Treatments in Respiratory Medicine

, Volume 3, Issue 2, pp 97–105

Chronic Rhinosinusitis

Management for Optimal Outcomes
Therapy In Practice

Abstract

Chronic rhinosinusitis is characterized by nasal purulence accompanied by malaise, postnasal drip and nasal dryness or crusting. It is a condition that is very difficult to treat and can be very disabling to the patients. A clinical diagnosis is based on history and evaluation with endoscopy, and computerized tomographic scanning. The etiology of chronic rhinosinusitis is multifactorial and comprises a vicious cycle of pathophysiological, anatomical, and constitutive factors. Predisposing factors include ciliary impairment, allergy, nasal polyposis, and immune deficiency. Treatment is aimed at reducing mucosal inflammation and swelling, controlling infection, and restoring aeration of the nasal and sinus mucosa.

The choice of treatment is influenced by many factors including past medication, duration of symptoms and the presence of allergy/nasal polyps. Pharmacologic treatment, with local or systemic corticosteroids such as mometasone furoate, fluticasone propionate, beclometasone dipropionate or oral prednisolone coupled with nasal lavage with isotonic saline solutions are the cornerstones of disease management. Systemic antibiotics including amoxicillin/clavulanic acid, ciprofloxacin, clarithromycin, and trimethoprim/sulfamethoxazole (cotrimoxazole) are often administered to patients with chronic sinusitis and underlying bacterial infection. In patients with underlying allergy, additional treatment with antihistamines should be considered. Aeration of the sinuses may temporarily be improved with local nasal decongestants such as oxymetazoline. If symptoms persist after aggressive medical treatment, surgery should be considered. Surgery should be functional and involve widening the natural drainage openings of the sinuses and preserving the ciliated epithelium as much as possible. In the case of nasal polyposis surgery is more aggressive involving removal of the diseased polypous mucosa. It is recommended that medical treatment should be continued post sinus surgery.

