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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 and the typical age of diagnosis ranging
Chronic rhinosinusitis (CRS) is an from 40 to 60 years.3,4,5
inflammatory condition affecting the nose CRS is associated with both allergic
and paranasal sinuses that, by previously and non-allergic disease. There is
defined criteria, lasts 12 weeks or more. increasing evidence that CRS is an
CRS is a common condition worldwide inflammatory disease and not an infectious
and a public health problem that has a process. Consistent with its underlying
significant socio-economic impact. 1,2 inflammatory etiologies, chronic
The disorder is commonly divided rhinosinusitis is associated with other
into two subtypes: CRS with nasal polyps inflammatory diseases such as allergic
(CRSwNP) and CRS without nasal polyps rhinitis and asthma.6,7
(CRSsNP). Nasal polyps are inflammatory CRSwNP is frequently associated with
outgrowths of sinonasal tissue that are asthma and allergic rhinitis, but the
estimated to occur in 1% to 4% of the US cellular and molecular mechanisms that
general population. Although nasal polyps contribute to the clinical symptoms are not
are observed in various clinical conditions fully understood. Elevated IgE, mast cell
including cystic fibrosis and malignancy, degranulation, eosinophilia and a helper T-
they are more frequently associated with a cell type 2 (Th2) cytokine profile within
subset of CRS. In this condition, nasal the sinonasal mucosa is often seen in
polyps are benign and typically develop CRSwNP.These features may be seen in
bilaterally in the sinonasal cavity.3,4 allergic conditions as well. Thus an
Recent data have demonstrated that association between these two entities has
CRS affects approximately 5–15% of the frequently been assumed given their
general population. CRS, both with and pathophysiologic overlap. It would also be
without polyps, has an estimated expected that nasal polyps would be more
prevalence of 4.9% (or 490 in 10,000 prevalent in patients with allergy and
people) in the United States. DEPKES RI conversely that allergy would be more
in 2003 explained that nasal and sinus prevalent in patients with nasal polyps.1,4
diseases were ranked 25th out of 50 major Diagnosis of CRS is based on
disease patterns. CRSwNP occurs in symptoms, nasoendoscopic examination,
approximately 20% of persons with CRS. and computed tomography (CT). The
CRSwNP is a disease of middle age, with symptoms are either nasal obstruction or
the average age of onset being 42 years nasal discharge, with or without facial pain
and with or without reduction or loss of

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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

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of the nose since a year ago. The Polypectomy and FESS procedure
complaints have been increasing since 3 have been performed. On the right and left
months ago. The patient felt headache. The nasal cavity tampon was attached. This
patients feels smelly discharge coming out patient was diagnosed with chronic
from his nose, decreasing olfaction rhinosinusitis with nasal polyp bilateral
sensation, and sneezing when he exposed post polypectomy and FESS procedure
to dust. He denied about fever, and D0. Post Surgical treatment is ringer lactat
nosebleed. There was no complaint of ear 20 drips per minute, cefotaxime injection 1
and throath. gram per 12 hours, ketorolac injection 30
On general examination, the patient mg per12 hours, ranitidine injection 50 mg
was good condition, vital signs revealed per 12 hours, tranexamic acid 500 mg per
blood pressure 120/70 mmhg, respiration 8 hours. Keep the tampon to 5 days after
rate 20x/minute, heart rate 86x/minute, and surgery. Change the outer gauze per 24
temperature 36.60C. On ENT examination, hours.
the right and left auricular was within First day follow up pain post surgery
normal limit. From otoscopy tympanic was minimum. The tampon was attached
membrane was intact, cone of light was on the right and left nasal cavity.
normal. On examination of the anterior Diagnosed with chronic rhinosinusitis with
and posterior rhinoscopy of both nasal nasal polyp bilateral post polypectomy and
cavity, there was a shimmer white mass FESS procedure D1. The terapy was ringer
with discharge. Oropharyngeal lactat 20 drips per minute, cefotaxime
examination there was post nasal drips. injection 1 gram per 12 hours, ketorolac
Laryngoscopy indirect was within normal injection 30 mg per 12 hours, ranitidine
limit. From nasoendoscopy both nasal injection 50 mg per 12 hours, tranexamic
cavity there was white mass. From MSCT acid 500 mg per 8 hours. Keep the tampon
scan SPN Coronal slices, there were to 5 days after surgery. Change the outer
isodens lessions on the turbinate bilateral, gauze per 24 hours.
irregular. Second day follow up pain post
Based on the history and physical surgery was minimum. The tampon was
examination, patients was diagnosed with attached on the right and left nasal cavity.
chronic rhinosinusitis with nasal polyp Diagnosed with chronic rhinosinusitis with
bilateral. Patient would treat with nasal polyp bilateral post polypectomy and
Polypectomy and FESS procedure. FESS procedure D2. The terapy was ringer
lactat 20 drips per minute, cefotaxime

