Chronic rhinosinusitis

Chronic
Rhinosinusitis
30th August 2019
Nattasasi Suchamalawong ,MD
Pediatric Allergy and Immunology unit
King Chulalongkorn memorial hospital

OUTLINE
 Definition
 Epidemiology
 Pathogenesis
 Phenotype & Endotype of chronic Rhinosinusitis
 Diagnosis
 Treatment
 Complication

DEFINITION CHRONIC RHINOSINUSITIS
Chronic rhinosinusitis with and without Nasal polyposis:
> 12 weeks without complete resolution of symptoms
Inflammation of the nose and the
paranasal sinuses ≥2 symptoms;
• Nasal blockage/obstruction/congestion
• Nasal discharge
(anterior/posterior nasal drip)
• Facial pain/pressure
• Reduction or loss of smell
Endoscopic signs;1 or more;
• Polyps
• Mucopurulent discharge primarily from
middle meatus
• Edema/mucosal obstruction primarily in
middle meatus
CT changes
• Mucosal changes within the ostiomeatal
complex and/or sinuses
Sarbjit S. Saini. Middleton's 8th edition. European position paper on rhinosinusitis and nasal polyp 2012

CLASSIFICATION OF RHINOSINUSITIS
Diagnosis and Management of Rhinosinusitis: Highlights from the 2015 Practice Parameter
Recurrent acute rhinosinusitis (RARS) : ≥ 3 episode/year each lasting >7 day

EPIDEMIOLODY
 Affects about 10 -15% of adults
 CRS : significant effect on health-related quality of
life and is associated with substantial health care
and productivity costs.
 Prevalence
• CRS without nasal polyp (CRSsNP) : 10.9%
• CRS with nasal polyps (CRSwNP) : 2-4 %
Zhang et al.J Allergy Clin Immunol 2017;140:1230-9

Zhang et al. Chronic rhinosinusitis in asia. J Allergy Clin Immunol 2017;140:1230-9.

 CRS with Nasal polyps occur more frequently in
• Asthma patients with aspirin sensitivity
• Cystic fibrosis (children and adolescents)
• Churg-Strauss syndrome and Kartagener syndrome (situs inversus).
 incidence of nasal polyps : higher in men > women
Sarbjit S. Saini. Middleton's 8th edition. European position paper 2012
EPIDEMIOLODY

DEVELOPMENTAL OF SINUSES
Sarbjit S. Saini. Middleton's 8th edition. European position paper 2012
paranasal sinuses are cavities
-partially present at birth : maxillary sinus
ethmoidal sinus
Frontal and sphenoid: later, complete pneumatization at mid to
late adolescence

The ostiomeatal complex : region for ventilation and drainage of
the maxillary ethmoidal and frontal sinuses

SINUS PHYSIOLOGY
The sinus cavities
• Air, pseudostratified, ciliated columnar epithelia with goblet cells.
• Cilia sweep mucus toward the ostial opening.
Obstruction ostia :
- mucous impaction → oxygenation → anaerobic condition →
purulent secretions → growth of bacteria
-  air pressure →pain and pressure sensation
Sinonasal biofilms
• communities of bacteria >> mucus layer
• evasion of host defenses, decreased susceptibility to antibiotic therapy
A.T. Peters et al. Ann Allergy Asthma Immunol 2014;113:347-385

MICROBIOLOGY IN CRS
 Children
• Aerobes:
Alpha-hemolytic streptococcus
(20.8%),
H. influenzae (19.5%)
S. pneumoniae (14.0%)
S. epidermidis (13.0%)
S. aureus (9.3%)
• Anaerobes: 8.0%
Adults
• Aerobes
Streptococcus species (21%)
H. influenzae (16%)
P. aeruginosa (16%)
S. aureus (10%)
M. catarrhalis (10%)
• Anaerobes:
Prevotella species (31%)
Fusobacterium species (16%)

