CASE REPORT

CHRONIC RHINOSINUSITIS WITH NASAL POLIP

Presentator :
dr. Kristianto Aryo Nugroho

Moderator :
Dr. dr. Sagung Rai Indrasari, M.Kes., Sp.T.H.T.K.L(K), FICS

Otorhinolaryngology Head and Neck Surgery Departement

Faculty of Medicine, Public Health and Nursing
Universitas Gadjah Mada
Dr. Sardjito Hospital Yogyakarta
2019
Introduction
Chronic rhinosinusitis (CRS) is an
inflammatory condition affecting the nose
and paranasal sinuses that, by previously
defined criteria, lasts 12 weeks or more.
CRS is a common condition worldwide
and a public health problem that has a
significant socio-economic impact. 1,2
The disorder is commonly divided
into two subtypes: CRS with nasal polyps
(CRSwNP) and CRS without nasal polyps
(CRSsNP). Nasal polyps are inflammatory
outgrowths of sinonasal tissue that are
estimated to occur in 1% to 4% of the US
general population. Although nasal polyps
are observed in various clinical conditions
including cystic fibrosis and malignancy,
they are more frequently associated with a
subset of CRS. In this condition, nasal
polyps are benign and typically develop
bilaterally in the sinonasal cavity.3,4
Recent data have demonstrated that
CRS affects approximately 5–15% of the
general population. CRS, both with and
without polyps, has an estimated
prevalence of 4.9% (or 490 in 10,000
people) in the United States. DEPKES RI
in 2003 explained that nasal and sinus
diseases were ranked 25th out of 50 major
disease patterns. CRSwNP occurs in
approximately 20% of persons with CRS.
CRSwNP is a disease of middle age, with
the average age of onset being 42 years
2
and the typical age of diagnosis ranging
from 40 to 60 years.3,4,5
CRS is associated with both allergic
and non-allergic disease. There is
increasing evidence that CRS is an
inflammatory disease and not an infectious
process. Consistent with its underlying
inflammatory etiologies, chronic
rhinosinusitis is associated with other
inflammatory diseases such as allergic
rhinitis and asthma.6,7
CRSwNP is frequently associated with
asthma and allergic rhinitis, but the
cellular and molecular mechanisms that
contribute to the clinical symptoms are not
fully understood. Elevated IgE, mast cell
degranulation, eosinophilia and a helper T-
cell type 2 (Th2) cytokine profile within
the sinonasal mucosa is often seen in
CRSwNP.These features may be seen in
allergic conditions as well. Thus an
association between these two entities has
frequently been assumed given their
pathophysiologic overlap. It would also be
expected that nasal polyps would be more
prevalent in patients with allergy and
conversely that allergy would be more
prevalent in patients with nasal polyps.1,4
Diagnosis of CRS is based on
symptoms, nasoendoscopic examination,
and computed tomography (CT). The
symptoms are either nasal obstruction or
nasal discharge, with or without facial pain
and with or without reduction or loss of
smell. These symptoms occur more than laryngologists and even intensivists and
12 weeks.8,9 neurosurgeons when severe complications
Nasal endoscopy discovers nasal occur. The greatest impact of CRS is
polyp and/or mucopurulent discharge decreased quality of life through
and/or edema, primarily from middle burdensome chronic sinonasal symptoms
meatus, and/or result of CT scan that and acute exacerbations. 7,8
findsmucosal changes within the The goals of treatment in patients with
osteomeatal complex and/or sinuses are chronic rhinosinusitis are to manage
results of additional examination that are symptoms and improve or maintain quality
referred to diagnosis of rhinosinusitis.8 of life. Treatment is directed at enhancing
The CT scan is the gold standard for mucociliary clearance, improving sinus
diagnosis of rhinosinusitis, but its high drainage, eradicating local infection and
cost and lack of availability become the inflammation, and improving access for
problems in Indonesia. Hence, nasal topical medications. Treatment options for
endoscopy becomes the choice for CRS include topical intranasal steroid, oral
diagnosing rhinosinusitis. Many studies antibiotics, topical antibiotics, nasal saline
also found that nasal endoscopy is suitable irrigation, oral steroids or combination of
for diagnosing rhinosinusitis. Therefore, it oral antibiotics and steroids. Surgery may
is not necessary to reevaluate the findings be necessary when aggressive medical
with CT scan. Besides that, nasal management fails to control disease.7,10
endoscopy also has functions to assess Orbital and intracranial complications
predisposing factors and contributors of are the most serious sequelae of CRS but
rhinosinusitis, such as variations in are extremely rare, usually arising in
anatomical structure dan mucosal changes patients with superimposed acute sinusitis.
in middle meatus and osteomeatal Orbital complications include periorbital
complex.9 cellulitis, orbital cellulitis, and orbital
Chronic rhinosinusitis with abscess. Intracranial complications include
(CRSwNP) and without nasal polyps cavernous sinus thrombosis, meningitis,
(CRSsNP) in its many forms, constitutes and epidural abscess.7
one of the commonest conditions
encountered in medicine and may present Case Report
to a wide range of clinicians from primary A 51 years old man came to the ENT
care to accident and emergency, policlinic Dr. Sardjito General Hospital
pulmonologists, allergists, otorhino with chief complaint nasal blockage both