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injection 1 gram per 12 hours, ketorolac sneezing when he exposed to dust. In order
injection 30 mg per 12 hours, ranitidine to diagnose CRS as prescribed in the
injection 50 mg per 12 hours, tranexamic European Position Paper on Rhinosinusitis
acid 500 mg per 8 hours. Keep the tampon and Nasal Polyps (EPOS), at least two of
to 5 days after surgery. Change the outer four cardinal symptoms have to be
gauze per 24 hours. diagnosed. At least one of two cardinal
Third day follow up pain post surgery symptoms has to be present: either nasal
and headache was denied. The tampon was discharge or nasal obstruction. The two
attached on the right and left nasal cavity. remaining symptoms are smell distortion
Diagnosed with chronic rhinosinusitis with (dysosmia) and facial pain/pressure.
nasal polyp bilateral post polypectomy and Complaints on CSR felt more than 12
FESS procedure D3. The patient return weeks.13
with oral therapy amoxicillin 500 mg per 8 In general, persons with CRSwNP
hours and paracetamol 500 mg per 8 hours. present with symptoms of prominent nasal
Change the outer gauze, and education to obstruction and hyposmia/anosmia and
come to ENT policlinic after 2 days. complain less of facial pain. Patients with
Fifth day follow up in ENT policlinic, CRSwNP are thought to have more severe
after surgical pain and headache was sinonasal symptoms compared with
denied. Take off the tampon on day 5 after patients with CRSsNP.4,11
surgical treatment. On physical examination, on anterior
The problem with this case is and posterior rhinoscopy of both nasal
treatment. cavity, there was a shimmer white mass
with discharge. Oropharyngeal
Discussion examination there was post nasal drips.
CRS is defined as inflammation of the From nasoendoscopy both nasal cavity
nose and paranasal sinuses lasting 12 there was white mass. From MSCT scan
weeks or longer. Diagnosis of CSR is SPN Coronal slices, there were isodens
based on symptoms, nasoendoscopic lessions on the turbinate bilateral,
examination, and computed tomography irregular.
(CT).8,11 Finding nasal polyps, presence of
From the anamnesis, this patient feel mucopurulent discharge, swelling in the
nasal blockage both of the nose, headache, middle nasal meatus, or obstruction found
smelly discharge coming out from his in physical examination, help to diagnose
nose, decreasing olfaction sensation, and the CRS. Large polyps can sometimes be