MICROBIOLOGY IN CRS
 Nosocomial
• Gram-negative enteric species:
P. aeruginosa,
Klebsiella pneumoniae
Enterobacter species
Proteus mirabilis
Serratia marcescens
• Gram-positive cocci:
Streptococci, Staphylococci
CRSwNP
• Polymicrobial aerobic and
anaerobic flora

CLINICAL MANIFESTATION
History
• Persistent cough, prolonged anterior and
posterior nasal drainage, congestion
• low-grade fever, irritability, and behavioral
difficulties
• Headache, especially in the frontal area, is a less
common
• Frequent URI or recurrent sinusitis
• Additional history should focus on identification
of any potential contributing factors
CRS in children. Pediatr Clin N Am 2013

NASAL & SINUS SYMPTOMS AND CHRONIC
RHINOSINUSITIS IN A POPULATION-BASED SAMPLE

CO-MORBID OF CRS
Pedro C. Avila GLOBAL ATLAS OF ALLERGIC RHINITIS AND CHRONIC RHINOSINUSITIS
Chapurin et al. Otolaryngol Head Neck Surg 2017

PREDISPOSING FACTORS TO RHINOSINUSITIS

SIMILARITIES AND DIFFERENCES
IN PEDIATRIC VERSUS ADULT CRS
Diagnosis and Classifi cation of Chronic Rhinosinusitis with and Without Polyposis in Adults and Children 2014

APPROACH TO CRS
CRSsNP CRSwNP
• Anatomical defect/ variation
• Trauma, foreign body
• Environmental triggers
• Allergy
• Immunodeficiency
• GERD
• Eosinophilic mucin RS (EMRS)
• Aspirin intolerance
• Allergic fungal RS (AFRS)
• Cystic fibrosis
• Primary ciliary dyskinesia

CHRONIC RHINOSINUSITIS WITHOUT NASAL POLYP
 Present chronic maxillary sinus
Local obstruction sinus , encourages bacterial growth ,
mucosal remodeling
Environmental triggers
• Pollution: carbon monoxide, nitrous dioxide, sulfur dioxide
• Irritants in air pollution: sulfur dioxide ozone and PM2.5
formaldehyde (indoor pollutant)
• Indoor dampness and mold exposure
• Active and secondhand cigarette smoking

Otolaryngol Head Neck Surg. 2018 Feb
• strong correlation between active and passive
cigarette smoke with the prevalence of CRS
• Pediatric patients exposed to secondhand smoke
appear to have particularly poor outcomes

Allergic/ nonallergic rhinitis
• Congestion interfere drainage, ↑secretion→ hypoxic and
acidosis leads to mucociliary dysfunction→ bacteria multiply
• CRS 36-60% have AR children, 40-84% in adult
• Test: SPT, specific IgE
Adenoid hypertrophy , Chronic adenoiditis
- Nearly 50% of CRS had adenoid hypertrophy while
<30% presented in ARS
CHRONIC RHINOSINUSITIS WITHOUT NASAL POLYP

Nasal polyps are edematous semitranslucent masses in the
nasal and paranasal cavities,
originating from the mucosal linings of the sinuses and
prolapsing into the nasal cavities.
CHRONIC RHINOSINUSITIS WITH NASAL POLYP
Sarbjit S. Saini. Middleton's 8th edition.

Typical history : most prominent symptoms nasal obstruction
and discharge
Anosmia is a typical symptom for nasal polyps.
Viral infections : prolonged episodes of severely obstructed
nasal passages and colored secretions, with subsequent
bacterial infection.
Inhalant allergens do not cause polyps.

Asthma
• CRSwNP frequently is found in association with asthma and
nonspecific bronchial hyperresponsiveness.
• medical or surgical treatment of CRSwNP may have a
favorable impact on the control of asthma.

