Chronic Rhinosinusitis

and Nasal Polyposis

Philippe Gevaert , MD, PhD
Michael A. Kaliner, MD
Paul Van Cauwenberge, MD, PhD
Reviewers: Kamal Hanna, Richard F. Lockey, Todor Popov

Updated: June 2011

Sponsored by an unrestricted educational grant from

Global Resources in Allergy

(GLORIA)
Global Resources In Allergy (GLORIA) is
the flagship program of the World Allergy
Organization (WAO). Its curriculum
educates medical professionals
worldwide through regional and national
presentations. GLORIA modules are
created from established guidelines and
recommendations to address different
aspects of allergy-related patient care.

World Allergy Organization

(WAO)
The World Allergy Organization is
an international coalition of 89
regional and national allergy and
clinical immunology societies.

WAOs Mission
WAOs mission is to be a global
resource and advocate in the field
of allergy, advancing excellence in
clinical care, education, research
and training through a world-wide
alliance of allergy and clinical
immunology societies

Module 10:
Chronic Rhinosinusitis
and Nasal Polyposis

Lecture objectives
At the end of this presentation, participants will
be able to:
Discuss the underlying pathology of acute and
chronic rhinosinusitis and nasal polyposis
Describe the management of acute and chronic
rhinosinusitis and nasal polyposis

Rhinosinusitis
Facts:
14.7% incidence in US population: 31,000,000 cases
per year
Incidence increased by 18% over the past 11 years
26 million office visits for sinusitis in 1997
>21 million antibiotic prescriptions in 1997
Third most common diagnosis for antibiotics
>70 restricted activity days in 1992
250,000 surgeries per year

Survey IMS Health 2001

Germany, 7/2000-6/2001

USA, 1997

Acute sinusitis
Diagnosis: 6.3 million
Prescriptions: 8.5 million

Prevalence of sinusitis: 14.7%

Chronic sinusitis
Diagnosis: 2.6 million
Prescriptions: 3.4 million

985
1992

Nasal polyposis:
Diagnosis: 221 000

Prescriptions of antibiotics for

sinusitis
5.8 million
13 million

Work loss (days)

1986
50 million
1992
73 million

1.
2.
3.
4.
5.
6.
7.
8.
9.

Maxillary sinus
Ethmoidal bulla
Ethmoidal cells
Frontal sinus
Uncinate process
Middle turbinate
Inferior turbinate
Nasal septum
Ostiomeatal
complex

Infections induce changes in

sinus mucosa
The ostiomeatal
complex

B
Key

MT
MS

B:

bulla
ethmoidalis
IT: inferior
turbinate
MT: middle
turbinate
MS: maxillary sinus

Ventilation
and
Drainage

IT

Inflammation
and
Remodeling

Anatomy & physiology

RADIOGRAPHIC ANATOMY OF THE PARANASAL SINUSES
Coronal
Anterior

Axial
Posterior

Frontal
sinuses

Sphenoid sinus

Ethmoid
sinus

Maxillary sinus

Posterior ethmoid
Anterior
ethmoid

Sphenoid sinus

Anatomy and physiology

MUCOSAL IMMUNITY
Anatomical and mechanical factors: Epithelial barrier
Mucus/mucociliary clearance
Mucosal immune system:
Innate immunity:
Rapid,
nonspecific

Antimicrobial peptides: Defensins

Receptors: Toll-like receptors
Cells: Macrophages, neutrophils,
dendritic cells, NK cells, mast cells

Adaptive
Specific, immunity: Antigen-presenting cells
memory

T-lymphocytes
B-lymphocytes => IgA

Aetiology of rhinosinusitis

Allergy
Seasonal
Perennial
Infection
Acute
Chronic: specific e.g.
Bacterial, fungal or
nonspecific
Possible host defense
deficency
Structural
Ostiomeatal complex:
Deviated nasal septum
Hypertrophic turbinates

After International Consensus Report on

the diagnosis and management of

Others
Dental, periapical
abcess
Underlying diseases,
cystic fibrosis
Occupational irritants
and allergens
Drug induced, rhinitis
medicmentosa
Irritants induced
rhinitis
Atrophic rhinitis

