CRS.pdf important for learning mbbs students

Important slide for learning
Asthma , allergy and immunology

1. Rhinosinusitis and Nasal
Polyps
Dr Gayatri S Pandit, MBBS, DLO, DAA
Samarth ENT and Allergy Centre
Manipal Hospital, Yeshwanthpur, Bangalore

2. Para nasal Sinus

3. •Anterior wall- soft tissue soft
skin
•Posterior wall- infra temporal
fossa
•Floor- palatine process of maxilla
•Roof – floor of Orbit
•Drains to middle meatus – non
gravity dependent
•Accessory ostium


Maxillary sinus

4. •Inner and outer table of frontal
bone

•Funnel shaped

•Septate

•Fronto ethmoidal Recess
Frontal sinus

5. •Multiple

•Anterior group- middle meatus

•Posterior group- spheno
ethmoidal recess

•Anatomical variations
Ethmoidal Air cell

6. •Body of sphenoid

•Drains to spheno ethmoidal
recess

•Important Neurological
landmarks
Sphenoid sinus

7. •Uncinate process

•Hiatus Semilunaris

•Anterior group of sinus

•Posterior group of Sinus
Osteo meatal complex

9. •Inflammation of Nose and PNS characterized by 2 or more symptoms
, one of which should be either nasal
blockage/obstruction/congestion or nasal discharge (anterior/post
nasal )
+/- facial pain / pressure
+/-reduction or loss of smell


Clinical definition of Rhinosinusitis

10. Endoscopic signs of :
•-nasal polyps, and /or
•-mucopurulent discharge primarily from middle meatus and /or
•-0edema or mucosal obstruction primarily in middle meatus and/or

CT changes:
•-mucosal changes within the ostiomeatal complex and /or sinuses

12. •Acute and Chronic Rhinosinusitis are usually very different conditions.

•Acute rhinosinusitis usually related to Infection.

•Chronic rhinosinusitis usually related to Inflammation.

13. •1 billion viral URIs each year

•Mostly Viral, Self resolving

•0.5% - 2% lead to secondary bacterial infection of the sinuses.
1,2

Acute Sinusitis

14. Obstruction to sinus ostium causes Acute Sinusitis
Kern EB JACI 1984:73:25
Retained Thick Secretions
Stagnation Transudation Viscid Fluid
Ciliary
Dysfunction
Vasodilation
Mucous Gland
Dysfunction
O
2

17. •Tenderness overlying the sinuses
•Nasal erythema
•Purulent nasal secretions
•Increased posterior pharyngeal secretions
•Fetid breath
•Periorbital edema
•Ear examination may reveal eustachian tube dysfunction

Additional symptoms of Acute sinusitis

18. Acute clinical pattern

Objective confirmation either / or
•Purulent discharge at meatus- either by direct examination or by endoscopy

X-ray--?


CT scan Not recommended for routine management
•May be helpful in complex cases

Diagnosis of Acute Sinusitis

19. Orbital Intra cranial Osseous
Pre septal cellulitis Sub dural empyema Potts puffy tumor
Orbital cellulitis Meningitis Maxillary osteomyelitis
Sub periosteal abscess Intra cerebral abscess
Orbital abscess Superior sagittal sinus thrombosis
Cavernous sinus thrombosis
Complications of Acute Bacterial Rhino
sinusitis

20. •Supportive

•Nasal decongestants

•Anti histamines

•Nasal irrigation

•Antibiotic in ABRS only
Treatment

22. •Clinical signs of Sinusitis <12 weeks are Acute sinusitis and>12 weeks are chronic
sinusitis

•Acute sinusitis is infective pathology where as Chronic sinusitis is inflammatory
pathology
•Majority of Acute sinusitis are viral, self resolving

