Welcome to module three, chronic rhinosinusitis diagnosis and treatment. Over the next 15 minutes or so we're gonna focus on chronic rhinosinusitis, which is a disease entity that's different from what we talked about in module two, which is acute sinusitis. And the reason why is, chronic sinus disease tends to cause more low-grade, chronic, or persistent symptoms, that over time will effect, negatively, your patients' quality of life. It's not that classic sinus infection where you see some with fever or a lot of purulent drainage, the severe headaches. It's more these persistent low-grade symptoms that go on, that really affect someone, fatigue, loss of quality of life, low-grade headaches. In order to make that diagnosis, patients need at least 12 weeks of symptoms, before even the diagnosis of chronic sinusitis can be even thought of. And there's four main subjective criteria that need to be fulfilled. Two out of those four should be present. One, mucopurulent drainage, two, nasal obstruction, three, facial pressure, pain, or fullness, and lastly decreased sense of smell. The smell symptom is something that's different and added on when compared to the acute sinusitis diagnostic criteria. So if a patient has two of these four, is starting to meet a diagnosis of chronic sinusitis. But in order to confirm that diagnosis, objective criteria are also necessary. And those objective criteria are purulent drainage, edema, or polyps known in the middle meatus on nasal endoscopy. So performing some visual view of the nasal cavity with an endoscope is important. If you're a primary care physician you just don't have that technology in the office, then a CT scan that demonstrates chronic rhinosinusitis can fulfill that objective criteria. So by having two of the four subjective symptoms or signs as well as one of the objective then, you meet that diagnosis of chronic sinusitis if these issues have gone on for three months or more. So, we talked about nasal endoscopy and the need to visualize edema polyps within the ethmoid region or middle meatus. And, the way we do that is with nasal endoscopy. Sometimes in certain cases like the patient on the left, you see here just by opening the nasal speculum and looking with the naked eye, you see inflammatory polyps originating up to the nasal vestibule. However on the patient on the right, without a nasal endoscope looking more posteriorly you may miss these subtle polyps originating from the maxillary and ethmoid sinus. So really looking in and having that magnification is critical. And it's even more critical if you miss a patient who has this which although appear like polyps, biopsying that polyps gives you a diagnosis of squamous cell carcinoma. So visualization of polyps is important but also the ability to biopsy them and make sure what we're dealing with is inflammation and not something more significant is also critical. If you don't have nasal endoscopy in the office, most physicians have an odoscope with a magnifying port that you see here. So just by looking in the nose you actually get a reasonable view about midway through the nasal cavity, and can pick up polyps that may be located more posteriorly. And if you just don't have this ability, then you get that CAT scan potentially to see what's going on within those sinuses. As we talked about what is the role of that CAT scan in chronic rhinosinusitis. He ordered the CAT scan because one, it could be part of the diagnostic process, the CRS, especially in a case where a physician may not have nasal endoscopy and wants to confirm objectively the presence of chronic sinusitis. It also lets us rule out tumor. Or extrasinus spread of this disease process. Especially if it's unilateral. You see this young gentlemen on the top right, he's smiling, he looks happy, but if you look carefully at his face, especially on the right side, you'll see a little bit of fullness under the right eyebrow. And if you look at his right eye, it's slightly depressed when compared to the left. And this is a patient who has subtle findings of extra sinus spread of a chronic sinus process. And this is imaged. Cuz when we do, we see this. Inflammatory polyps, essentially eroding the medial orbital wall and pushing on the orbit and displacing it. There's additional findings you see here in the where the skull base has been elevated, and the bone between the cavity and the brain is actually missing and then thinned out. This is a patient although it looks happy, may not have severe symptoms, based on these CT scan findings something needs to be done to treat that chronic sinusitis. Also the CAT scan is a roadmap for us in sinus surgery, it tells us the anatomic areas that need to be addressed. As well as the air cells or any abnormalities in the anatomy like in this patient here where the integrity of the [INAUDIBLE] wall to wall is not intact. And lastly, it should be done in any patient potentially who fails medical therapy for chronic sinusitis, especially if it's a unilateral process. In addition to that CAT scan, we also have to think about associated disorders that are part of chronic sinusitis. And the first being allergic rhinitis. 60% of patients who have CRS also have associated allergies, and adequate control and management of those allergies will help those patients hopefully achieve a much better result when it comes to treatment for their chronic sinusitis. In addition, Cystic Fibrosis is another condition to consider in a patient who has refractory sinusitis. 36% of Cystic Fibrosis carriers have refractory chronic sinus disease. That's very important, as many times, the pulmonary aspect gets looked at, but the sinus issues are forgotten. 