Anatomy and physiology

COMMON COLD
BACTERIAL SUPERINFECTION
Strep pneu./Haemo inf./Morax
catar.
Increasing symptoms after 5 DAYS
No resolution after 10 DAYS
ACUTE rhinosinusitis
MULTIFACTORIAL ETIOLOGY

CHRONIC rhinosinusitis

EAACI Position Paper on Rhinosinusitis

and Nasal Polyps, Allergy 2005: 60:
583-601

Underlying conditions

Sinusitis and Immunodeficiencies

Humoral immunodeficencies
frequently associated with sinusitis
Congenital immunodeficencies
Selective IgA deficency, Common variable IgG
immunodeficency, Agammaglobulinemia, specific
antibody deficency, (rarely IgG Subclass deficency)
Acquired immunodeficencies
Immunosupressive agents, HIV

Sinusitis and cystic fibrosis

Classification: chronic
rhinosinusitis
with and without nasal polyps
2 OR MORE MAJOR SYMPTOMS

nasal blockage

anosmia/hyposmia

purulent nasal discharge/post-nasal drip

facial pain/pressure
AND EITHER

endoscopic findings of polyps

mucopurulent discharge

edema or obstruction
OR

CT scan abnormality: mucosal changes within ostiomeatal

complex or sinus
cavity
EAACI Position Paper on
Rhinosinusitis and Nasal Polyps,

Classification: chronic
rhinosinusitis
with and without nasal polyps
DURATION
ACUTE/intermittent < 12 weeks
complete resolution of symptoms
CHRONIC / persistent > 12 weeks
incomplete resolution of symptoms

EAACI Position Paper on Rhinosinusitis and Nasal

Polyps, Allergy 2005: 60: 583-601

Symptoms associated with

rhinosinusitis
Major symptoms:

Minor symptoms:

Facial pain/pressure
Headache
Facial congestion/fullness
Fever
Nasal obstruction/blockage
Halitosis
Nasal discharge/purulence/postnasal drip
Hyposmia/Anosmia
Dental pain
Fever Cough
Ear pain/fullness

Fatigue

Microbiology
Normal sinuses: Free of growth
Acute rhinosinusitis:
Viral
Bacterial (Strept. Pneumoniae,H. Influenzae, M. Catharralis)
Chronic rhinosinusitis:
Anaerobes: Propionibacterium, Bacteriodes, Peptococcus
Aerobes: Staphylococcus, Corynebacterium, Pseudomonas
Fungi (Aspergillus fumigatus, Curvularia, Dreschelaria)
Dental sinusitis: Microaerophilic strept. species

Nasal
polyps

Imaging of sinsuses
MRI: only recommended in tumor diagnosis
CT sinuses: current standard imaging
- Acute rhinosinusitis: only for possible complications
- Chronic sinusitis: only after 4+ weeks of treatment!

Septal
deviation

Chronic
Sinusitis

Dental
sinusitis

Nasal
polyps

The signs and symptoms of

acute sinusitis
(>10 days and < 12 weeks):

Prerequisite symptoms
Persistent upper
respiratory infection (>10
days)
Persistent muco-purulent
nasal or posterior
pharyngeal discharge
Cough

Supporting symptoms

Congestion
Facial pain/pressure
Post-nasal drip
Fever
Headache
Anosmia, hyposmia
Facial tenderness
Periorbital edema
Ear pain, pressure
Halitosis
Upper dental pain
Fatigue
Sore throat

Diagnosis of acute bacterial

sinusitis (ABS)
A diagnosis of ABS is suggested when
Symptoms of a viral URI

or

Have not improved

after 10 days

International Rhinosinusitis Advisory Board. ENT J

1997;76(suppl):1; Lanza and Kennedy. Otolaryngol

Have worsened
after 5 to 7 days

Association between viral and

bacterial sinusitis infections

Viral infections
Self-limiting
2 to 3 acute viral respiratory infections per year (6-8
in children)
>80% symptoms resolve in 7-8 days
Often inciting event for development of sinusitis and
other respiratory tract infections
0.5%2% of cases complicated by acute bacterial
infection (>20 million cases)

Brook. Primary Care 1998;25:633; Gwaltney. Clin

Infect Dis 1996;23:1209; Gwaltney et al. N Engl J
Med 1994;330:25.

