Chronic Rhinosinusitis with Nasal Polyps

Moderator : dr. Camelia Herdini , M.Kes., Sp.THT-KL, FICS

DEPARTMENT OF OTORHINOLARYNGOLOGY-HEAD AND NECK

SURGERY
UNIVERSITAS GADJAH MADA
2016
GROUP MEMBERS
• Joeffery Sylvester S. : 11/324399/KU/14851
• Glorian Paul Bosco V. : 11/324403/KU/14853
• Amaliah Syamra : 11/317210/KU/14459
• Fatin Atiqah B.I. : 11/324384/KU/14841
• Taufik Indrawan : 11/317167/KU/14436
• Belinda Meynar A. : 11/317121/KU/14414
INTRODUCTION
• Chronic sinusitis is one of the more prevalent chronic illnesses in the
United States, affecting persons of all age group
• prevalence in the United States is 146 per 1000 population
• Chronic sinusitis is a common disease worldwide, particularly in places
with high levels of atmospheric pollution
• Rhinosinusitis is more common in the pediatric population because this
term includes both acute and chronic infection and both viral and bacterial
disease
• Chronic rhinosinusitis may or may not be accompanied with nasal polyps.
Involvement of nasal polyps affect the management, treatment and
prognosis of this case
• Chronic rhinosinusitis may or may not be accompanied with nasal polyps.
Involvement of nasal polyps affect the management, treatment and
prognosis of this case
LITERATURE REVIEW
Anatomy of the Nose and Paranasal
Sinus
Paranasal Sinus
Osteomeatal Complex
Chronic Rhinosinusitis with Nasal
Polyps
Definition
• Rhinosinusitis is an inflammatory process involving
the mucosa of the nose and one or more sinuses.
• Chronic Rhinosinusitis with nasal polyps (CRSwNP):
Bilateral chronic rhinosinusitis, endoscopically
visualised polyps in middle meatus
• Duration : more than 12 weeks or 3 months
Definition
Symptoms Endoscopic sign CT-Scan of PNS
• blockage/congestion • polyps • mucosal changes
• discharge: • mucopurulent within ostiomeatal
anterior/post nasal discharge from complex and/or
drip middle meatus sinuses
• facial pain/pressure • oedema/mucosal
• reduction or loss of obstruction primarily
smell in middle meatus

Fokkens, WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position Paper on Rhinosinusitis and Nasal
Polyps, 2005; EPOS
Etiology

Underlying factors contributing to the etiology and pathophysiology of CRS

Johnson JT and Rosen CA Bailey's Head and Neck Surgery-Otolaryngology 5th ed., 2014; Lippincott Williams & Wilkins
Pathophysiology
OMC ↓ventilation of the sinuses ↓pO2
obstruction ↓drainage of the sinuses ↑pCO2
Mucous statis

Inflammation and viscous mucous

Statis and poteolytic enzymes
↓ciliary movement

Ciliary damage Anaerobic microorganism

Multiple episodes Chronic rhinosinusitis

Diagnosis
• American Academy of Otolaryngology – Head and Neck
Surgery proposes the symptom-based criteria for
diagnosing chronic rhinosinositis. Symptoms of CRS
vary in severity and prevalence, there are :
1) nasal obstruction (81%–95%),
2) facial congestion-pressure-fullness (70%–85%),
3) discolored nasal discharge (51%–83%), and
4) hyposmia (61%–69%).
The presence of two or more signs or symptoms persisting
beyond 12 weeks is highly sensitive for diagnosing CRS, but
symptom-based criteria alone are relatively non-specific.
• Diagnosing CRS requires that inflammation be documented in
addition to persistent symptoms by one or more of the following
findings :
1) purulent (not clear) mucus or edema in the middle meatus or
anterior ethmoid region,
2) polyps in nasal cavity or the middle meatus, and/or
3) radiographic imaging showing inflammation of the paranasal
sinuses.
• the criteria of chronic rhinosinusitis from EPOS,
characterised by 2 or more symptoms, one of which should be
either :
▫ nasal blockage/obstruction/congestion or
▫ nasal discharge (anterior/posterior nasal drip);
▫ ± facial pain/pressure;
▫ ± reduction or loss of smell for ≥12 weeks
Management

Algorithm of AAO-HNS
for adult with possible
sinusitis
Algorithm of PERHATI-KL for management sinusitis
 Complications
ORBITAL ENDOCRANIAL OSSEOUS