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visualized with anterior rhinoscopy alone. management should be evaluated for sinus
They appear translucent, have a yellow surgery. Conventional nasal polypectomy
gray color, lack sensitivity, and typically has lost its charm due to high rate of
arise around the ostiomeatal complex at recurrence. Nowadays, the standard of
the middle meatus. In addition, CRS can surgical treatment of CRS is Functional
be diagnosed upon finding inflammatory Endoscopic Sinus Surgery (FESS). FESS
lesions of the mucous membrane in the is a complex procedure used by
ostiomeatal complex in a computed otorhinolarynologists to treat chronic
tomography (CT) scan. Some polyps may sinusitis, nasal polyps, pituitary tumors,
only be detected with CT imaging and a host of other nasal sinus
studies.8,11,13 pathologies.4,13,14,15
Patients was diagnosed with chronic Nasal polyps affect approximately
rhinosinusitis with nasal polyp bilateral. 20% of patients with CRS. From a clinical,
Patient would treat with Polypectomy and radiological and histological perspective
FESS procedure. the mucosal inflammatory response is
Medical treatment options for patients more florid in CRS patients with nasal
with CRSwNP remain limited. Both polyps than in those without, and the rate
topical corticosteroids and nasal saline of relapse after surgery for nasal polyps
irrigations are recommended as initial tends to be higher. Endoscopic sinus
medical therapies for affected patients. surgery for nasal polyposis has been
Intranasal corticosteroids can decrease generally reported to be a safe and
nasal polyp size, lessen sinonasal effective procedure. FESS involves the
symptoms, and improve patients’ quality clearance of polyps and polypoid mucosa
of life. Oral corticosteroids can also reduce and opening of the sinus ostia. The
polyp size and improve symptoms but removal of inflammatory tissue and
should always be administered cautiously reduction of the load of antigens inciting
given their association with serious that inflammation, as well as the
systemic side effects. Antibiotics may be improvement of sinus ventilation and
useful in treating infectious exacerbations mucociliary clearance, are the probable
of CRSwNP, but clinically significant mechanisms whereby FESS improves
efficacy (ie, polyp shrinkage) in large, symptoms in nasal polyposis.8
randomized trials is lacking.4 International studies conducted hence
Patients with significant sinonasal it demonstrates that FESS is a treatment
disease and/or those who fail medical modality of choice for both primary and

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recurrent nasal polyposis. There is superior It is important to note that although
access and visualization of middle meatus endoscopic sinus surgery improves
mucosa, uncinate process and symptoms and quality of life, it does not
infundibulum, which are the sites from cure the condition, and patients will
which 80% of polyps arise, it is a safe and require medical therapy postoperatively to
successful treatment with low morbidity maintain these improvements.7
and improved patient comfort.15
The goals of endoscopic sinus surgery Summary
in the treatment of CRS are to provide A 51 years old man came to the ENT
ventilation and drainage of the paranasal policlinic Dr. Sardjito General Hospital
sinuses and to enlarge the paranasal sinuses with chief complaint nasal blockage both
to create greater access for topical of the nose, headache, smelly discharge
medications. A recent prospective study coming out from his nose, decreasing
that compared medical management with olfaction sensation, and sneezing when he
surgical management of CRS showed that exposed to dust.
patients who underwent FESS had greater On physical examination, on anterior
improvements in quality of life, reduced and posterior rhinoscopy of both nasal
exposure to antibiotics, and fewer missed cavity, there was a shimmer white mass
days from work or school.7,11 with discharge. Oropharyngeal
A number of significant complications examination there was post nasal drips.
have been reported after FESS for nasal From nasoendoscopy both nasal cavity
polyps. Fortunately the frequency of there was white mass. From MSCT scan
occurrence of severe complications would SPN Coronal slices, there were isodens
appear to be reducing with time, and the lessions on the turbinate bilateral,
risk of major orbital, intracranial or irregular.
vascular injury occurring is now very low.8 Patients was diagnosed with chronic
FESS is a preferred modality of rhinosinusitis with nasal polyp bilateral.
treatment for nasal polyposis. It is an Patient would treat with Polypectomy and
efficient and safe modality with minimum FESS procedure.
morbidity and complication rates. The
recurrent rate of nasal polyposis is
sufficiently reduced with greater References
improvement of symptoms and quality of 1. Marcus S, Roland LT, DelGaudio M,
life in more than 90% of cases.15 Wise SK. The Relationship Between