3
of the nose since a year ago. The
complaints have been increasing since 3
months ago. The patient felt headache. The
patients feels smelly discharge coming out
from his nose, decreasing olfaction
sensation, and sneezing when he exposed
to dust. He denied about fever, and
nosebleed. There was no complaint of ear
and throath.
On general examination, the patient
was good condition, vital signs revealed
blood pressure 120/70 mmhg, respiration
rate 20x/minute, heart rate 86x/minute, and
temperature 36.60C. On ENT examination,
the right and left auricular was within
normal limit. From otoscopy tympanic
membrane was intact, cone of light was
normal. On examination of the anterior
and posterior rhinoscopy of both nasal
cavity, there was a shimmer white mass
with discharge. Oropharyngeal
examination there was post nasal drips.
Laryngoscopy indirect was within normal
limit. From nasoendoscopy both nasal
cavity there was white mass. From MSCT
scan SPN Coronal slices, there were
isodens lessions on the turbinate bilateral,
irregular.
Based on the history and physical
examination, patients was diagnosed with
chronic rhinosinusitis with nasal polyp
bilateral. Patient would treat with
Polypectomy and FESS procedure.
4
Polypectomy and FESS procedure
have been performed. On the right and left
nasal cavity tampon was attached. This
patient was diagnosed with chronic
rhinosinusitis with nasal polyp bilateral
post polypectomy and FESS procedure
D0. Post Surgical treatment is ringer lactat
20 drips per minute, cefotaxime injection 1
gram per 12 hours, ketorolac injection 30
mg per12 hours, ranitidine injection 50 mg
per 12 hours, tranexamic acid 500 mg per
8 hours. Keep the tampon to 5 days after
surgery. Change the outer gauze per 24
hours.
First day follow up pain post surgery
was minimum. The tampon was attached
on the right and left nasal cavity.
Diagnosed with chronic rhinosinusitis with
nasal polyp bilateral post polypectomy and
FESS procedure D1. The terapy was ringer
lactat 20 drips per minute, cefotaxime
injection 1 gram per 12 hours, ketorolac
injection 30 mg per 12 hours, ranitidine
injection 50 mg per 12 hours, tranexamic
acid 500 mg per 8 hours. Keep the tampon
to 5 days after surgery. Change the outer
gauze per 24 hours.
Second day follow up pain post
surgery was minimum. The tampon was
attached on the right and left nasal cavity.
Diagnosed with chronic rhinosinusitis with
nasal polyp bilateral post polypectomy and
FESS procedure D2. The terapy was ringer
lactat 20 drips per minute, cefotaxime
injection 1 gram per 12 hours, ketorolac
injection 30 mg per 12 hours, ranitidine
injection 50 mg per 12 hours, tranexamic
acid 500 mg per 8 hours. Keep the tampon
to 5 days after surgery. Change the outer
gauze per 24 hours.
Third day follow up pain post surgery
and headache was denied. The tampon was
attached on the right and left nasal cavity.
Diagnosed with chronic rhinosinusitis with
nasal polyp bilateral post polypectomy and
FESS procedure D3. The patient return
with oral therapy amoxicillin 500 mg per 8
hours and paracetamol 500 mg per 8 hours.
Change the outer gauze, and education to
come to ENT policlinic after 2 days.
Fifth day follow up in ENT policlinic,
after surgical pain and headache was
denied. Take off the tampon on day 5 after
surgical treatment.
The problem with this case
treatment.
Discussion
CRS is defined as inflammation of the
nose and paranasal sinuses lasting 12
weeks or longer. Diagnosis of CSR is
based on symptoms, nasoendoscopic
examination, and computed tomography
(CT).8,11
From the anamnesis, this patient feel
nasal blockage both of the nose, headache,
smelly discharge coming out from his
nose, decreasing olfaction sensation, and
sneezing when he exposed to dust. In order
to diagnose CRS as prescribed in the
European Position Paper on Rhinosinusitis
and Nasal Polyps (EPOS), at least two of
four cardinal symptoms have to be
diagnosed. At least one of two cardinal
symptoms has to be present: either nasal
discharge or nasal obstruction. The two
remaining symptoms are smell distortion
(dysosmia) and facial pain/pressure.
Complaints on CSR felt more than 12
weeks.13
In general, persons with CRSwNP
present with symptoms of prominent nasal
obstruction and hyposmia/anosmia and
complain less of facial pain. Patients with
CRSwNP are thought to have more severe
sinonasal symptoms compared with
patients with CRSsNP.4,11
On physical examination, on anterior
is and posterior rhinoscopy of both nasal
cavity, there was a shimmer white mass
with discharge. Oropharyngeal
examination there was post nasal drips.
From nasoendoscopy both nasal cavity
there was white mass. From MSCT scan
SPN Coronal slices, there were isodens
lessions on the turbinate bilateral,
irregular.
Finding nasal polyps, presence of
mucopurulent discharge, swelling in the
middle nasal meatus, or obstruction found
in physical examination, help to diagnose