• Periorbital • Epidural or • The most common

cellulitis (preseptal subdural osseous
edema), abscesses, complications are
• Orbital cellulitis, • Brain abscess, osteomyelitis of
• Subperiosteal • Meningitis (most the maxillary
abscess, commonly), (typically in
infancy) or frontal
• Orbital abscess or • Cerebritis, and
bones
• Phlegmon and • Cavernous sinus
cavernous sinus thrombosis
thrombosis
CASE REPORT
Patient identity
• Name : Mr. NS
• Age : 39 years old
• MR : 7874xx
• Address : Patikraja, Banyumas
• Date of examination: August 8th 2016
Anamnesis
• Chief complain : runny nose and nasal blockage
• History of present illness
▫ Since approximately 4 months before came to ENT clinic of
RSUD Banyumas, patient had recurrent runny nose,
yellowish-green colored discharge of mucous with liquid
consistency, foul smelling, and nasal blockage. He has been
having this complaint for approximately 4 months. The
patient experiences runny nose very often and can feel the
discharge dripping into his throat. He mentioned that his
head feels heavy and has facial pain whenever he bent or
faced down. He complained of difficulty in breathing during
meal times. He had no complains about his ear and throat
but stated that he had dental caries. The patient had
received therapeutic management for his complaint for the
past 4 months but could not recall the name of the drugs
prescribed.
Anamnesis
• History of past ilness :
He is allergic to seafood (the patient has never been
formally tested for allergy).
• History of (similar or other) family illnesses :
 His family do not have complain likes him, and do not
have history of diabetes mellitus, hypertension, and allergy
or other systemic illnesses.
Resume of Anamnesis
• Rhinorrhea (+)
• nasal congestion (+)
• foetor ex nasale (+) and
• post nasal drainage (+)
Physical Examination
• General status : good, compos mentis
• Vital sign
▫ BP : 140/80 mmHg
▫ respiratory rate : 20 times/minute
▫ temperature : 36,5˚C
▫ pulse : 71 times/minute
Nose Examination

Anterior rhinoscopy:
hyperemic in right and left nasal cavity,
mucopurulent discharge (+), inferior
concha not well visualized, septum
deviation (-), mass (+) with smooth
surface, did not easily bleed and almost
covered the entire nasal cavity
Facial palpation and percussion:
pain over right and left cheek
Oropharyngeal Examination

Palatine and lingual tonsils size were

within normal limit, pharyngeal
posterior wall within normal limit,
good gag reflex, post nasal drip (+),
dental cavities in premolar 1 and 2,
molar 1 and 2 in both side of the
upper teeth.
Posterior rhinoscopy:
mucopurulent discharge (+)
Indirect Laryngoscopy

Indirect laryngoscopy: within normal limit.

Ear Examination

Right and left ears within normal limit

Dental Cavities
Supporting Examination

Endoscopy
Sinistra Dextra
CT scan of SPN:
Homogenous opacity with ROI density around 25 in both of
maxillary sinuses
Bilateral concha nasalis hypertrophy
Nasal septum within normal limit
Skeletal seems intact
Diagnosis
Chronic rhinosinusitis with nasal polyp bilateral
Treatment and Plan
Pro-polypectomy and inferior anthrostomy
Refer to dentist for dental cavities care
DISCUSSION
• Chief complaint : nasal congestion especially
in the left nose with difficulty in breathing,
especially while eating.
• Signs and symptoms : recurrent rhinorrhea,
foul-smelling and yellowish-green colored
discharge from nose, heavy head and pain
around the face when he looked down and
mucus on his throat, for ±4 months
• The constellation of symptoms in this patient is
in accordance with he criteria of CRS from EPOS
• Rhinoscopy examination : nasal polyps in both side
of the nasal cavity. In the left side, it can be seen that the
nasal polyps almost covered the entire cavity.
• Oropharyngeal examination : presence of post nasal
drip and dental cavities in premolar 1 and 2, molar 1 and
2 in both sides of upper teeth.
• Face palpation and percussion : pain in ;eft and
right cheeks when palpated.
• CT-Scan : homogenous opacity with ROI density
around 25 in both of maxillary sinuses, ethmoidalis
sinuses, frontalis sinuses and nasal cavity. Thre is also
bilateral nasal concha hyperthrophy.
• CT findings suggestive of chronic sinusitis include.
• CRS can become a significant cause of morbidity. If
it is left untreated, it can reduce the quality of life
and the productivity of the affected person. CRS
rarely life threatening, but serious complication can
occur.