Aspirin sensitivity
• Samter’s triad : aspirin sensitivity,
corticosteroid- dependent asthma
nasal polyposis
• Aspirin sensitivity is suspected after a typical respiratory reaction.
15% of patients : aspirin- provoked asthma and rhinitis attack
Investigation : oral , bronchial or nasal provocation test
Aspirin-exacerbated respiratory disease (AERD)
- increased blood eosinophil counts
- increase of eosinophils in the nasal and bronchial mucosa
- Elevated cysteinyl-leukotriene concentrations in the tissue and urine

Fungal disease
• Fungal sinusitis is currently divided into four primary categories:
• Acute/ fulminant
• Chronic/ indolent
• Fungus ball : mycetoma (unilateral, chronic maxillary sinusitis)
• Allergic fungal sinusitis; AFS (most common , associated nasal polyps)
 Imaging studies (CT or MRI) may show
heterogeneous opacification,calcification in CT
hypointense signal onT2-weighted MRI
 typical sinus : creamy or claylike secretions
invasive

 Fungi associated allergic fungal rhinosinusitis (AFS) :
predominantly dematiaceous family
• Aspergillus, Rhizopus,Alternaria, Curvularia, Bipolaris specifera,
 AFS
- Atopic young hosts, nasal polyps
- Positive skin testing for fungus
- Elevated serum total IgE and fungus-specific IgG
 Invasive forms
• indolent chronic, slowly destructive disease ,caused by Aspergillus flavus.
• fulminant acute, necrotizing form in immunocompromised hosts
caused by Aspergillus fumigatus
lethal within days , hematogenous dissemination
Treatment high-dose intravenous antifungal

Cystic fibrosis
• Involvement of the nose and sinuses is common in patients with CF.
• no sinonasal complaints but detected in radiologic investigations.
 Incidence of CRSwNP in CF varies (6-48%)
 CF reported that 37% had CRSwNP.
 50% of the children who present with CRSwNP have CF
 affect bilateral paranasal cavities,
possibly causing facial deformities (hypertelorism )
 Radiological signs bulging of the lateral nasal wall
erosion of the uncinate process

Cystic fibrosis
• Predominant organisms
Pseudomonas aeruginosa, S. aureus, H. influenzae, and anaerobes.
• Suboptimal response to antimicrobial therapy
• Sinus surgery should only be performed in case of severe symptoms or
before lung transplantation.
• functional endoscopic sinus surgery (FESS) has decreased morbidity
of sinus surgery and reduced the recurrence of nasal polyposis in cystic
fibrosis.

CRS IN SYSTEMIC VASCULITIS
Granulomatosis with polyangiitis
Three of the following criteria
• renal involvement
• positive histopathology
• upper airway involvement
• laryngotracheobronchial involvement
• pulmonary involvement
• ANCA positive

CHRONIC RHINOSINUSITIS AND IMMUNE DEFICIENCY
Candidate for immunological evaluation in
chronic/recurrent RS
• Failure of treatment despite of appropriate treatment
- At least 2 serious sinus infections
• Recurrence within 1 month after discontinuation of antibiotic therapy
• Recurrence/persistent of CRS after sinus surgery
• Associated with other recurrent respiratory tract infections e.g.
bronchitis, pneumonia, bronchiectasis

Immunodeficiency
 Humoral immune deficiency: Predominantly Antibody deficiency
: Specific antibody deficiency (SAD)
Selective IgA deficiency
Common variable immunodeficiency (CVID)
IgG subclass deficiency
CHRONIC RHINOSINUSITIS AND IMMUNE DEFICIENCY

PIDS AND CRS
 PIDs with CRS: 842 predominantly antibody deficiencies children
Int J Pediatr Otorhinolaryngol. 2006 Sep;70(9):1587-92

PIDS AND CRS
 Prevalence of common PIDs in adult patients with CRS
at an academic institution
Peters AT. GLOBAL ATLAS OF ALLERGIC RHINITIS AND CHRONIC RHINOSINUSITIS
Am J Rhinol Allergy 2015;29:115-118

