Amrita Journal of Medicine Vol. 8, No: 1

Jan - Jun 2012. Page 1 - 44

review article

Rinosinusitis Kronis Ikhtisar

N.V Deepthi*, U.K. Menon*, K. Madhumita*

Abstrak

Rinosinusitis kronis (CRS) adalah kondisi umum dengan implikasi sosial yang signifikan karena menyebabkan hilangnya jam kerja. Patofisiologis umum untuk hampir semua bentuk CRS adalah peradangan, yang pengobatannya tersedia luas. Namun, tidak semua pasien sembuh atau dapat mengontrol gejala mereka bahkan dengan manajemen medis yang maksimal. Dalam kasus tersebut, dianjurkan untuk bedah sinus endoskopi fungsional (FESS). Modalitas manajemen, meskipun bervariasi, dapat bermanfaat pada pasien yang patuh terhadap pengobatan. Bagaimanapun, ada variabilitas yang signifikan dan kurangnya standarisasi pedoman sehubungan dengan modalitas di atas. Artikel ini mencoba untuk memberikan pembaca gambaran tentang metodologi investigasi dan pengobatan masalah THT tersebut.

Kata kunci: Rinitis kronis, sinusitis, CT scan Sinus Paranasal, bedah

Pendahuluan

Rinosinusitis kronis (CRS) adalah salah satu penyakit otorhi-nolaryngologic yang paling sering ditemui dalam praktek sehari-hari. Dengan kondisi medis yang cukup umum, di mana diagnosis dan prognosis tergantung pada gejala, tanda-tanda, penilaian klinis dan evaluasi radiologi. Hal ini sering tidak mudah, banyak peneliti telah berusaha untuk mengkarakterisasi kondisi ini didasarkan pada berbagai faktor. Beberapa di antaranya adalah sebagai berikut: skor gejala, skor Computed Tomography, temuan endoskopi, temuan bedah, hasil Kebudayaan dan hasil Histopatologi.

CRS adalah sekelompok gangguan karakteristik berupa peradangan pada mukosa hidung dan sinus paranasal dengan durasi minimal 12 minggu berturut-turut. Selain itu, osteitis tulang dapat mendasari gangguan ini. Beberapa faktor, baik intrinsik dan ekstrinsik memberikan kontribusi pada pengembangan dari CRS.

Pendekatan manajemen untuk menyajikan pasien dengan CRS adalah secara bertahap logis dengan tujuan memaksimalkan manajemen medis dan meredakan gejala. Bedah sinus endoskopi fungsional (FESS) sekarang diterima secara luas dalam pengaturan kegagalan manajemen medis.

*Dept. of ENT, AIMS, Kochi.

Metode

Informasi yang digunakan untuk menulis makalah ini pada dasarnya telah dikumpulkan sebagai bagian dari pasca sarjana diterima oleh National Board of Examination. Teks standar, artikel dari Jurnal diindeks dan berbagai sumber di basis data secara elektronik dengan menggunakan kata-kata kunci rinosinusitis kronis, poliposis hidung dan bedah sinus endoskopi fungsional yang digunakan untuk melakukan penelitian latar belakang. Preferensi diberikan kepada penelitian yang lebih baru.

Insidensi

Rinosinusitis kronis (CRS) adalah penyakit umum yang mempengaruhi lebih dari 30 juta orang secara global setiap tahun dengan lebih dari 200.000 orang setiap tahunnya membutuhkan tindakan bedah1. Hal ini dilaporkan lebih banyak dibandingkan arthritis atau hipertensi, yang mempengaruhi antara 5% dan 15% dari populasi menurut literatur Barat. Ini adalah masalah umum yang menuntut biaya tinggi dalam hal perawatan kesehatan langsung serta hilangnya produktivitas.Definisi

Rinosinusitis adalah sekelompok gangguan ditandai dengan peradangan pada mukosa hidung dan sinus paranasal. Rinosinusitis kronis adalah sekelompok gangguan yang

ditandai dengan peradangan pada mukosa hidung dan sinus paranasal durasi minimal 12 minggu berturut-turut3.

Faktor Etiologi

A] Faktor Host:

Sistemik

Alergi, defisiensi imun, genetik/kongenital, disfungsi mukosiliar, dll.

Lokal

Anatomi, neoplasma dan disfungsi mukosiliar yang didapat

B] lingkungan:

Mikroorganisme, bahan kimia, polusi, asap, obat-obatan, dll.

C] Lain-lain:

Asma, alergi, penyakit gigi, poliposis, fibrosis sistik, dan

Sindrom defisiensi imun3.