Acute bacterial rhinosinusitis

(ABRS)
Copyright permission for reproduction
pending

Sinus and Allergy Health Partnership, 2000

Therapy

Decongestives/pain
Saline washes
Antibiotics (oral, IV)
Corticosteroids (local, oral)
Surgery:
Adenoidectomy (child)
Endoscopic sinus surgery (adult)

acute

chronic

Strength of evidence for treatment

of
acute
rhinosinusitis
Therapy
Level
Recommendation Relevance
antibiotic

Ia (49 studies)

yes: after 5-10days,

or in severe cases

topical corticosteroid

1b (1 study)

yes

addition of topical steroid to

antibiotic

Ib (5 studies)

yes

oral steroid

no evidence
(1 study)

no

addition of oral antihistamine

in allergic patients

Ib (1 study)

no

nasal douche

no evidence
(3 studies)

no

decongestion

no evidence
(3 studies)

Yes as symptomatic
relief

mucolytics

no evidence
(3 studies)

no

EAACI Position Paper on Rhinosinusitis and Nasal

Polyps, Allergy 2005: 60: 583-601

An update on acute
rhinosinusitis management:
antibiotics in adults

Cochrane Review Antibiotics for acute maxillary sinusitis

7330 subjects in 32 studies (10 double blind)

antibiotic vs. control (n=5)
newer, non-penicillin antibiotic vs. penicillin class
(n=10)
amoxicillin-clavulanate vs. other extended spectrum
antibiotics (n=10)
Confirmed radiographically or by aspiration, current
evidence is limited but supports penicillin or amoxicillin for
7 to 14 days. Clinicians should weight the moderate
benefits of antibiotic treatment against the potential for
adverse effects

Williams Jr JW, The Cochrane Library 2003

Evidence for treatment of

rhinosinusitis with topical
corticosteroids plus antibiotics - 1
Study

Drug

Antibiotic

Number

Effect

X-ray

Meltzer,
2000
(340)

Momet.
furuate

amox/clav

407

Significant effect in No
congestion, facial
statistical
pain, headache and difference in
rhinorrhea. No
CT outcome
significant effect in
postnasal drip

Nayak, 2002 Momet.

(341)
furuate

amox/clav

967

Total symptom
Score (TSS) was
improved
(nasal congestion,
facial pain,
rhinorrhea
and postnasal drip)

No
statistical
difference in
CT outcome

Evidence for treatment of

rhinosinusitis with topical
corticosteroids plus antibiotics - 2
Study

Drug

Antibiotic

Number

Effect

X-ray

Dolor,
2001
(342)

FP

cefurox

95

Significant
effect.
Effect measured
As clinical
success
depending on
Patients
self-judgment of
symptomatic
improvement

Not done

Evidence for treatment of

rhinosinusitis with topical
corticosteroids plus antibiotics - 3

Study

Drug

Antibiotic

Number

Effect

X-ray

Barlan,
Bud
1997 (343)

amox/clav

89
children

Improvement in
cough and nasal
secretion seen at
the end of the
second week of
treatment in the
BUD group

Not done

Meltzer,
Flunisol.
1993 (344)

amox/clav

180

Significant
sympt: overall
score for global
assessment of
efficacy was
greater in the
group with
flunisolide

No effect
on xray

Copyright permission for reproduction

pending

J Allergy Clin Immunol. 2005 Dec;116(6):1289-95.

Community-acquired
acute sinusitis

Inflammatory component:
Topical corticosteroids
Symptomatic treatment
If unsuccessful,
prolonged,
or primary signs

Primary signs
of bacterial infection:
Localized severe headache
Pus in the middle meatus
Complications (orbital, skin, etc.)