References

  1. 1.
    van Agthoven M, Fokkens WJ, van de Merwe JP, et al. Quality of life of patients with refractory chronic rhinosinusitis: effects of filgrastim treatment. Am J Rhinol 2001; 15(4): 231–7PubMedGoogle Scholar
  2. 2.
    Kaliner MA, Osguthorpe JD, Fireman P, et al. Sinusitis: bench to bedside: current findings, future directions. Otolaryngol Head Neck Surg 1997; 116 (6 Pt 2): S1–20PubMedGoogle Scholar
  3. 3.
    Melen I. Chronic sinusitis: clinical and pathophysiological aspects. Acta Otolaryngol Suppl 1994; 515: 45–8PubMedCrossRefGoogle Scholar
  4. 4.
    de Benedictis FM, Bush A. Rhinosinusitis and asthma: epiphenomenon or causal association? Chest 1999; 115(2): 550–6PubMedCrossRefGoogle Scholar
  5. 5.
    Van der Baan S, Fokkens WJ. Mucosa and mucus [in Dutch]. In: Brenkman CJ, de Vries N, editors. The report of the Dutch otorhinolaryngology/HNS society: Neusbijholtechirurgie — goedaardige aandoeningen. The Hague: Kugler Publications/SPB Academic Publishing bv, 2002: 57–62Google Scholar
  6. 6.
    Fokkens WJ, van der Baan S. Non-surgical therapy [in Dutch]. In: Brenkman CJ, de Vries N, editors. The report of the Dutch otorhinolaryngology/HNS society: Neusbijholtechirurgie — goedaardige aandoeningen. The Hague: Kugler Publications/SPB Academic Publishing bv, 2002: 131–9Google Scholar
  7. 7.
    Lanza DC, Kennedy DW. Adult rhinosinusitis defined. Otolaryngol Head Neck Surg 1997; 117(3 Pt 2): S1–7PubMedCrossRefGoogle Scholar
  8. 8.
    Konen E, Faibel M, Kleinbaum Y, et al. The value of the occipitomental (Waters’) view in diagnosis of sinusitis: a comparative study with computed tomography. Clin Radiol 2000; 55(11): 856–60PubMedCrossRefGoogle Scholar
  9. 9.
    Al-Rawi MM, Edelstein DR, Erlandson RA. Changes in nasal epithelium in patients with severe chronic sinusitis: a clinicopathologic and electron microscopic study. Laryngoscope 1998; 108(12): 1816–23PubMedCrossRefGoogle Scholar
  10. 10.
    Hadfield PJ, Rowe-Jones JM, Mackay IS. The prevalence of nasal polyps in adults with cystic fibrosis. Clin Otolaryngol 2000; 25(1): 19–22PubMedCrossRefGoogle Scholar
  11. 11.
    Rowe-Jones JM, Trendell-Smith N, Shembekar M, et al. Polypoid rhinosinusitis in patients with host defence deficiencies: cellular infiltration and disease severity. Rhinology 1997; 35(3): 113–7PubMedGoogle Scholar
  12. 12.
    Wojtczak HA, Kerby GS, Wagener JS, et al. Beclomethasone diproprionate reduced airway inflammation without adrenal suppression in young children with cystic fibrosis: a pilot study. Pediatr Pulmonol 2001; 32(4): 293–302PubMedCrossRefGoogle Scholar
  13. 13.
    Karlsson G, Holmberg K. Does allergic rhinitis predispose to sinusitis? Acta Otolaryngol Suppl 1994; 515: 26–8PubMedCrossRefGoogle Scholar
  14. 14.
    Emanuel IA, Shah SB. Chronic rhinosinusitis: allergy and sinus computed tomography relationships. Otolaryngol Head Neck Surg 2000; 123(6): 687–91PubMedCrossRefGoogle Scholar
  15. 15.
    Blair C, Nelson M, Thompson K, et al. Allergic inflammation enhances bacterial sinusitis in mice. J Allergy Clin Immunol 2001; 108(3): 424–9PubMedCrossRefGoogle Scholar
  16. 16.
    Bachert C, Wagenmann M, Hauser U, et al. IL-5 synthesis is upregulated in human nasal polyp tissue. J Allergy Clin Immunol 1997; 99 (6 Pt 1): 837–42PubMedCrossRefGoogle Scholar
  17. 17.
    Hedman J, Kaprio J, Poussa T, et al. Prevalence of asthma, aspirin intolerance, nasal polyposis and chronic obstructive pulmonary disease in a population-based study. Int J Epidemiol 1999; 28(4): 717–22PubMedCrossRefGoogle Scholar
  18. 18.
    Larsen K. The clinical relationship of nasal polyps to asthma. Allergy Asthma Proc 1996; 17(5): 243–9PubMedCrossRefGoogle Scholar
  19. 19.
    Settipane GA, Chafee FH. Nasal polyps in asthma and rhinitis: a review of 6037 patients. J Allergy Clin Immunol 1977; 59(1): 17–21PubMedCrossRefGoogle Scholar
  20. 20.
    Caplin I, Haynes JT, Spahn J. Are nasal polyps an allergic phenomenon?. Ann Allergy 1971; 29(12): 631–4PubMedGoogle Scholar
  21. 21.
    Rhyoo C, Sanders SP, Leopold DA, et al. Sinus mucosal IL-8 gene expression in chronic rhinosinusitis. J Allergy Clin Immunol 1999; 103 (3 Pt 1): 395–400PubMedCrossRefGoogle Scholar
  22. 22.