CHRONIC RHINOSINUSITIS
WITHOUT NASAL POLYPOSIS
(CRSSNP)
chronic rhinosinusitis with
nasal polyposis (CRSwNP)

PHENOTYPES & ENDOTYPE
OF CHRONIC RHINOSINUSITIS

PHENOTYPES OF CHRONIC RHINOSINUSITIS
1. EPITHELIAL PHENOTYPE
• loss of epithelial barrier function
• reflects numerous inflammatory process
2. NASAL POLYPOSIS
•chronic rhinosinusitis without nasal polyps [CRSsNP] :
noneosinophilic disease
•chronic rhinosinusitis with nasal polyps [CRSwNP] :
eosinophil-mediated TH2 (IL-4–, IL- 5–, and IL-13–high)
Gurrola and Borish. J Allergy Clin Immunol 2017;140:1499-508.

PHENOTYPES OF CHRONIC RHINOSINUSITIS
3. INFLAMMATORY CELL PROFILE
(NEUTROPHILIC AND EOSINOPHILIC CRS)
Nasal polyp : surrogate for assessing eosinophil status
 Alternative approach : evaluate sinus tissue and quantify eosinophil
expression.
 CRSwNP : significantly greater concentrations of eosinophil cationic
protein (ECP)

INFLAMMATORY ENDOTYPES IN CHRONIC
RHINOSINUSITIS
Hoggard et al. Front. Immunol. 9:2065

Clin Exp Allergy. 2016 January ; 46(1): 21–41

ENDOTYPING OF CRS
Concept ‘‘distinct’’ endotypes in patients with CRS is misguided
• defined by absolute presence or absence of eosinophils, cytokine,
other specific marker.
Robust expression of any of these markers can serve as an aid for
guiding therapeutic decisions.

PATHOPHYSIOLOGY IN CRSSNP
Deficiencies in epithelial immune barrier function and the production of
antimicrobial proteins
Two main defensive strategies
 1. Nonspecific phase
• Mucus and its contents: lysozyme and defensins
• VEGF: promote nasal epithelial cell growth and inhibit apoptosis.
 2. Innate and adaptive immune response
•Innate immune system : phagocytosis of microorganisms by neutrophils,
monocytes and macrophages.
• Adaptive immunity reacts on antigen presentation through formation of immune
products (Th1&Ab).
Sarbjit S. Saini. Middleton's 8th edition

SINONASAL EPITHELIAL DYSFUNCTION
Clin Exp Allergy. 2016 January ; 46(1): 21–41
CRS cultures
• Staphylococci
• streptococci spp.
• H. Influenzae
• Prevotella
• Peptostreptococcus

PATHOPHYSIOLOGY IN CRSWNP
 highest concentrations of IL-5, eosinophil cationic protein (ECP) , were
found in polyp tissue in subjects with nonallergic asthma and aspirin
sensitivity.
 Eosinophil recruitment is mediated mainly by the chemokines RANTES and
eotaxins, in cooperation with IL-5.
 Treatment :
anti-IL-5 monoclonal antibodies
- Eosinophil apoptosis and decreased eosinophil-infiltrated polyp tissue
Topical glucocorticosteroids
- Expression of VCAM-1 in polyps, eotaxin and IL-5
- marked reduction of tissue eosinophils.

upregulation of GATA3 : Upregulation ofTh2 cytokines •
Downregulation of Foxp3
Downregulation of regulatoryT cells (Tregs)
Nasal polyps (large quantities B lymphocytes and plasma cells)
upregulated of B cell–activating factor of the TNF family (BAFF)

Role of Staphylococcus aureus Enterotoxins (SAEs)
S. aureus may form biofilms & enterotoxins with superantigenic activity
• modify the functions of T and B cells, eosinophils, inflammatory cells.
 S. aureus enterotoxin :
- Th2-polarized eosinophilic inflammation
- impairment of T regulatory function, secrete multiclonal IgE production
 IgE antibodies to SAEs : local eosinophilic inflammation
 IgE antibodies to Staphylococcal enterotoxins : increase in local total IgE ,
increases risk asthma.

