Chapter 26 - Chronic Rhinosinusitis

Question 1

Diagnosis of chronic rhinosinusitis

Answer 1

Subjective and objective (CT) evidence of sinusitis for
at least 12 wk

Adults: Nasal obst/block/congestion or anterior/posterior discharge, PLUS either facial pain/pressure or hyposmia

Children: Change hyposmia to cough

Objective: polyps, mucopurulent drainage, edema, OMC obstruction, thickening/opacification sinuses

Question 2

Sx associated with CRS

Answer 2

nasal obstruction, hyposmia, discharge, facial pressure

Cough, HA, throat discomfort, laryngeal irritation, hoarse, halitosis, ear pressure, dental pain, malaise

Question 3

Difference between diagnosis of CRS in adults vs children

Answer 3

In children, cough accepted as a symptom, and CT scans ordered less frequently

Question 4

Sinuses involved in CRS, in order of common

Answer 4

Ant ethmoid
Maxillary
Post ethmoid
Sphenoid
Frontal

Question 5

Molecular difference between CRS w NP and w/o NP

Answer 5

w NP: INC eosinophils, TH2 pathway (IL 4, 5, 13)
s NP: predominance of TH1 pathway, fibrosis, TGF-B
Both: more inflammatory leukotrienes, less anti-inflam prostaglandins

Question 6

Organisms in CRS

Answer 6

Same as acute (H Flu, Morax, S Pneumo)

Coag neg Staph (epidermidis), S Aureus, Pseudomonas, GNR, anaerobes

Question 7

Diagnosis of AFRS and Mycetoma

Answer 7

AFRS: nasal polyps, hyperdense sinus infiltrate or calcification, eosinophilic mucin, fungal identification. Antifungals don’t help –> need surgery

Mycetoma: inspissated fungal debris and mucous in sinus, usually maxillary. Heterogenous hyperdensity, microcalcify. Surgery (no antifungals usually)

Question 8

How many CRS patients have asthma? Does CRS Tx improve asthma?

Answer 8

50% s NP
80% w NP

Yes

Both dz involve eosinophilia, TH2

Question 9

AERD: association with CRS, pathogenesis, Sx in response to aspirin

Answer 9

10-25% of CRS w NP (25-40% in those w/ asthma too)
Dysfxn arachidonic acid pathway –> INC pro-inflamm leukotrienes, DEC anti-inflam prostaglandins
Aspirin –> bronchospasm, mucosal edema, eosinophils (with NSAIDs too)
Pts tend to have severe polyposis

Part of tx is aspirin desensitization

Question 10

Tx of CRS

Answer 10

Inflammation: nasal saline, steroids, leukotriene modifier, asthma tx, ImmunoTx. Inflamm may be more important than bacteria in the dz for some pts

ABx: Cx-directed, 3-6 weeks if bacterial thought to be major factor

Surgery: unresponsive, surgery will not cure though, works better than continuing to try medical therapy after failing initial medical therapy