7
Allergy and Chronic Rhinosinusitis. Gevaert P, Georgalas C, Goossens H,
Laryngoscope Investigative Harvey R, Hellings P, Hopkins C,
Otolaryngology. 2018; DOI: Jones N, Joos G, Kalogjera L, Kern B,
10.1002/lio2.236 Kowalski M, Price D, Riechelmann H,
2. Mustafa M, Patawari P, Iftikhar HM, Schlosser R, Senior B, Thomas M,
Shimmi SC, Hussain SS, Sien MM. Toskalaw E, Voegels R, Wang DY,
Acute and Chronic Rhinosinusitis, Wormald PJ.European Position Paper
Pathophysiology and Treatment. on Rhinosinusitis and Nasal Polyps.
International Journal of 2012.
Pharmaceutical Science Invention. 9. Dharmaputri S, Lasminingrum L,
2015; ISSN (Online): 2319 – 6718, Sofiatin Y. Nasal Endoscopy Findings
ISSN (Print): 2319 – 670X in Acute and Chronic Rhinosinusitis
3. Bachert C, Pawankar B, Zhang L, Patients.Althea Medical Journal.
Bunnag C, Fokken WJ, Hamilos DL, 2017;4(3):420–5.doi:http://dx.doi.org/
Jirapongsananuruk O, Kern R, Meltzer 10.15850/amj.v4n3.1192
EO, Mullol J, Naclerio R, Pillan R, 10. Bose S, Grammer LC, Peters AT.
Rhee CS, Suzaki H, Veohels R, Blaiss Infectious Chronic Rhinosinusitis.
M. ICON: chronic rhinosinusitis. Journal Allergy Clinical Immunology
World Allergy Organization Journal. Practice. 2016 ; 4(4): 584–589.
2014; 7:25 doi:10.1016/j.jaip.2016.04.008.
4. Stevens WW, Schleimer RP, Kern RC. 11. Ocampo CJ, Grammer LC. Chronic
Chronic Rhinosinusitis with Nasal Rhinosinusitis. American Academy of
Polyps. J Allergy Clin Immunol Pract. Allergy, Asthma & Immunology.
2016 ; 4(4): 565–572. 2013; pp 205-211. http://dx.doi.org/
doi:10.1016/j.jaip.2016.04.012. 10.1016/j.jaip.2012.12.001
5. Halderman AA, Tully LJ. The Role of 12. Zhang Y, Gevaert E, Liu H, Wang X,
Allergy in Chronic Rhinosinusitis. Zhang L, Bachert C, Zhang N.
Otolaryngol Clin N Am. 2017; Chronic Rhinosinusitis in Asia.
http://dx.doi.org/10.1016/j.otc.2017.08 Journal Allergy Clinical Immunology.
.003 2017;140:1230-9.https://doi.org/10.10
6. Clarhed UKE, Svendsen M, Schioler 16/j.jaci.2017.09.009
L, Kongerud J, Toren K, Hellgren J, 13. Kluczyński L, Kiszka JJ, Kaźmierczak
Fell AK. Chronic rhinosinusitis related W. The sense of smell in chronic
to occupational exposure – the rhinosinusitis — literature review.
Telemark population study. Journal of Medical Research Journal. 2018;
Occupational and Environmental Volume 3, Number 1, 1–9
Medicine. 2018; DOI : 10.1097/ 10.5603/MRJ.2018.0001
JOM.0000000000001312 14. Sandhaus H, Chen PG. Intraoperative
7. Sedaghat AR. Chronic Rhinosinusitis. Functional Endoscopic Sinus Surgery
American Academy of Family Training: Efficient Teaching
Physicians. 2017; 96(8):500-506 Techniques—A New Method. Clinical
8. Fokkens WJ, Lund VJ, Mullol J, Medicine Insights: Ear, Nose and
Bachert C, Alobid I, Baroody F, Throat. 2018; Volume 11: 1–4. DOI:
Cohen N, Cervin S, Douglas R, 10.1177/1179550618758647

8
15. Gohar SG, Niazi SA, Niazi SB.
Functional Endoscopic Sinus Surgery
as a primary modality of treatment for
primary and recurrent nasal polyposis.
Pak J Med Sci. 2017;33(2):380-382.
doi:https://doi.org/10.12669/pjms.332.
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