Patofisiologi

Patologi penting dalam CRS terdiri dari drainase yang tidak memadai atau diblokir dari sinus paranasal [PNS] menyebabkan stasis dan / atau infeksi sekunder . Situs blok adalah selalu daerah yang telah digambarkan sebagai ' ostiomeatal kompleks ' [OMC] . Sistem anatomi-fisiologi normal dari PNS berisi udara, pengeringan sekresi dan lendir melalui ostia kecil ke daerah yang relatif kecil di dinding lateral hidung { } Gambar 1 , Salah satu atau lebih dari faktor etiologi dapat berkontribusi untuk mengganggu baik anatomi atau fisiologi sistem PNS.4 Amrita Journal of Medicine

Mucociliary clearance of frontal sinus

Osteomeatal complex

MucociliaryFluid

collected in

clearance of

sinus

maxillary

sinus

Cilia drain sinuses by propelling mucus toward natural ostia (mucocilisty clearance)

Fig. 1: Schematic representation of ostiomeatal complex and normal mucociliary clearance

by a host of factors. Most of these have been mentioned in the earlier list. One or many of them can contribute to disrupt either the anatomy or the physiology of the PNS system.

Recent findings

Rhinologic literature has suggested the involvement of a significant inflammatory component that has been largely attributed to cytokines and inflammatory cells mediated by the adaptive immune system 4. Recent papers have implicated staphylococcal super antigens, bacterial biofilms, and fungal colonization as key ele-ments in CRS5.

Clinical features, standardized

In August 1996, the American Academy of Otolaryn-gologyHead and Neck Surgery (AAOHNS) convened a multidisciplinary Rhinosinusitis Task Force (RSTF) to confront difficult issues related to defining, staging, and research of rhinosinusitis5. The resulting article Adult Rhinosinusitis Defined, emerged in 1997 and was endorsed by the AAO-HNS, the American Academy of Otolaryngologic Allergy (AAOA), and the American Rhinologic Society (ARS)6.

The article Adult Rhinosinusitis Defined character-izes rhinosinusitis into 5 separate clinical categories: acute, sub acute, chronic, recurrent acute and acute exacerbation of CRS. Acute rhinosinusitis is a clinical condition lasting less than 4 weeks; sub acute rhinosi-

nusitis, more than 4 weeks but less than 12 weeks. As earlier stated, the RSTF further defined chronic rhinosi-nusitis as lasting more than 12 weeks7

The major and minor symptoms and signs suggested by RSTF are given in Table 1.

TABLE 1

Factors associated with diagnosis of rhinosinusitis3 (Requires two major factors or one major and two minor factors)

Major factorsMinor factorsFacial pain/pressure (this

alone does not constituteHeadachea suggestive history for

rhinosinusitis in the ab-

sence of another major

nasal symptom or sign)

Nasal obstruction/Fever (all non-acute)blockage

Nasal discharge/Halitosispurulence/

Discoloured postnasalFatiguedrainage

Hyposmia/ anosmiaDental pain

Purulence in nasal cavityCoughon examination

Fever (in acute sinusitisEar pain/pressure/alone does not constitutefullnessa strongly suggestive his-

tory for rhinosinusitis in

the absence of another

major nasal symptom or

sign)

Measures for diagnosing CRS for adult clinical care

History:

Duration of disease is qualified by continuous symp-toms for > 12 consecutive weeks or > 12 weeks of physical findings

Clinical examination:

One of these signs of inflammation must be present and identified in association with ongoing symptoms consistent with CRS

Discoloured nasal drainage arising from the na-sal passages, nasal polyps, or polypoid swelling

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as identified on physical examination, either by anterior rhinoscopy in the decongested nose or by nasal endoscopy. {Figure 2}

Fig. 2: Nasal endoscopic appearance of polyp in the right middle meatus

Oedema or erythema of the middle meatus or ethmoid bulla as identified by nasal endoscopy.

Generalized or localized erythema, edema, or granulation tissue. If it does not involve the mid-dle meatus or ethmoid bulla, radiologic imaging is required to confirm a diagnosis (Other chronic rhinologic conditions such as allergic rhinitis can have such findings, and therefore they may not be associated with rhinosinusitis. It is recommended that a diagnosis of rhinosinusitis requires radiologic confirmation under these circumstances)8.

Investigations:

Imaging modalities for confirming the diagnosis:

Plain sinus radiographCaldwells and Waters views revealing:

Mucous membrane thickening of > 5 mm

Complete opacification of one or more sinuses

Fig. 3: Coronal study of Computed tomography of para-nasal sinus showing opacification and diffuse mucosal thickening of maxillary and ethmoid sinuses, right > left Chronic Rhinosinusitis An Overview

An air-fluid level - more predictive of acute rhinosinusitis, but may also be seen in chronic rhinosinusitis

(A plain sinus x-ray without the equivocal signs listed in a, b, or c is not considered diagnostic. Aside from an air-fluid level, plain sinus radio-graphs have low sensitivity and specificity)

Computed Tomography (CT) scandemonstrat-ing isolated or diffuse mucosal thickening, bone changes and air-fluid level. {Figure 3} This is the gold standard investigation for CRS.