    Bachert C, Wagenmann M, Rudack C, et al. The role of cytokines in infectious sinusitis and nasal polyposis. Allergy 1998; 53(1): 2–13PubMedCrossRefGoogle Scholar
  23. 23.
    Vento SI, Ertama LO, Hytonen ML, et al. Nasal polyposis: clinical course during 20 years. Ann Allergy Asthma Immunol 2000; 85(3): 209–14PubMedCrossRefGoogle Scholar
  24. 24.
    Ponikau JU, Sherris DA, Kern EB, et al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc 1999; 74(9): 877–84PubMedCrossRefGoogle Scholar
  25. 25.
    Schubert MS. A superantigen hypothesis for the pathogenesis of chronic hypertrophic rhinosinusitis, allergic fungal sinusitis, and related disorders. Ann Allergy Asthma Immunol 2001; 87(3): 181–8PubMedCrossRefGoogle Scholar
  26. 26.
    Chee L, Graham SM, Carothers DG, et al. Immune dysfunction in refractory sinusitis in a tertiary care setting. Laryngoscope 2001; 111(2): 233–5PubMedCrossRefGoogle Scholar
  27. 27.
    Bachmann G, Hommel G, Michel O. Effect of irrigation of the nose with isotonic salt solution on adult patients with chronic paranasal sinus disease. Eur Arch Otorhinolaryngol 2000; 257(10): 537–41PubMedCrossRefGoogle Scholar
  28. 28.
    Taccariello M, Parikh A, Darby Y, et al. Nasal douching as a valuable adjunct in the management of chronic rhinosinusitis. Rhinology 1999; 37(1): 29–32PubMedGoogle Scholar
  29. 29.
    Homer JJ, England RJ, Wilde AD, et al. The effect of pH of douching solutions on mucociliary clearance. Clin Otolaryngol 1999; 24(4): 312–5PubMedCrossRefGoogle Scholar
  30. 30.
    Talbot AR, Herr TM, Parsons DS. Mucociliary clearance and buffered hypertonic saline solution. Laryngoscope 1997; 107(4): 500–3PubMedCrossRefGoogle Scholar
  31. 31.
    Boek WM, Keles N, Graamans K, et al. Physiologic and hypertonic saline solutions impair ciliary activity in vitro. Laryngoscope 1999; 109(3): 396–9PubMedCrossRefGoogle Scholar
  32. 32.
    Di Lorenzo G, Gervasi F, Drago A, et al. Comparison of the effects of fluticasone propionate, aqueous nasal spray and levocabastine on inflammatory cells in nasal lavage and clinical activity during the pollen season in seasonal rhinitics. Clin Exp Allergy 1999; 29(10): 1367–77PubMedCrossRefGoogle Scholar
  33. 33.
    Kleinjan A, Holm AF, Dijkstra MD, et al. Preventive treatment of intranasal fluticasone propionate reduces cytokine mRNA expressing cells before and during a single nasal allergen provocation. Clin Exp Allergy 2000; 30(10): 1476–85PubMedCrossRefGoogle Scholar
  34. 34.
    Lund VJ, Flood J, Sykes AP, et al. Effect of fluticasone in severe polyposis. Arch Otolaryngol Head Neck Surg 1998; 124(5): 513–8PubMedGoogle Scholar
  35. 35.
    Meltzer EO, Orgel HA, Backhaus JW, et al. Intranasal flunisolide spray as an adjunct to oral antibiotic therapy for sinusitis. J Allergy Clin Immunol 1993; 92(6): 812–23PubMedCrossRefGoogle Scholar
  36. 36.
    Sykes DA, Wilson R, Chan KL, et al. Relative importance of antibiotic and improved clearance in topical treatment of chronic mucopurulent rhinosinusitis: a controlled study. Lancet 1986; II(8503): 359–60CrossRefGoogle Scholar
  37. 37.
    Qvarnberg Y, Kantola O, Salo J, et al. Influence of topical steroid treatment on maxillary sinusitis. Rhinology 1992; 30(2): 103–12PubMedGoogle Scholar
  38. 38.
    Parikh A, Scadding GK, Darby Y, et al. Topical corticosteroids in chronic rhinosinusitis: a randomized, double-blind, placebo-controlled trial using fluticasone propionate aqueous nasal spray. Rhinology 2001; 39(2): 75–9PubMedGoogle Scholar
  39. 39.
    Holm AF, Godthelp T, Fokkens WJ, et al. Long-term effects of corticosteroid nasal spray on nasal inflammatory cells in patients with perennial allergic rhinitis. Clin Exp Allergy 1999; 29(10): 1356–66PubMedCrossRefGoogle Scholar
  40. 40.
    Holm AF, Fokkens WJ, Godthelp T, et al. A 1-year placebo-controlled study of intranasal fluticasone propionate aqueous nasal spray in patients with perennial allergic rhinitis: a safety and biopsy study. Clin Otolaryngol 1998; 23(1): 69–73PubMedCrossRefGoogle Scholar
  41. 41.
    Qvarnberg Y, Valtonen H, Laurikainen K. Intranasal beclomethasone dipropionate in the treatment of common cold. Rhinology 2001; 39(1): 9–12PubMedGoogle Scholar
  42. 42.