the CRS. Large polyps can sometimes be
5
visualized with anterior rhinoscopy alone.
They appear translucent, have a yellow
gray color, lack sensitivity, and typically
arise around the ostiomeatal complex at
the middle meatus. In addition, CRS can
be diagnosed upon finding inflammatory
lesions of the mucous membrane in the
ostiomeatal complex in a computed
tomography (CT) scan. Some polyps may
only be detected with CT imaging
studies.8,11,13
Patients was diagnosed with chronic
rhinosinusitis with nasal polyp bilateral.
Patient would treat with Polypectomy and
FESS procedure.
Medical treatment options for patients
with CRSwNP remain limited. Both
topical corticosteroids and nasal saline
irrigations are recommended as initial
medical therapies for affected patients.
Intranasal corticosteroids can decrease
nasal polyp size, lessen sinonasal
symptoms, and improve patients’ quality
of life. Oral corticosteroids can also reduce
polyp size and improve symptoms but
should always be administered cautiously
given their association with serious
systemic side effects. Antibiotics may be
useful in treating infectious exacerbations
of CRSwNP, but clinically significant
efficacy (ie, polyp shrinkage) in large,
randomized trials is lacking.4
Patients with significant sinonasal
disease and/or those who fail medical
6
management should be evaluated for sinus
surgery. Conventional nasal polypectomy
has lost its charm due to high rate of
recurrence. Nowadays, the standard of
surgical treatment of CRS is Functional
Endoscopic Sinus Surgery (FESS). FESS
is a complex procedure used by
otorhinolarynologists to treat chronic
sinusitis, nasal polyps, pituitary tumors,
and a host of other nasal sinus
pathologies.4,13,14,15
Nasal polyps affect approximately
20% of patients with CRS. From a clinical,
radiological and histological perspective
the mucosal inflammatory response is
more florid in CRS patients with nasal
polyps than in those without, and the rate
of relapse after surgery for nasal polyps
tends to be higher. Endoscopic sinus
surgery for nasal polyposis has been
generally reported to be a safe and
effective procedure. FESS involves the
clearance of polyps and polypoid mucosa
and opening of the sinus ostia. The
removal of inflammatory tissue and
reduction of the load of antigens inciting
that inflammation, as well as the
improvement of sinus ventilation and
mucociliary clearance, are the probable
mechanisms whereby FESS improves
symptoms in nasal polyposis.8
International studies conducted hence
it demonstrates that FESS is a treatment
modality of choice for both primary and
recurrent nasal polyposis. There is superior
access and visualization of middle meatus
mucosa, uncinate process and
infundibulum, which are the sites from
which 80% of polyps arise, it is a safe and
successful treatment with low morbidity
and improved patient comfort.15
The goals of endoscopic sinus surgery
in the treatment of CRS are to provide
ventilation and drainage of the paranasal
sinuses and to enlarge the paranasal sinuses
to create greater access for topical
medications. A recent prospective study
that compared medical management with
surgical management of CRS showed that
patients who underwent FESS had greater
improvements in quality of life, reduced
exposure to antibiotics, and fewer missed
days from work or school.7,11
A number of significant complications
have been reported after FESS for nasal
polyps. Fortunately the frequency of
occurrence of severe complications would
appear to be reducing with time, and the
risk of major orbital, intracranial or
vascular injury occurring is now very low.8
FESS is a preferred modality of
treatment for nasal polyposis. It is an
efficient and safe modality with minimum
morbidity and complication rates. The
recurrent rate of nasal polyposis is
sufficiently reduced with greater
improvement of symptoms and quality of
life in more than 90% of cases.15
7
It is important to note that although
endoscopic sinus surgery improves
symptoms and quality of life, it does not
cure the condition, and patients will
require medical therapy postoperatively to
maintain these improvements.7
Summary
A 51 years old man came to the ENT
policlinic Dr. Sardjito General Hospital
with chief complaint nasal blockage both
of the nose, headache, smelly discharge
coming out from his nose, decreasing
olfaction sensation, and sneezing when he
exposed to dust.
On physical examination, on anterior
and posterior rhinoscopy of both nasal
cavity, there was a shimmer white mass
with discharge. Oropharyngeal
examination there was post nasal drips.
From nasoendoscopy both nasal cavity
there was white mass. From MSCT scan
SPN Coronal slices, there were isodens
lessions on the turbinate bilateral,
irregular.
Patients was diagnosed with chronic
rhinosinusitis with nasal polyp bilateral.
Patient would treat with Polypectomy and
FESS procedure.
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