Management of Chronic Rhinosinusitis

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Presented by: Jennifer Y. Lee, MD
Clinical Assistant Professor, Otolaryngology
Stanford University Medical Center
March 13, 2014

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Chronic rhinosinusitis is an inflammatory disease associated with infection and allergy in the nasal cavity and sinuses—the holes in the face and skull. It is one of the most common diseases in the United States, affecting about 15 percent of the population and costing more than $8 billion in lost work days and productivity.

Although scientist are not certain on the reason humans have sinuses, there are several theories.  Scientist think sinuses may make the head lighter or serve as a buffer zone for trauma to the face and eyes. They may have developed to provide a resonance chamber for the voice, or to humidify and filter air. Certainly their function includes all of the above.

Chronic rhinosinusitis is based on length of time of symptoms. Acute sinusitis is a temporary infection of the sinuses often associated with a cold or flu that lasts four weeks or less.  When the condition continues for 12 weeks or more, with thick discharge, nasal obstruction, facial pressure, and reduced sense of smell and taste, it is considered to be chronic sinusitis, said Jennifer Y. Lee, MD, a clinical assistant professor of otolaryngology, at a presentation sponsored by the Stanford Hospital Health Library.

Ongoing Condition
Normally, the sinuses produce mucus and drain it through small openings into the nasal passages. But rhinosinusitis causes swelling in the paranasal sinuses, the four sets of air-filled spaces that surround the nasal cavity (maxillary sinuses), above the eyes (frontal sinuses), between the eyes (ethmoidal sinuses), or behind the eyes (sphenoid sinuses).

Diagnosing chronic sinusitis involves taking a detailed medical history as well as a physical exam to observe the signs of inflammation. It often includes nasal endoscopy, in which a thin tube with a light is inserted into the nostrils for a visual inspection of the sinuses. Nasal and sinus cultures are sometimes used to determine the best antibiotic for treatment. Imaging the sinuses is becoming a less common approach, Dr. Lee added, but is useful when patients have certain symptoms like unilateral facial pressure, bleeding, or nasal obstruction, which imply there may be polyps, tumors, or deep inflammation.

Most patients are given a Sino-Nasal Outcome Test (SNOT-22), a rating system to help define symptoms and patient priorities. “The test helps to look at quality of life concerns,” Dr. Lee said. “It’s not just how bad the symptoms are but how important they are to the patient.”

The condition can stem from different causes. In mucociliary dysfunction, cilia fail to function properly from anatomic, environmental, or genetic reasons. There can be allergens that lead to chronic red, swollen mucosa And infections in the respiratory tract—most commonly, colds—viruses, or bacterial can congregate to create biofilms that clog the airways.

Treatment Options
The most effective first-line intervention, said Dr. Lee, is nasal irrigation using a large volume saline irrigation bottle, which helps flush out mucus and any inflammatory bacteria or allergens. Sprays have been shown to not always deliver sufficient irrigation, so she recommends a bottle because it allows patients to control the flow better. It’s also important to use distilled water with the salt packet, since tap water may have bacteria that can exacerbate the situation.

Sometimes sinusitis stems from an allergy rather infection, but allergy testing is usually done after trying more standard options because of the cost and time involved in identifying the allergen for the patient. Allergy-induced sinusitis tends to come in cycles and is treated using a daily routine of topical steroids plus an antihistamine spray.

She also advised to clean the nasal passages before using a topical steroid, comparing the process to cleaning a house before starting to paint.

“You can’t overdose on saline, so it’s OK to use it more than once or twice a day,” she said. “You don’t have to use it, but it breaks the cycle for symptom control. When you’re in a cycle, stick to rinses until you find a regimen that works.”

Antibiotics are used when the source of the inflammation is bacterial. Topical nasal steroids, such as Flonase and Nasonrex, can help control swelling and show few side effects. Oral corticosteroids can cause serious side effects when used long term, so they’re used only to treat severe symptoms.

“Studies show topical steroids really work,” she said. “The trouble is that most studies use higher dosages than typically prescribed, and patients may not use enough.”

Surgical Approach
If all else fails—using maximal medical therapy: saline at the right dosage, topical steroids, oral steroids, and antibiotics—surgery may provide relief. Surgery is done as an outpatient procedure, using a nasal endoscope. The procedure usually takes about two to four hours to cut back the inflamed bone and tissue. There is no bruising, no outer incision, and no nasal packing, so patients are back to regular activities in no time.

“Surgery is only for people who do not respond to maximal medical therapy for chronic rhinosinusitis. Even with surgery, however, there is no guarantee that you’ll never have problems again. But it will reduce symptoms, so there will be less medication and the passages are opened up so it’s easier for topical treatments to get in deep enough to be effective,” Dr. Lee said.

The field is evolving, she added, with promising studies using drug-eluding stents that may provide more refined therapies in the future. Studies are also ongoing on the pathophysiology of the condition and what genes may be involved that make some people more susceptible than others.

About the Speaker
Jennifer Y. Lee, MD, is a clinical assistant professor in the Department of Otolaryngology-Head and Neck Surgery. A University of California, Davis, undergraduate, she received her MD at Albert Einstein College of Medicine and completed her internship and residency at the University of Pennsylvania. She joined the Stanford faculty in 2013 in the Division of Comprehensive Otolaryngology.

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About Dr. Lee

Stanford Hospital Otolaryngology Clinic

Department of Otolaryngology – Head and Neck Surgery

Stanford Hospital Sinus Center