•Un necessary prescription of Anti biotics should be avoided in ARS

23. •Chronic rhinosinusitis with nasal polyps- CRSwNP


•Chronic rhinosinusitis without nasal polyps- CRSsNP




Phenotypes of Chronic sinusitis

25. EPOS classification 2020- Secondary CRS

26. CRSwNP CRSnNP
Nasal blockage, anosmia Facial pain, post nasal drip
Eosinophilic predominance Neutrophilic
Th2 inflammation Th1 inflammation
Intense edematous stroma Fibrosis , basement membrane
thickening
Responds to steroids Responds to Macrolides
Associated with Asthma Not associated with Asthma

28. Endoscopic view of polyps

29. •Immunodeficiency(hypogammaglobulinemia, 12% adults with CRSsNP)

•GERD

•Defect in mucociliary clearance (cystic fibrosis and primary ciliary dyskinesia)

•Systemic disease( Wagener's granulomatosis , Sarcoidosis)

• Asthma (20% CRS have asthma , 2/3 of Asthmatics have evidence of CRS)
Co morbidities and associated conditions

30. •Chronic adenoiditis in children have significant impact on
development of Chronic Rhino sinusitis

•Children who were exposed to passive smoking had more severe
form of disease

•There is high association of Gastro esophageal reflux and sinusitis in
children
Pediatric Chronic rhinosinusitis

31. Central Compartment Atopic disease
•Central pattern of inflammatory changes are
highly associated with allergy

•Patients with isolated middle turbinate
changes have higher association with
allergen sensitization rather than diffuse
polyps

•Other sites to be involved are posterior-
superior septum , middle turbinate

•Proposed theory is that anterior aspect of
middle turbinate is exposed vial nasal airflow

32. Defined by 5 criteria: (Bent and Kuhn)
•allergy to cultured fungi
•gross production of eosinophilic mucin that contains noninvasive
fungal hyphae
•nasal polyposis
•characteristic radiographic changes
•immunocompetence

Allergic Fungal Rhino sinusitis

33. Fungal ball Allergic mucin

34. •Aspirin intolerance, Nasal polyps and Asthma

•Refractory to medical Rx, rapid recurrence of disease

•Rhinorrhea and congestion are first to develop followed by
development of polyp and Asthma

Aspirin Exacerbated Respiratory disease
(AERD)

35. Pathophysiology

36. •0.6- 2.5% of all asthma patients. But 15 % were AERD among SEVERE
asthma


•8.7% of Chronic Rhinosinusitis with Nasal Polyps (CRS wNP) were
AERD


•20% of ADULT ONSET ASTHMA are AERD

AERD..

37. •Unlike other allergic disorders AERD develops in 3rd decade of Life
(Late onset)

•Male predominance, when occurs in females disease is much more
severe

•Rhinitis symptoms typically precedes asthma by 1-5 years

•Symptoms of Asthma and sinusitis can me much more SEVERE in
AERD
Some more features of Aspirin exacerbated
respiratory disease (AERD)

38. •Complete medical history.
•Review of old medical records.
•Operative reports.
•CT scan Nose and PNS
•Nasal endoscopy
•Allergy evaluation
•Aspirin Challenge test
•Immune work up
•Histopathology
How to evaluate Chronic rhinosinusitis
patients

39. Some Evaluations to help Phenotyping
History Family h/o Atopy, Personal h/o AR,
Presence of Asthma
Indicates Type 2
NSAID Intolerance e CRS- AERD
Investigations Total Ig E very high Ig E in AFRS
AEC Can be normal in Type 2, but higher
the AEC severe the disease
Skin Prick Allery test Type 2
Histopathology Eosinophil count, basement
membrane thickening , Fungal
elements
Aspirin challenge AERD
? Tests for primary ciliary dyskinesia
Sweat chloride test
Cystic fibrosis
Autoimmune work up Wegener
Tests for Immuno deficiency

40. •Intra nasal steroids
•Oral steroid
•FESS
• Antibiotics
•Nasal saline irrigation