7% of CRS patients have Cystic Fibrosis. So, sometimes that condition could present within the sinuses if the patient has a milder form. So if you see refractory sinus disease, CF is something to always keep in mind in the diagnostic process. Third, immunodeficient states, that's also to be considered if the patient have associated otitis media, pneumonia, or bronchiectasis. CVID are common variable immunodeficiency is present in 10% of patients with refractory chronic rhinosinusitus. And Ig A deficiency in 6%. Ciliary dyskinesia is a condition, it's the zebra, but also has to be considered. The patients have an abnormality in their ciliary function throughout their body, in the intestines, in the ovarian tubes, in the sinuses. And when I first started to practice, a patient I'd operated on, who had allergies did a good surgery, managed their allergies, but had really persistent refractory sinusitis. And we sent to an immunologist, everything was coming back negative. Lost to follow up. Comes back to see me about five years later. Tells me that she's been having difficulty conceiving. Had an atopic pregnancy, and then it clicked. Did a swab or brush biopsy, and that patient had ciliary dyskinesia. So just a point in the case to keep in mind that never give up on a patient who has refractory chronic rhino sinusitis and you've done everything you can. You gotta look deeper. Think of the zebras, think of things that you may not have realized, something you learned in med school. And accelerated discanesia is something that, when I first saw that patient, was not in my mind, but I can tell you now. After that experience, every patient who walks through that door with refractory sinus disease, I'm thinking about that disease process. Now, as far as chronic sinusitis and the immune evaluation, if you suspect immune deficiency for the reasons we talked about Bronchitis, bronchiectasis, otitis media. IgA Deficiency, Selective IgG and CVID are the most commonly associated immunodeficient states that we'll see in CRS patients. What's interesting is and sad is that an average of three sinus surveys are performed in this study before diagnosis of chronic sinusitis was made. So before embarking even on your first surgery, if you suspect that a patient has severe disease and may qualify for one of those associated disorders, especially in the efficiency, work that out first before taking the surgery. It will only improve your overall surgical result. And then their trust in your care. In this study, 19% of these patients who were diagnosed with an immune deficiency went on to receive IV IgG, which is essentially an immune boost once a month to help bring up the immune system and protect them against infection. Now how do we evaluate for immunodeficiency? What could we do before sending that patient to an immunologist? Well serum blood work is the first step, looking for IgA, IgG and IgM levels. A lot of people will order IgG subclasses and in our recent guidelines, it talked about the utility of that Is not indicated because we don't know what the significance of an IGG sub class deficiency is and many times it is not a addressed. So really just sticking with the A, the G, and tithe N, and those total values. Pre and post immunization type for titres for tetanus ans pneumococcus is also important. We talked about strep pneumonia being the most common cause of acute sinusitis. So, if you're immunized against it, then they protect you. But more importantly, after vaccine, the post vaccine titres tell us about immune system function. The patient that does not develop an adequate response, is somebody who has a selective antibody deficiency, that should be referred potentially. To an immunologist, so those immunization titres are not just for treatment, potentially, but also for diagnosis. Lastly, T cell function evaluation by delayed hypersensitivity testing and quantification with flow cytometry, can also be performed. Now what is the ideal medical therapy for chronic sinusitis? You know there's no real consensus for what is the optimal treatment. So as multiple studies and our academies put forth clinical practice guidelines to help guide the clinician as far as how best to treat these patients. And one study looked at dividing these people into both chronic rhino sinusitis without polyps, and those patients with polyps and two different treatments. Those patients with polyps a three month course of topical steroid, sinus irrigations, and in certain cases chronic low dose macrolide therapy could be considered. More using it for the immunomodulatory effects rather than the antibacterial effects. That's where antibiotic use could potentially be used in the chronic sinus patient but not for infection. You see here we don't talk about cultures, the study didn't mention the use of oral steroids in this subset. However in CRS with polyps where topical steroids and irrigations are still part of the [INAUDIBLE]. And in those patients who fail that treatment regiment oral steroids could be used as a potential adjunct. As far as the ideal and optimal regimen for oral steroids, that varies by patient. We tend to use primosome a dose of 30 milligrams, 20 milligrams, 15, ten and five each for three days. And a patient who does not have a contra indication to the use without medication. Now the role of antibiotics, the key thing is that it's used to treat acute exacerbations on top of the patient's chronic sinusitis. And culture directed antibiotic therapy is critical, because the organisms here, which we'll talk about soon can be different than what we see with acute sinusitis. So having a culture directed antibiotic can help dictate better therapy. Also can help avoid antibiotic resistance and creating superbugs and super bacteria that can fight all these antibiotics. The duration