Rhinosinusitis (Non-polypoid)

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Rhinosinusitis (Non-polypoid)

Rhinology
Author Credentials 

Sarfaraz M Banglawala, MD, MPH
Clinical Assistant Professor
Department of Otolaryngology – Head & Neck Surgery
McMaster University, University of Toronto
Toronto, Ontario, Canada

Module Summary

Rhinosinusitis (non-polypoid) is a very prevalent disease in the general population. It can be classified into acute, sub-acute and chronic in nature. The causes of rhinosinusitis are multifactorial and can be related to various environmental, anatomical and genetic factors. The diagnosis is based on specific cardinal symptoms along with abnormal findings on endoscopy and imaging. The medical treatment option include nasal saline irrigation, topical intranasal corticosteroid sprays, oral antibiotics and oral steroids. Surgical treatment includes endoscopic sinus surgery in recalcitrant or chronic cases although the risks of orbital and intracranial complication needed to be considered and discussed in detail with the patient. The evolving technology of balloon catheter dilatation is gaining popularity in treating patients with rhinosinusitis although the evidence is mixed with limited long term data. At the completion of this module, the learner should feel comfortable in managing patients with rhinosinusitis (non-polypoid).

 

Module Learning Objectives 
  1. Explain the anatomy and physiology of the paranasal sinuses.
  2. Classify acute, subacute, and chronic sinusitis.
  3. Describe the unified airway model and its implication in sinusitis.
  4. Recognize the natural history of the disease.
  5. Cite the medical and surgical treatments for sinusitis.
  6. Summarize the risks and benefits of endoscopic sinus surgery.

Embryology

Learning Objectives 
  1. Be familiar on the embryological derivation of the paranasal sinuses.
  2. Importance on the age related pneumotization of sinuses which may affect surgical planning in children.
References 
  1. Hengerer AS. Embryological development of the sinuses. Ear Nose Throat J. 1984; 63(4):134-6.
  2. Lee AS, Solyar AY, Lanza DC, Georgalas C. Nasal and paranasal sinus anatomy and embryology. Georgalas C and Fokkens W. Rhinology and skull base surgery: From the lab to the operating room: An evidenced-based approach. Stuttgart, Germany: Thieme; 2013:16-24.

Anatomy

Learning Objectives 
  1. Understand the anatomy of the paranasal sinuses.
  2. Recognize the surrounding anatomical structures and their implications when performing endoscopic sinus surgery.
    1. Skullbase (slope and symmetry)
    2. Orbits (Dehiscense)
    3. Carotid artery
    4. Optic nerve
  3. Be familiar with anatomical variation in sinus air cells.
    1. Haller Cell
    2. Onodi Cell
    3. Frontal Cells
    4. Supraortibal Cells
References 
  1. Dalgorf DM, Harvey RJ. Chapter 1: Sinonasal anatomy and function. Am J Rhinol Allergy. 2013 May-Jun. 27 Suppl 1:S3-6.
  2. Lund VJ, Stammberger H, Fokkens WJ et al. European position paper on the anatomical terminology of the internal nose and paranasal sinuses. Rhinol Suppl. 2014 Mar;24:1-34.
  3. Davis WE, Templer J, Parsons DS. Anatomy of the paranasal sinuses. Otolaryngol Clin North Am. 1996;29(1):57-74.

Pathogenesis

Learning Objectives 
  1. Understand the pathogenesis of sinusitis (non-polypoid).
  2. Be able to differentiate between acute, sub-acute and chronic sinusitis.
  3. Recognize the concept of unified airway theory and its role in sinusitis.
References 
  1. Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg. 1997 Sep;117(3 Pt 2):S1-7.
  2. Chan Y, Kuhn FA. An update on the classifications, diagnosis, and treatment of rhinosinusitis. Curr Opin Otolaryngol Head Neck Surg. 2009;17(3):204-8.
  3. Fokkens WJ, Lund VJ, Mullol et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012;50(1):1-12.
  4. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS. Clinical Practice guideline (update): Adult Sinusitis Executive Summary. Otolaryngol Head Neck Surg. 2015;152(4):598-609.
  5. Meena RS, Meena D, Aseri Y. Chronic Rhino-Sinusitis and Asthma: Concept of Unified Airway Disease (UAD) and its Impact in Otolaryngology. Indian J Otolaryngol Head Neck Surg. 2013;65(2):338-42.