Treatment option

41. I
•Excellent safety profile

•Beneficial in both sub group

•Effect size and penetration is less when compared to irrigation

•Greater response when used post operatively


Intranasal steroid spray

42. •No significant adverse effect on short term usage of steroid (2-4weks)

•In CRSwNP significant reduction in polyp size and subjective
improvement in nasal symptoms

•Course should last at least as long as life span of eosinophil (14-21
days)

•Cumulative dose of less than 1000mg
Oral Steroids

43. •Long term macrolides are used for their anti inflammatory property
based on their effect on lower respiratory tract

• They target reduction in IL8, IL4,and IFN3- predominant effect on
neutrophilic inflammation

•Long term use may associated with macrolide resistance and GI
disturbances


Immuno modulatory antibiotics

44. •In RCT 20 day course of Doxycycline showed reduction in
myeloperoxidase, eosinophil cationic protein, matrix
metalloproteinase 9 in CRS wNP with sustained effect for 12 weeks

•Doxy may be good adjunct in eosinophilic CRS subgroup while
macrolides may assist in non eosinophilic CRS patients




Immuno modulatory anti biotics

45. •Saline nasal irrigation

•Muco active agents – Surfactants ( useful in treating crusting, thick
mucous and Bacterial mucosal colonization)

•Addition of steroids to irrigation
Treatment aimed at improving muco ciliary
function

47. •Fungal ball , Allergic Fungal Sinusitis, Odontogenic sinusitis requires
Surgery as first option

•Failed medical line of management

•Combined therapy/ Sandwich therapy is required quite often

•Ventilation Vs access to topical treatment



Indications for Surgery for CRS

48. •achieve highest drug concentration
in target tissue without undesirable
systemic effect

•Budesonide spray in Automised
spray on low volume saline rinse,
low volume solutions of dexa /
prednisolone o.1% ophthalmic eye
drops

Post operative irrigation
Post sinus surgery irrigation

49. Intra Nasal Spray VS neck extension steroid
irrigation

51. Immunotherapy in Chronic Rhinosinusitis
•A systematic review by DeYoung et al. , looked at sinusitis-specific
outcomes in CRS patients who underwent IT.

•Seven studies were included which demonstrated symptom reduction
in the short-term, however the number and quality of studies
included deemed this conclusion to be weak.


•De Young K., Wentzel J.L., Schlosser R.J., Nguyen S.A., Soler Z.M. Systematic review of immunotherapy for chronic
rhinosinusitis. Am. J. Rhinol. Allergy. 2014;28:145–150. doi: 10.2500/ajra.2014.28.4019. [PubMed] [CrossRef]
[Google Scholar

52. Additional observations..
•Improvement in objective endoscopic examination

•Improvement in radiographic assessment

•Decreased necessity for revision surgery

53. •Biologicals are Choice when disease control remain Sub optimal
Despite Standard therapy

56. •Dupilumab is the only monoclonal antibody that is
approved for the treatment of CRS w NP at the
moment

57. •Aspirin sensitive asthma/rhinosinusitis
•Patients with aggressive polypoid CRS
•Patients do not responding to pharmacological
treatment
•Corticosteroid-induced side effects

•ASA-sensitive patients with
•Coronary heart disease
•Antiphospholytic syndrome
•Chronic inflammatory diseases (AR; OA)
Indications for Aspirin desensitization

58. Desensitization

59. Protocol

60. ●NO TOLERANCE is induced

●Patients who have been successfully desensitized
should continue to take Aspirin life

●Refractory period is 2-3 days and within not more
than 5days patient would loose de-sensitization

61. •Chronic rhinosinusitis is disease with NO END POINT

•Treatment option should be chosen on phenotyping of sinusitis

•Allergic fungal rhinosinusitis and Aspirin exacerbated respiratory disease
are tough to treat CRS

•Medical therapy + Surgical intervention and + continuation of medical
therapy is often required

•Biologicals are hope in difficult cases
Summary