Infectious bacterial
component:
Antibiotic treatment
If unsuccessful
on
several trials,
or complications
Surgical intervention

Considerations in antibiotic
selection
Pharmacokinetics (PK)/
Pharmacodynamics (PD)
Medication
Allergy

Activity Against Likely Pathogen

Ease of Dosing

Considerations
in Antibiotic
Selection

Cost/ Formulary
Status

Adverse Effects
Resistance Patterns

Adapted from Kennedy et al. Ann Otol Rhinol Laryngol

Suppl 1995;167:22; Sinus & Allergy Health
Partnership. Otolaryngol Head Neck Surg.

Conditions for effective

antibiotic treatment

Appropriate spectrum
Appropriate penetrance and local activity
Minor side-effects
Good tolerance
Liklihood of no resistence
Affordable
Available

Antibiotic therapy for sinusitis

2007
Penicillin
Amoxicillin
Amoxicillin/clavulanate
Cephalospor
in
Cefuroxime
Cefopodoxime
Cefixime
Cefprozil
Cefdinir

Macrolid
e
Erythromycin/sulfisoxazole
Clarithromycin
Azithromycin
Miscellaneou
sKetolides
Quinalones
Metronidazole
Trimethoprin/sulfamethoxaz
ole
Clindamycin

Recommended antibiotic
choices - 2007
First choice:
Amoxicillin/clavulante or cephalosporin
Good second choice: Clarithromycin
Back-ups:
Quinalones
Use metronidazole plus one of the above or clindamycin
when gram negative is suspected
Topical mupiricin very useful in select cases

An update on acute rhinosinusitis

management: Antibiotics in acute
rhinosinusitis?

Dont treat viral common cold with antibiotics

Use symptomatic treatment in mild acute rhinosinusitis
saline
decongestant
NSAID
Use topical steroids in acute and chronic sinusitis
(evidence)
Reserve antibiotics for severe acute presumably
bacterial
rhinosinusitis
Prescribe antibiotics based on local resistance patterns

Sinusitis - conclusions

Sinusitis is common and over-looked

Causes are complex
Treatment requires appreciation of causes and careful
follow-up
Medical management is effective in most cases
Functional endoscopic surgery is helpful in resistant
sinusitis after adequate medical management

Definitions and classification

CLINICAL DEFINITION OF RHINOSINUSITIS/NASAL
POLYPS
2 OR MORE MAJOR SYMPTOMS
nasal blockage
smell dysfunction
nasal discharge/post-nasal drip
facial pain/pressure
AND EITHER

endoscopic findings of polyps

mucopurulent discharge

edema or obstruction
OR
CT scan abnormality: mucosal changes within ostiomeatal
complex or sinus cavity
EAACI Position Paper on Rhinosinusitis
and Nasal Polyps, Allergy 2005: 60:
583-601

The signs and symptoms

of chronic sinusitis
(symptoms persisting >12 weeks):
Prerequisite symptoms
Purulent nasal and
posterior pharyngeal
discharge
Plus:
Facial pain/pressure
Persistent nasal
obstruction
Cough/post-nasal
drip/throat clearing

Supporting symptoms

Hyposmia, anosmia

Sore throat

Malaise

Fever

Headache, facial
pressure, dental pain

Halitosis

Sleep disturbance

Fatigue

Diagnosis of chronic
rhinosinusitis
Symptoms suggestive of chronic rhinosinusitis
Initial evaluation:

Medical history: major, minor symptoms

General examination

Evaluation of underlying disease and co-morbidities

Anterior rhinoscopy,

Nasal endoscopy

CT scan (not in an acute episode)

Special indications (differential

diagnosis and underlying
disease)

Allergy tests
Microbiology (eventually
sinus puncture)
Challenge test for aspirin
sensitivity
Nasal cytology
(eosinophils,
neutrophils)
MRI (if tumor or fungus
suspected)
Ciliary function studies
Biopsy

Biopsy
Blood examinations
(Wegeners,
immunodeficencies)
Sweat chloride test
Electron microscopy of cilia
Genetic analyses
Consultations of other
specialities
(ophthalmologist,
neurologist etc.)

