS) is one of the most common chronic illnesses in the United States. Although CRS has been viewed traditionally as an infectious disease, treatment focused on antibiotics and surgery has not infrequently provided disappointing results.

RECENT FINDINGS

Recently much of CRS has been shown to be an eosinophilic inflammatory disease and new anti-inflammatory treatments are being studied.

SUMMARY

This review discusses medical management for chronic hyperplastic eosinophilic sinusitis, including antifungal treatment, low-dose macrolide treatment, antilipid mediator therapy, and new immune-modifying treatments.