Magnetic Resonance Imaging (MRI) is not recom-mended as an alternative to CT for routine diagnosis of CRS because of its excessively high sensitivity and lack of specificity3.

Other investigations:

A number of other tests that may be important to individual studies and protocols include the following:

Allergy testing: There is good evidence that the incidence of CRS is increased in the allergic patient. Therefore allergy testing by Skin prick test or Specific IgE or RAST may be measured in many studies.

Validated outcomes instruments to measure the quality of life and patient perception of dis-ability.

Rhinomanometry and acoustic rhinometry to objectively measure nasal patency and resist-ance

Mucociliary clearance testing including sac-charine methods or radioisotopes

Olfactory evaluations with validated threshold and suprathreshold testing

Nasal cytology

Directed laboratory evaluation to detect un-derlying associated systemic disease such as measurement of serum eosinophilia, IgE levels, and genetic testing.

Nasal Endoscopy:

Most commonly used endoscopes are 4.0mm, 30 degree rigid scope and/or 0 degree scope. In adults with narrow nasal passages or in children, a 2.7mm, 30 degree rigid endoscope or a flexible nasopharyngo-scope may be better tolerated. 30 and 45 degree scopes provide direct line of sight and angled visualization.

An organized nasal endoscopy in 3 passes is the usual method adopted.

The first pass is along the floor of the nose. Inferior meatus, Eustachian tube orifices, Torus tubarius, ad-enoid pad and entire nasopharynx can be visualized. Secretions originating from the OMC will typically drain below the Eustachian tube orifice, while those originat-ing from the posterior ethmoids or sphenoid sinuses will pass above the torus tubarius.

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For the second pass, the endoscope is reinserted between the middle and inferior turbinates, and ad-vanced in a posterior direction. The inferior portion of the middle turbinate, middle meatus, the fontanelles and accessory ostia are examined. Sphenoethmoidal recess, superior turbinate and natural sphenoid os may also be visualized.

Third pass view is by lateral rotation of the endo-scope beneath the posterior aspect of middle turbinate to gain access to the deeper areas of the middle meatus, bulla ethmoidalis, hiatus semilunaris and infundibular entrance. As the scope is withdrawn, further excellent view of the uncinate process is obtained.

Once diagnosed, attempts to further define the sever-ity of CRS include methods to assess patient symptoms. Here again, various study groups have come up with different evaluation systems.

Rhinosinusitis Task Force Major and Minor symptom criteria920 item Sinonasal Outcome Test 10 (SNOT20) Chronic Sinusitis Survey9 (CSS)

Rhinosinusitis Symptom Inventory (RSI)10 Visual Analogue Score (VAS) Questionnaire11

An approximate algorithm in a CRS case could be as follows:

Diagnostic Nasal Endoscopy (DNE)

Normal

Positive

Findings

Findings

Allergic

Discharge

Polyps

Anti-allergic

Culture &

Protocol treatment

Consider

treatment

sensitivity -

(Including oral

CT PNS

directed

steroids)

antimicrobials

Role and relevance of CT PNS study

To confirm the diagnosis of rhinosinusitis

To assess the severity of cases refractory to medical therapy prior to surgery

To provide the anatomic precision needed to guide endoscopic sinus surgery

To assess response to surgical intervention {Figure

4 a, b}

Lund-Mackay staging system, proposed in 1993, is considered as the most widely accepted staging system in CRS (Table 2).

Sinus systemRightLeftMaxillary0,1and 20,1and 2

Anterior ethmoidal0,1and 20,1and 2Posterior ethmoidal0,1and 20,1and 2

Sphenoidal0,1and 20,1and 2

Frontal0,1and 20,1and 2

Ostiomeatal complex0, and 20, and 2

Total points for each side0-120-12

Scoring: For all sinus systems, except the ostiomeatal complex:

0 - no abnormalities, 1- partial opacification, 2- total opacification

For the ostiomeatal complex: 0 - not occluded, 2 - occluded Treatment modalities Medical therapy12.

Absolute medications

Allergen or irritant avoidance, 3-weeks course of culture-directed or broad spectrum antibiotics and 8-weeks course of topical nasal steroid spray

Supportive Treatment

Systemic decongestants, Antihistamines and tapering systemic corticosteroids

Role and relevance of endoscopic sinus surgery

In those patients who have failed medical manage-ment, functional endoscopic sinus surgery (FESS) has been demonstrated and is generally accepted to pro-vide improved relief of symptoms and better quality of life. Although there is some controversy as to the best or most appropriate surgical technique for treat-ing patients with CRS with polyposis (CRSwP) most surgeons will recommend that these patients undergo polypectomy, complete ethmoidectomy, and middle meatal antrostomy, with or without frontal sinusotomy or sphenoidotomy.