Differential diagnosis of
chronic rhinosinusitis - 1

Infectious rhinitis: viral upper respiratory tract

infection
Allergic rhinitis: seasonal, perennial, occupational
Nonallergic rhinitis: Vasomotor rhinitis, NARES,
aspirin- exacerbated respiratory disease
Rhinitis medicamentosa
Rhinitis secondary to pregnancy, hypothyroidism
Anatomical abnormalities: severe septal deviation,
foreign body
Nasal polyps
Inverted papilloma, benign and malignant tumors

Claus Bachert, Allergy: principles and

practice.

Differential diagnosis of
chronic rhinosinusitis - 2

Cerebrospinal fluid leak, meningoencephaloceles

Mucoceles
Wegeners granulomatosis
Cocaine abuse
Atrophic rhinitis
Specific or tropic infections
Fungal sinus disease
Ophthalmologic or neurologic diseases

Claus Bachert, Allergy: principles and

practice.

Chronic rhinosinusitis: why?

Chronic inflamed (eosinophilic) mucosa

Possible superimposed infections
Bacteria
Fungi
Superantigens
Biofilms
Osteitis

Chronic rhinosinusitis
with and without nasal polyps
Chronic
Rhinosinusitis

Nasal Polyps

The spectrum of sinus disease

Rhinosinusiti
s

- Eosinophils +

Nasal Polyps

Chronic rhinosinusitis
with and without nasal polyps
Chronic
Sinusitis

Nasal
Polyposis

Facial pain/pressure

Yes

Sometimes

Facial congestion/fullness

Yes

Yes

Nasal obstruction/blockage

Yes

Yes

Nasal discharge/purulence/postnasal drip

Yes

Yes

Anosmia

Sometimes

Yes

Blood eosinophils

Sometimes

Often

Yes

Often

Rarely

10% of
cases

Asthma
Aspirin exacerbated respiratory disease

Chronic sinusitis - without nasal

polyps
Prevalence of 14.7% in the
normal population
Th1 type Inflammation with

increased IFN

increased TGF and

remodeling
Pathogenic role of infections
is unclear

Nasal polyposis
Prevalence approx. 2- 4%
Asthma in approx. 40-65%
Aspirin sensitivity in 10-15%
Mixed cellular infiltrate with
prominent eosinophilia in 90%
Inflammation with

local IgE production

increased IL-5, eotaxin,

cys-LTs and ECP

Superantigens or
superallergens

Bacterial Superantigens
Staph aureus enterotoxins: SEA, SEB, SEC, SED,
SEE, TSST-1
Strep. pyogenes,
Mycoplasma arthritidis,
T-Cell
Yersinia pseudotuberculosis
Highly potent immune stimulators
TCR V V
Interact with T-cell R
SA
MHC
and MHC class II
g
II
20% of all T-cells are
APC
activated by SEA

S. aureus colonization and IgE

antibodies to
S. aureus enterotoxin mix in mucosal
tissue
Copyright permission for reproduction
pending

T. Van Zele, P. Gevaert et al. JACI 2004

Nasal polyposis: aetiology and

pathogenesis
Epithelial damage
(barrier dysfunction)
chronic microbial
trigger

Hyper IgE Cytokines

Polyclonal IgE

Albumin

Superantigens

Eosinophils
( apoptosis)

IL-5

Chemokines

Eotaxin

S. Aureus enterotoxins: disease modifiers

ECP

Recommended approach to the

treatment of chronic rhinosinusitis
2007

Hydration (6 - 8 glasses of water per day)

Antibiotics X 14-21+ days (until asymptomatic +7 days)
Choices: cephalosporin, amoxicillin/clavulanate,
clarithromycin, quinalone
Long-acting nasal decongestant, BID X 7 days
(oxymetazoline)
Nasal saline applied with nasal irrigation device, BID
Topical nasal CCS:

2 sprays BID, until symptoms resolved

Reduce to lowest effective dose, to maintain remission

Aim towards the eye and away from the nasal septum

Next recommended approaches

Switch antibiotics
CT scan; limited cut, coronal plane
Treat bacterial rhinitis
rarely MRI fungal or possible tumors
Add metronidazole or clindamycin (especially with foul
smell)
Consider fungal Rx (itraconazole, amphotericin)
Oral CCS (Daily followed by QOD)
Topical antibiotics (tobramycin, mupirocin nasal ointment)

Evidence-based treatment of CRS

Therapy

Level

Grade of
Recommend.

Relevance

oral antibiotic therapy

short term < 2 weeks

III (4)

no

oral antibiotic therapy

long term ~ 12 weeks

III (6)

yes

topical steroids
without significant
systemic absorption

II (2)

yes

oral steroid

no data
available

no

nasal douche

III

yes, for
symptom
relief

decongestion topical/oral

no data in
single-use

no

Evidence-based treatment of CRS

Therapy

Level

Grade of
Recommend.

mucolytics
systemic antimycotics

IV (1)
VI

D
D

no
no

topical antimycotics

III

no

oral antihistamine
in allergic patients

Ib (1)

no

allergic therapy
in allergic patients

Studies include D
patients with
NP

yes

allergen avoidance
in allergic patients

Studies include D
patients with
NP

yes

proton pump inhibitors

III (3)

no

Relevance

Evidence-based long-term antibiotics

in CRS
Study

Drug

Number

Time/Dose

Effect on
symptoms

Evidence

Hashiba et
al,
1996(379)

clarithromycin

45

400mg/d
for 8 to 12
weeks

clinical
improvement in
71%

III

Nishi et al,
1995 (381)

clarithromycin

32

400mg/d

pre- and postTherapy

assesment of
nasal clearance

III

Gahdhi et al,
1993 (382)

Prophylatic
antibiosis
details not
mentioned

26

Not
mentioned

19/26 decrease
III
Of acute
exacerbation by
50%
7/26 decrease of
acute
exacerbation by
less than 50%

Evidence-based long-term antibiotics

in CRS
Study

Drug

Ichimura
et
al, 1996
(18)

Number

Time/Dose

Effect on
symptoms

Evidenc
e

roxithromycin 20

150mg/d
for at least
8 weeks

clinical
improvement
and polypshrinkage in
52%

III

Roxithromyci
n
and
azelastine

1mg /d

Clinical
improvement
and polyp
shrinkage in
68%

20

Strength of evidence for

treatment of CRS/NP
Intervention

Chronic rhinosinusitis

Corticosteroids TopicalA
A
Systemic / C
Antibiotics Oral short term < 2w C
Oral long term >12w
C
Antimycotics Topical / Systemic D
Antihistamines D B
Anti-leukotrienes / C
Nasal saline douche C D
Decongestants DD
Allergen avoidance D D

C
D

Nasal polyps

Treatment options for polyposis

Treat underlying sinusitis

High dose nasal CCS
Oral CCS
Chronic/prophylactic antibiotics, systemic and/or
topical
Anti-fungal, systemic and/or topical
Anti-IL5

Nasal corticosteroid spray in nasal

polyposis
Copyright permission for reproduction
pending

Lund V, et al. Arch Otolaryngol Head Neck

Surg 1994; 124: 513-8

Nasal corticosteroid drops in nasal

polyps
Copyright permission for reproduction
pending

Aukema, Mulder,
Fokkens; JACI

Budesonide use, 2007

Dilute budesonide solution (Pulmicort Respules), 5001000 ug in 2-4 Oz saline and irrigate the sinuses BID