of antibiotics really is dependent on physician preference. There are a few studies looking at the difference between a three week course of antibiotics and a six course of antibiotics not really showing any difference. So three weeks should be enough time to treat this with antibiotics if needed. The bacterial pathogens that we see. We still see the Streptococcus species as being the highest. But Pseudomonas, a gram negative rod, comes into play here with chronic sinus patients. Haemophilus influenzae and Moraxella catarrhalis are still part of the acute exacerbations in the CRS patient. Staph for us as well, we also see less common ones like Enterobacter, Stenotrophomonas, so that's where that culture is very important. Try to find out which one of these bacteria we have because that dictates antibiotic therapy. This is an example of a culture report for a patient Who is cultured in the office on the endoscopic guidance, you see here the patient grew Pseudomonas Aeruginosa which is the mucoid phenotype which can be a little bit more aggressive. It tends to form something called biofilms but more importantly you see what antibiotics in that list work against that bacteria that tells us if it's successable to each one. And the MIC tells us what is the best antibiotic and the most antibiotic to treat that patient. The lower the MIC, the better the efficacy. Trying to find out the oral option that has the lowest MIC that the patient is not allergic to is our way of using that culture to help us. What about chronic lose dose macrolide therapy? This is an option in someone who has failed topical steroid therapy and saline irrigations. You think maybe prednisone dependent otherwise. This is where you could bring in the macrolide to see if their immunomodulatory effects can be helpful. As far as the optimal dosing it can vary. But one option is azithromycin. 250mg Monday, Wednesday and Friday in the patient who does not have a contra-indication. And it tends to be more effective in the patient's who have normal IgE levels, and who did not make polyps. So just something to think about. Thasacyclin is another, long term antibiotic use in patients now in Europe, who have a chronic sinusitis with polyps. It actually was shown to have a similar degree of efficacy to prednisone, in the management of polyps. So let's move on to topical therapy and chronic sinusitis. This, over the years, has been the workhorse in how we manage these patients. Topical saline, steroids, antibiotics and lastly, antifungal's. So let's start off with saline. Level one a evidence for the use of saline irrigation so, strong evidence that saline irrigations work in both types of CRS patients. Those with and those without polyps. The same go for topical steroids. So those two tend to be the main modalities of cream that we'll start. We're bringing in others if those two do not work. Topical antibiotics are something that have been used a great deal, and still are too some day now. But one thing you have to understand, there's only level four evidence with its use. And these tend to be used in patients who are dependant on systemic antibiotics and hopefully find some way to decreasing a systemic antibiotic need. But the evidence for topical antibiotics are not as good. They're usually given for a duration of four weeks, and try to be culture directed in or to optimize treatment. The unknowns of Topical Therapy, one is are pulmicort irrigations superior to topical sprays? And that's something we don't know, and trials are going on and studies are going on to look at this. But we still don't know is one more superior to the other. Two is, what is the systemic absorption of pulmicort irrigation to steroids provided in a irrigation on nebulized form. There's no FDA approved study that's looked at that to see see what risks are we putting the patient at. And the key thing you have to counsel patients is, that steroids in irrigation form is a non FDA approved use of this medication, it's an off label use. A lot of success that we had from it generates from its use in the pulmonary literature. But still, it's something you need to counsel your patients on before subscribing. And lastly, is there a role for topical, or even systemic antifungal therapy? In our most recent guidelines, in April of 2015, they highlight multiple randomized control trials. That show no benefit to the use of topical as well as systemic antifungals in the treatment of chronic rhinosinusitis. So they feel that there's no role for them in this setting. So just something to keep in mind, and somewhat new with our recent guidelines. So let's summarize chronic sinusitis and what we learned. One is that the diagnosis requires both objective as well as subjective findings that must be present for a period of 12 weeks or more. Second, distinguishing between patients with polyps and without polyps can help dictate the medical regimen to initiate. And inflammatory treatment is the mainstay of therapy. In acute sinusitis, we're focusing on the infectious component. In chronic sinusitis, we're actually looking more at the inflammatory component. And treating that infectious component if it coexists with antibiotics. And lastly, topical saline and steroids by far have the most evidence as far as benefit and ethic for the treatment for those patients who suffer from chronic sinusitis. So that concludes module three where we discussed both the diagnosis as well as the treatment of chronic sinusitis. I hope you enjoyed it and will hopefully have a better understanding of how to treat your patients moving on into the future and I hope you'll join us for module four where we will talk about more of the role of surgery in those patients who suffer from sinus disease. Thank you.