Surgical anatomy

Of all the paranasal sinuses, the ethmoid sinus is the most complex and is aptly referred to as a labyrinth. The ethmoids attain adult size by the twelfth year. However, when infection spreads from the ostiomeatal area to involve the maxillary and frontal sinuses, it is the symptoms and the roentgenographic changes in these latter sinuses that predominate. Thus the surgeon may attempt to correct the secondary pathologic changes while overlooking the underlying problem in the osti-omeatal complex.

The introduction of Functional Endoscopic Sinus Surgery by Messerklinger and Wigand radically changed the way Otolaryngologists treat sinusitis14. The purpose of functional endoscopic sinus surgery is to re-establish ventilation and mucociliary clearance of the sinuses. This is achieved by removing disease from key areas of the anterior ethmoid and middle meatus. Middle

7Amrita Journal of Medicine Chronic Rhinosinusitis An Overview

turbinate is preserved and sphenoethmoidectomy is done. The technique allows for excellent visualization, whilst causing minimal bleeding and low morbidity15.

In 1978 Messerklinger introduced the concept of functional endoscopic sinus surgery based on endo-scopic observation and documentation of anatomy and pathology in the middle meatal area and sinus muco-ciliary clearance in normal and diseased mucosa16. In 1980 Stammberger published a series of papers on FESS.

The principle of the technique is limited resection of inflammatory tissue or anatomic defects that interfere with normal mucociliary clearance and result in local-ized persistent inflammation.

Routinely carried out steps in FESS for CRS w/wo Polyps would include:

Uncinectomy: removal of the comma-shaped piece of bone at the anterior edge of the middle meatusInfundibulotomy: entering the narrow space just anterior to the ethmoid air cells

Ethmoidectomy: exentration of the diseased anterior, middle and posterior ethmoid air cells

Sphenoidotomy: opening into the sphenoid sinus to clear disease within and widening the natural ostium

Midde meatal antrostomy: widening the natural os-tium of the maxillary antrum and clearing disease withinFrontal recess and sinus clearance: careful identifi-cation and clearance of the frontal sinus ostium area to ensure drainage of the sinus into the nose

{Figure 5 a, b}

a)Pre-operative endo- b) Post-operative endo-scopic viewscopic view of theof sino-nasalsame case,

polyposis2 months later

Recent advances

The role of various inflammatory mediators CD3, CD25, IFN-r, TGF-B, IL-1, MMP in the pathogenesis of CRS and thereby the role for targeted therapy is gaining attention17.

Ramanathan et al demonstrate IL-22R1 mRNA and protein expression on nasal epithelial cells. Failure of medical and surgical therapy in CRSwNP is associated with significantly decreased expression of IL-22R118.

Studies have shown the role of biofilm detection in characterization of CRS. BacLight/ confocal scan-ning laser microscope (CSLM) and fluorescence in situ hybridization (FISH) / CSLM are complementary

techniques for biofilm detection on the sinus mucosal specimens of CRS patients19.For better understanding of the anatomy of paranasal sinuses, Tolsdorff et al demonstrated a virtual reality simulator for endonasal sinus surgery based on a volume model. This is a fully operational simulator for sinus surgery based on standard PC hardware20.

Balloon sinuplasty is a new surgical technique to manage CRS, being done as an office procedure at many Centres.

Conclusions

An improved understanding of the underlying dis-ease process has led to an evolution in the treatment of CRS.

Detailed recording of the clinical symptoms and physical findings, followed by diagnostic nasal endos-copy (DNE) and CT scan of PNS play a crucial role in the diagnosis, prognosis and follow-up of CRS patients.

Medical therapy has begun to shift from antibiotics and decongestants to a combination of topical steroids, systemic steroids, decongestants, antihistamines and antibiotics. Surgical treatment of CRS, still a crucial component of the overall treatment plan, has shifted from radical to a more conservative, yet complete ap-proach. Although important, surgery alone does not lead to a long term disease free state.

A comprehensive management plan incorporating both medical and surgical care remains the most likely way to provide long term disease control for CRS. The ex-act combination continues to be debated. Nevertheless, use of long term topical steroids and regular follow-up of all patients seem to be the best option till date.

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Murugappan Ramanathan, Jr, MD; Ernst W. Spannhake, PhD; Andrew P. Lane, MD. Chronic Rhinosinusitis with Nasal Polyps is Associated with Decreased Expression of Mucosal Interleukin 22 Receptor. Laryngoscope October 2007;117:1839-42

Hopkins et al.: Surgery Audit for Nasal Polyposis and CRS. Laryngoscope 2009:119:245965

Benninger et al Adult Chronic rhino sinusitis: Definitions, diagnosis, epidemiology, and pathophysiology. Otolaryngol Head Neck Surg 2003; 129S:S1-S32.

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