Basic Science

Learning Objectives 
  1. Understand the function of cilia in the upper airway
  2. Be familiar with natural bacterial flora of the paranasal sinuses.
  3. Role of nitric oxide in sinus physiology
  4. Importance of Staphloccus aureus in recalcitrant sinusitis
References 
  1. Beule AG. Physiology and pathophysiology of respiratory mucosa of the nose and the paranasal sinuses. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2011;9: Doc07.
  2. Lundberg JO. Nitric Oxide and the paranasal sinuses. Anat Rec (Hoboken) 2008;291(11):1479-84.
  3. Lefevere L, Willems T, Lindberg S et al. Nasal nitric oxide. Acta Otorhinolaryngol Belg. 2000;54(3):271-90.
  4. Gordts F, Halewyck S, Pierard D, Kaufman L, Clement PA. Microbiology of the middle meatus: a comparison between normal adults and children. J Laryngol Otol. 2000;114(3):184-8.
  5. Tan NC, Foreman A, Jardeleza C et al. Intracellular Staphyloccus aureus: the Trojan horse of recalcitrant chronic rhinosinusitis? Int Forum Allergy Rhinol. 2013;3(4):261-6.

Incidence

Learning Objectives 
  1. Know the incidence of sinusitis (non-polypoid) in the general population.
  2. Recognize population groups at increased risk.
  3. Recognize the economic burden of sinusitis.
References 
  1. Lucas JW, Schiller JS, Benson V. Summary health statistics for U.S. adults: National Health Interview Survey, 2011. Vital Health Stat 10. 2012 Dec;(256):1-218.
  2. Aitken M, Taylor JA. Prevalence of clinical sinusitis in young children followed by primary care physicians. Arch Pediatr Adolesc Med. 1998 Mar;152(3):244-8.
  3. Beule A. Epidemiology of chronic rhinosinusitis, selected risk factors, comorbidities, and economic burden. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2015; 14: Doc 11.

Genetics

Learning Objectives 
  1. Recognize mucociliary clearance disorders such as primary ciliary dyskinesia or cystic fibrosis and its role in sinusitis.
  2. Understand the current breakthroughs in genetic phenotyping in sinusitis.
References 
  1. Payne SC, Borish L, Steinke JW. Genetics and phenotyping in chronic sinusitis. J Allergy Clin Immunol. 2011;128(4):710-20.
  2. Chapelin C, Coste A, Reinert P, Boucherat M, Millepied MC, Poron F, Escudier E. Incidence of primary ciliary dyskinesia in children with recurrent respiratory diseases. Ann Otol Rhinol Laryngol. 1997;106:854–858.
  3. Cormier C, Bossé Y, Mfuna L, Hudson TJ, Desrosiers M. Polymorphisms in the tumour necrosis factor alpha-induced protein 3 (TNFAIP3) gene are associated with chronic rhinosinusitis. J Otolaryngol Head Neck Surg. 2009;38(1):133–141. 

Patient Evaluation

Learning Objectives 
  1. Understand key clinical symptoms necessary to diagnosis rhinosinusitis (non-polypoid) according to the AAOHNH Adult Sinusitis Guidelines
  2. Describe changes on endoscopy and imaging to suggest rhinosinusitis.
References 
  1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical Practice guideline (update): Adult Sinusitis Executive Summary. Otolaryngol Head Neck Surg. 2015;152(4): 598-609.
  2. Fokkens WJ, Lund VJ, Mullol et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012;50(1):1-12.
  3. Williams JW, Simel DL. Does this patient have sinusitis? Diagnosing acute sinusitis by history and physical examination. JAMA. 270:1242–1246.