Have head positioned to the side so that gravity helps

get washings into the sinuses; turn head as if to put the
ear on knee

Has resolved polyp resistant to nasal fluticasone sprays

Topical anti-fungal treatment

in nasal polyposis
Copyright permission for reproduction
pending

A Richetti et al. 2002 J

Laryngology & Otology

Topical anti-fungal treatment in nasal

polyposis
50
40

42% cured
48

Before treatment
After treatment

Nasal lavages with Amphotericin

B is in 2 DBPC studies:
30
n

27

20
0% cured
62% cured
- Ebbens F & Fokkens W J Allergy Clin
Immunol. 2006 Nov;118(5):1149-56.
10
13
13
13
- Weschta M & Riechelmann H. , Arch Otolaryngol
Head
Neck
Surg.
2006
Jul;132(7):743-7
5

Stage I
Stage II
Oral antifungal terbinafine is ineffective:

Stage III

Open study: - with 4 w Amphotericin B + nasal

-GCS
Kennedy DW, Laryngoscope. 2005 Oct;115(10):1793-9
- in 74 patients with NP
48% improvement of NP (>> small polyps)

Long term antibiotic treatment in

nasal polyposis

DBPC study in 90 patients:

3m low-dose erythromycin, nasal douche, nasal GCS vs. sinus su
50% Improvement of symptoms
no difference vs sinus surgery

Mupiricin use

Use mupiricin with

Recurrent crusting, particularly anterior
Congestion, headache, green secretions & normal CT
contact points, spurs
Polyps
Mupiricin (Bactroban 2%) anteriorly with finger or Q
tip, blot nose
Dissolved in saline, irrigate nose and sinuses with sinus
rinse, along with budesonide

Polyp treatments - 2007

Anticipate 25+% improve with sinus Rx + nasal CCS
Another 25-50% improve with sinus Rx + high dose nasal
CCS (FP drops or MDI, or nasal lavages with budesonide)
The remainder improve with oral CCS + FP or nasal lavages
with budesonide solution
Overall medical treatment can get close to 100% success
Mupiricin appears to help prevent regrowth, especially with
crusting
Surgery, properly done, is successful short-term but polyps
can and do recur and repeated surgery gets progressively
more difficult and dangerous!

Polyps recommended treatment 2007

Treat underlying sinusitis

High dose nasal CCS
Fluticasone (FP), either nasal drops (EU) or MDI (USA)
through nasal adapter (such as a baby bottle nipple)
Prednisone 20-30 mg
Daily x 3-4 weeks, then QOD, then taper to 0
Budesonide solution (Pulmicort Respules) dissolved in sinus
lavage
Wash with the head positioned with ear turned to the knee
Mupiricin ointment topically or dissolved in sinus lavavge
Consider careful surgery if polyps are persistent, resistant or
recur
Consider oral or topical anti-fungal treatment

Conclusions - 1
Lack of controlled studies in Chronic Rhinosinusitis/Nasal
Polyps!!
Current standard treatment for CRS:
Nasal douche with saline
Topical corticosteroids
BUT in NP: reversible effect, no resolution of NP
Surgery: endoscopic sinus surgery
BUT in NP: high recurrence rate!!

Conclusions - 2
Treat associated diseases: Allergic rhinitis
Combinations?
Nasal douche
Topical steroids (drops)
Antibiotic ointment (mupiricin)
Long term antibiotics (macrolides or doxycycline)

polyposis
Anti-IgE?

Anti-CCR3?
An
t

iI

Eotaxin

gE

IgE

Tacrolimus?

t
An

L
iI

Anti-IL-5?

IL-5

Corticosteroids?

Anti-LTs?

ECP
Antibiotics?

-5

Anti-fungal?

Summary - chronic
rhinosinusitis

CRS is common; nasal polyposis occurs in about 25%

CRS
Nasal polyposis is a complex disease to treat and few
etiologic answers are known
Polyposis is nearly always associated with CRS and
makes treating underlying sinusitis more difficult
Treat for sinusitis plus high dose nasal corticosteroids,
particularly in solution. Consider topical antibiotics
Surgery may be beneficial, especially when combined
with good medical care
Nasal polyps recur this is a chronic, relapsing disease

World Allergy Organization

(WAO)
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Organization (WAO), please visit
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Milwaukee, WI 53202
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Fax: +1 414 276 3349
Email: info@worldallergy.org