    Penttila M, Poulsen P, Hollingworth K, et al. Dose-related efficacy and tolerability of fluticasone propionate nasal drops 400 microg once daily and twice daily in the treatment of bilateral nasal polyposis: a placebo-controlled randomized study in adult patients. Clin Exp Allergy 2000; 30(1): 94–102PubMedCrossRefGoogle Scholar
  43. 43.
    van Camp C, Clement PA. Results of oral steroid treatment in nasal polyposis. Rhinology 1994; 32(1): 5–9PubMedGoogle Scholar
  44. 44.
    Klossek JM, Dubreuil L, Richet H, et al. Bacteriology of chronic purulent secretions in chronic rhinosinusitis. J Laryngol Otol 1998; 112(12): 1162–6PubMedCrossRefGoogle Scholar
  45. 45.
    Brook I, Frazier EH. Correlation between microbiology and previous sinus surgery in patients with chronic maxillary sinusitis. Ann Otol Rhinol Laryngol 2001; 110(2): 148–51PubMedGoogle Scholar
  46. 46.
    Grimer RJ, Karpinski MR, Andrews JM, et al. Penetration of amoxycillin and clavulanic acid into bone. Chemotherapy 1986; 32(3): 185–91PubMedCrossRefGoogle Scholar
  47. 47.
    Esposito S, Galante D, Barba D, et al. Ciprofloxacin concentrations in human fluids and tissues following a single oral dose. Int J Clin Pharmacol Res 1987; 7(3): 181–6PubMedGoogle Scholar
  48. 48.
    Shirtliff ME, Mader JT, Calhoun J. Oral rifampin plus azithromycin or clarithromycin to treat osteomyelitis in rabbits. Clin Orthop 1999; (359): 229–36Google Scholar
  49. 49.
    Kennedy DW, Senior BA, Gannon FH, et al. Histology and histomorphometry of ethmoid bone in chronic rhinosinusitis. Laryngoscope 1998; 108 (4 Pt 1): 502–7PubMedCrossRefGoogle Scholar
  50. 50.
    Infectious rhinosinusitis in adults: classification, etiology and management. International Rhinosinusitis Advisory Board. Ear Nose Throat J 1997; 76(12 Suppl.): 1–22Google Scholar
  51. 51.
    Cervin A. The anti-inflammatory effect of erythromycin and its derivatives, with special reference to nasal polyposis and chronic sinusitis. Acta Otolaryngol 2001; 121(1): 83–92PubMedCrossRefGoogle Scholar
  52. 52.
    MacLeod CM, Hamid QA, Cameron L, et al. Anti-inflammatory activity of clarithromycin in adults with chronically inflamed sinus mucosa. Adv Ther 2001; 18(2): 75–82PubMedCrossRefGoogle Scholar
  53. 53.
    Zalewska-Kaszubska J, Gorska D. Anti-inflammatory capabilities of macrolides. Pharmacol Res 2001; 44(6): 451–4PubMedCrossRefGoogle Scholar
  54. 54.
    Yamada T, Fujieda S, Mori S, et al. Macrolide treatment decreased the size of nasal polyps and IL-8 levels in nasal lavage. Am J Rhinol 2000; 14(3): 143–8PubMedCrossRefGoogle Scholar
  55. 55.
    Ciprandi G, Pronzato C, Passalacqua G, et al. Topical azelastine reduces eosinophil activation and intercellular adhesion molecule-1 expression on nasal epithelial cells: an antiallergic activity. J Allergy Clin Immunol 1996; 98 (6 Pt 1): 1088–96PubMedCrossRefGoogle Scholar
  56. 56.
    Westerveld GJ, Scheeren RA, Dekker I, et al. Anti-oxidant actions of oxymethazoline and xylomethazoline. Eur J Pharmacol 1995; 291(1): 27–31PubMedCrossRefGoogle Scholar
  57. 57.
    Graf P, Juto JE. Sustained use of xylometazoline nasal spray shortens the decongestive response and induces rebound swelling. Rhinology 1995; 33(1): 14–7PubMedGoogle Scholar
  58. 58.
    Pang YT, Willatt DJ. Do antral washouts have a place in the current management of chronic sinusitis?. J Laryngol Otol 1996; 110(10): 926–8PubMedCrossRefGoogle Scholar
  59. 59.
    Ricchetti A, Landis BN, Maffioli A, et al. Effect of anti-fungal nasal lavage with amphotericin B on nasal polyposis. J Laryngol Otol 2002; 116(4): 261–3PubMedCrossRefGoogle Scholar
  60. 60.
    Messerklinger W. Endoscopy technique of the middle nasal meatus [in German; author’s translation]. Arch Otorhinolaryngol 1978; 221(4): 297–305PubMedCrossRefGoogle Scholar
  61. 61.
    Stammberger H, Posawetz W. Functional endoscopic sinus surgery: concept, indications and results of the Messerklinger technique. Eur Arch Otorhinolaryngol 1990; 247(2): 63–76PubMedCrossRefGoogle Scholar
  62. 62.
    Lund VJ. Evidence-based surgery in chronic rhinosinusitis. Acta Otolaryngol 2001; 121(1): 5–9PubMedCrossRefGoogle Scholar

Copyright information

© Adis Data Information BV 2004

Authors and Affiliations

  1. 1.ENT DepartmentErasmus MC RotterdamRotterdamThe Netherlands

Personalised recommendations