Measurement of Functional Status

Learning Objectives 
  1. Be familiar with the impact of rhinosinusitis on quality of life.
  2. Recognize the importance of rhinosinusitis in sleep quality and congnition.
  3. Be familiar with various standardized indexes and questionaires to assess fuctional status in patient with rhinosinusitis. Eg. SNOT-22, RSDI, SCT etc.
References 
  1. Alt J, Smith TL, Mace JC et al. Sleep quality and disease severity in patients with chronic sinusitis. Laryngoscope. 2014;123:2364-70.
  2. Brandsted R, Sindwani R. Impact of depression on disease-specific symptoms and quality of life in patients with chronic rhinosinusitis. Am J Rhinol. 2007;21(1):50–54.
  3. Rudmik L, Hopkins C, Peters A et al. Patient-reported outcome meausures for adult chronic sinusitis: A systematic review and quality assessment. J Allergy Clin Immunol. 2015;136:1532-40.

Imaging

Learning Objectives 
  1. Understand the indications for imaging a patient with suspected rhinosinusitis.
  2. Be familiar in assessing a CT versus MRI for sinus disease.
  3. Recognize the low yield of plain film sinus xray for diagnosis.
References 
  1. Mafee MF, Tran BH, Chapa AR. Imaging of rhinosinusitis and its complications: plain film, CT, and MRI. Clin Rev Allergy Immunol. 2006;30:165-86.
  2. Triulzi F, Zirpoli S. Imaging techniques in the diagnosis and management of rhinosinusitis in children. Pediatr Allergy Immunol. 2007;18:46-9.

Pathology

Learning Objectives 
  1. Understand significance of biofilms and osteitis in rhinosinusitis
References 
  1. Zhao YC, Wormald PJ. Biofilm and osteitis in refractory chronic rhinosinusitis. Otolaryngol Clin North Am. 2017;50:49-60.

Treatment

Learning Objectives 
  1. Be able to recognize when a patient with rhinosinusitis (non-polypoid) needs to be treated.
  2. Be familiar with various medical and surgical treatment options available for patients with rhinosinutis (non-polypoid)
  3. Be familiar with comorbidities that may affect management strategy.
References 
  1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS. Clinical Practice guideline (update): Adult Sinusitis Executive Summary. Otolaryngol Head Neck Surg. 2015; 152(4): 598-609.
  2. Fokkens WJ, Lund VJ, Mullol et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012;50(1):1-12.
  3. Dao AM, Rereddy SK, Wise SK, DelGaudio JM, Patel ZM. Management of non-invasive rhinosinusitis in the immunosuppressed patient population. Laryngoscope. 2015 Aug;125(8):1767-71.

Medical Therapies

Learning Objectives 
  1. Understand the role of antibiotics, intranasal corticosteroids and saline lavages in treatment of rhinosinusitis (non-polypoid).
  2. Recognize the limited role of anti-fungals, mucolytics, antihistamines and leukotriene modifiers in treatment of rhinosinusitis (non-polypoid).
References 
  1. Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, et al. Clinical Practice guideline (update): Adult Sinusitis Executive Summary. Otolaryngol Head Neck Surg. 2015;152(4):598-609.
  2. Fokkens WJ, Lund VJ, Mullol et al. EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists. Rhinology. 2012;50(1):1-12.
  3. Hayward G, Heneghan C, Perera R. Intranasal corticosteroids in management of acute sinusitis: a systematic review and meta-analysis. Ann Fam Med. 2012;10:241-249.
  4. Falagas ME, Giannopoulou KP, Vardakas KZ. Comparison of antibiotics with placebo for treatment of acute sinusitis: a meta-analysis of randomised controlled trials. Lancet. 2008;8:543-552.

Pharmacology

Learning Objectives 
  1. Be familiar with pharmacology of intranasal corticosteroid spray and its systemic absorption.
  2. Be familiar with common side effects and complications of oral steroid treatments.
References 
  1. Sastre J, Mosges R. Local and systemic safety of intranasal corticosteroids. J Investig Allergol Clin Immunol. 2012;22:1-12.
  2. Derendorf H, Meltzer EO. Molecular and clinical pharmacology of intranasal corticosteroids: clinical and therapeutic implications. Allergy. 2008;63:1292-300.
  3. Liu D, Ahmet A, Ward L et al. A practical guide to monitoring and management of the complications of systemic corticosteroids therapy. Allergy Asthma Clin Immunol. 2013;9:30.