• Approximately 75% of all orbital infection are

directly related to sinusitis. Intracranial
complication rmain comparatively rare, with 3.7-
10% of intracranial infection reated to sinusitis.
• First-line therapy : topical corticosteroids
• Long-term treatment with topical nasal steroid
sprays has been shown to reduce sinus inflammation
and nasal polyps size and improve symptoms associated
with CRS.
• Short courses of oral steroids are used in the
treatment of CRS with nasal polyps but may also be used
in cases of severe CRS when rapid symptomatic
improvement is needed.
• A recent Cochrane review reviewed 8 randomized
clinical trials on the use of nasal saline irrigation for
CRS, and included studies demonstrated improvement
in symptoms quality of life, and endoscopy findings
• Antibiotics should be used when purulence is
identified, with combination of topical nasal steroid,
nasal irrigation, mucolytic agents, or other adjuvant
therapies i.e. macrolide, amoxicillin-cluvulanate,
clindamycin, sufamethoxazole/trimethoprim,
andlevofloxacin or ciprofloxacin.
• Functional Endoscopic Sinus Surgery (FESS) is to
clear blockage and ensure patency of the osteomeatal
complex.
• 80-90% of patients with recurrent or medically
unrenponsive CRS cases were restored sinus health with
complete or moderate relief of symptoms
• 70-98% of patient show subjective improvement
CONCLUSION
 This case reports a male patient of 39 years
diagnosed with chronic rhinosinusitis and suspect
bilateral nasal polyps after anamnesis, physical
examination and CT scan results. Polypectomy
and inferior anthrostomy were recommended for
this patient. Prognosis of this case ad vitam, ad
functionam and ad sanationam after surgery is to
be dubia ad bonam.
REFERENCE
• Pleis JR, Lucas JW. Summary health statistics for U.S. adults: National Health Interview
Survey, 2007.Vital Health Stat 10. 2009 May. 1-159.
• Shah AR, Hairston JA, Tami TA. Sinusitis in HIV: microbiology and therapy. Curr Allergy
Asthma Rep. 2005 Nov. 5(6):495-9.
• Watelet JCauwenberge P. Applied anatomy and physiology of the nose and paranasal sinuses.
Allergy. 1999;54(s57):14-25.
• Brook, Itzak, et al. Sinusitis From Microbiology to Management. New York: Taylor and
Francis, 2006.
• Shiffman, Melvin A and Alberto Di Giuseppe. Advanced Aesthetic Rhinoplasty. Berlin:
Springer, 2013. Print.
• Drake, Richard L et al. Gray's Anatomy For Students. Philadelphia, PA: Churchill
Livingstone/Elsevier, 2010. Print.
• Alsubael, Mohammad Omar and Abd El-Monem Awad Mustafa Hegazy. "Anatomical
Variations Of The Human Nasal Osteomeatal Complex, Studied By CT". Zagazig University
Medical Journal Special Issue (2009): 72-83. Print.
• Brennan, Peter A, Vishy Mahadevan, and Barrie T Evans. Clinical Head And Neck Anatomy
For Surgeons. Print.
• Fokkens, WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position
Paper on Rhinosinusitis and Nasal Polyps, 2005; EPOS
• Fokkens WJ, Lund VJ, Mullol J, Bachert C, Alobid I, Baroody F, et al. European Position
Paper on Rhinosinusitis and Nasal Polyps 2012. Rhinol Suppl. Mar 2012; (23): 1-298
• Johnson JT and Rosen CA Bailey's Head and Neck Surgery-Otolaryngology 5th ed., 2014;
Lippincott Williams & Wilkins
• Meltzer EO, Hamilos DL, Hadley JA, et al. Rhinosinusitis: establishing definitions for
clinical research and patient care. J Allergy Clin Immunol. 2004; 114(6 Suppl):155–212
• Ponikau JU, Sherris DA, Kern EB, et al. The diagnosis and incidence of allergic fungal
sinusitis. Mayo Clin Proc. 1999; 74:877–84
• Kern EB, Sherris D, Stergiou AM, Katz LM, Rosenblatt LC, and Ponikau J, Diagnosis and
treatment of chronic rhinosinusitis: focus on intranasal Amphotericin B, Ther Clin Risk
Manag. Jun 2007; 3(2): 319–325
• Rosenfeld RM, Piccirillo JF, Chandrasekhar SS, Brook I, Kumar KA, Kramper M, et al. 2015,
Clinical Practice Guideline (Update) Adult Sinusitis, Otolaryngol Head Neck Surg April 2015
vol. 152 no. 2 suppl S1-S39
• Rhinology Study Group – PERHATI-KL, Buku Saku EPOS 2007, PERHATI-KL, 2007;
Jakarta
• Kaplan A, Canadian guidelines for chronic rhinosinusitis Clinical summary, Canadian Family
Physician December 2013 vol. 59 no. 12 1275-1281
• Eugene BK, David S, Jens P, et al., Diagnosis and Treatment of Chronic Rhinosinusitis: focus
on intranasal Amphotericin B; 3(2). 2007.
• Witterick IJ, Kolenda J, Surgical Management of Chronic Rhinosinusitis, Immunol Allergy
Clin North Am. 2004; 24:119-34
Thank You
Pathophysiology
• A fundamental role in the pathogenesis of rhinosinusitis is played by the
ostiomeatal complex
• Specifically, ostial patency significantly affects mucus composition and
secretion; moreover, an open ostium allows mucociliary clearance to easily
remove particulate matters and bacteria eventually come in contact with the
sinusal mucosa.
• if mucus production is increased, for instance during an upper respiratory
tract infection (URI), or if ciliary function is impaired. Stasis of secretions
follows and bacterial export ceases, causing or exacerbating inflammation
of the mucosa whilst aeration of the mucosa is decreased, causing even
more ciliary dysfunction
• if the condition persists, it can result as chronic rhinosinusitis
• One might postulate that, over time in CRS patients, this chronic and
debilitating disease with accumulation of mucosa may result in polyps
Grading of Nasal Polyps
• Grade 0 : no visible polyps
• Grade 1 : Polyps confined to the middle meatus
• Grade 2 : polyps beyond the middle meatus but
not completely obstructing the nasal cavity
• Grade 3 : polyps completely obstructing the
nasal cavity

Lund and Mackay’s Nasal Polyps Grading System

Anterior Rhinoscopy
Right Left
TNSS