Surgical Therapies

Learning Objectives 
  1. Understand the rationale for endoscopic sinus surgery.
  2. Understand the rational for balloon sinuplasty
  3. Recognize the possible complication when performing endoscopic sinus surgery
References 
  1. Patel ZM, Thamboo A, Rudmik L, Nayak JV, Smith TL, Hwang PH. Surgical therapy vs continued medical therapy for medically refractory chronic rhinosinusitis: a systematic review and meta-analysis. Int Forum Allergy Rhinol. 2017 Feb;7(2):119-127.
  2. Svider PF, Baredes S, Eloy JA. Pitfalls in sinus surgery: An overview of complications. Otolaryngol Clin North Am. 2015;48:725-37.
  3. Catalano PJ. Balloon dilation technology: let the truth be told. Cur Allergy Asthma Rep. 2013;13:250-4.
  4. Levy JM, Marino MJ, McCoul ED. Paranasal sinus balloon catheter dilation for treatment of chronic rhinosinusitis: A systematic review and meta-analysis. Otolaryngol Head Neck Sur. 2016;154:33-40.
  5. Jaksja AF, Weitzel EK, Laury AM. Recent advances in the surgical management of rhinosinusitis. Version 1. F1000Res. 2016; 5: F1000 Faculty Rev-2377.
  6. http://www.american-rhinologic.org/videos (Surgical dissection videos on the ARS website, for members. ARS membership is FREE for residents.)

Case Studies

  1. A 26-year old male presents with 3 weeks history of facial pressure, purulent rhinorrhea, and nasal congestion. He notices post nasal drip when he is lying flat. He does not have history of sinusitis in the past. He is currently taking ibuprofen and a over-the-counter decongestant spray to help alleviate some his symptoms. How would you classify this patient’s sinusitis? What further investigations would you order? What would you recommend in terms of treatment?
  2. A 40-year old female who is known to you to have recurrent episodes of sinusitis that last for 3-4 weeks. She usually get 5-6 infections per year and treated with 3 week course of oral antibiotics, topical intranasal corticosteroid spray and nasal saline rinses. She is frusted with recurrent infections and would like to know her surgical options. How would you counsel the patient on the benefits and risks of endoscopic sinus surgery. Would you consider balloon sinuplasty as alternative option? What imaging modality would you order and what specific areas on the scan would you study in detail prior to performing the surgery to decrease risk of any intraop complication?

Complications

Learning Objectives 
  1. Recongize the side effects of oral antiobiotics and oral steroids.
  2. Recognize the rare complications of sinusitis especially in pediatric patients.
  3. Be familiar with intraop complications in endoscopic sinus surgery.
References 
  1. Svider PF, Baredes S, Eloy JA. Pitfalls in sinus surgery: An overview of complications. Otolaryngol Clin North Am. 2015;48:725-37.
  2. Bedwell J, Baumann NM. Management of pediatric orbital cellulits and abscess. Curr Opin Otolaryngol Head Neck Surg. 2011;19:467-73.
  3. Bayonne E, Kania R, Tran P et al. Intracranial complications of rhinosinusitis. A review, typical imaging data and algorithm of management. Rhinology. 2009;47:59-65.

Review

Review Questions 
  1. What are the subtypes of non-polypoid rhinosinusitis?
  2. What is the unified airway theory?
  3. What are orbital and intracranial complication of sinusitis?
  4. What is the chandler classification for orbital complication of sinusitis?
  5. What are some key anatomical areas to assess pre-operatively on a CT scan prior to performing endoscopic sinus surgery?
  6. What is the significance of a Onodi cell?
  7. What are some standardized patient outcome metrics available to use in patients with sinusitis?
Resources 

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