ROLE OF STAPHYLOCOCCUS AUREUS ENTEROTOXINS (SAES)
Zhang et a. J Allergy Clin Immunol2017;140:1230-9.

PATIENT EVALUATION IN CRSSNP
Evaluation
• Character,severity,duration and course of disease
• Comorbid illnesses,underlying pathologic condition
• Earlier management attempts
 Anterior rhinoscopy
hyperemia and swelling of the inferior turbinates, septum deformities
purulent secretions from the sinuses (middle meatus).
Endoscopy
Rigid scope after nasal decongestion (rapid and easy)
evaluate middle meatus and ostiomeatal complex, posterior nasal
structures, nasopharynx.

PATIENT EVALUATION IN CRSSNP
 Standard sinus radiographs
• diagnosis of acute frontal or maxillary sinusitis
• do not provide additional information over history alone.
 Ultrasound imaging: may be used in pregnant women
 CT
- define extent of the disease, anatomic abnormalities, and changes in the
ostiomeatal complex and evaluation of orbital or cerebral complications
 MRI: fungal sinusitis and extension into brain
 Nasal cultures:
• infections resistant to treatment
• immunocompromised hosts
• HIV,CMT recipients,DM, ICU patients

PATIENT EVALUATION IN CRSWNP
Diagnosis of CRSwNP : rigid nasal endoscopy
CT scan with coronal sections
- extent of disease within the sinuses
- mucosal structures and anatomy of the sinuses
CT scan
before sinus surgery is considered about anatomic variations.
MRI scan : for the diagnosis of fungal disease or tumor or
intracranial extension of disease.

PATIENT EVALUATION IN CRSWNP
Nasal endoscopy : confirm diagnosis ,exclude other diseases
• Turbinate hypertrophy, concha bullosa,CRSsNP, adenoid hypertrophy
Unilateral obstruction,nose bleeding,or crusting
• Papillomas,benign or malignant tumors, meningoencephaloceles
Nasal polyps
• Asthma, aspirin sensitivity,Churg-Strauss syndrome,CF, other lung disease
 SPT for inhalant allergens, cytologic examination of nasal secretions for
eosinophils, and a blood sample for an eosinophil
 Endoscopically guided microbiology from the middle meatus or biopsy

ENDOTYPING OF CHRONIC RHINOSINUSITIS
 CRS: inflammatory processes
high and variable expression of immune and inflammatory markers.
 Inflammatory endotype based on microarray-based detailed analyses
 Distinct endotypes or phenotypes in patients with CRS
- Presence or absence of eosinophils
- Cytokine, any other specific marker
 Robust expression of any of these markers can aid for guiding therapeutic

TREATMENT
Jivianne T. Lee Atlas of Endoscopic Sinus and Skull Base Surgery, Chapter 7, 47-63

A.T. Peters et al. Ann Allergy
Asthma Immunol 2014;113:347-385
CHRONIC
RHINOSINUSITIS
WITHOUT
NASAL POLYP

A.T. Peters et al. Ann Allergy
Asthma Immunol 2014;113:347-385
CHRONIC
RHINOSINUSITIS
WITH
NASAL POLYP

TREATMENT
Primary objectives of CRS medical therapy
• Treat infection : antibiotics
• Reduce inflammation : Topical or oral corticosteroids,
antihistamines
leukotriene modifiers
• Improve ventilation : Saline irrigations
Decongestants
Mucolytics

TREATMENT
Medical Therapy for Chronic Rhinosinusitis: Antibiotics
• Antibiotics are indicated to treat acute exacerbations , persistent
purulent drainage
• Eradication of infection : sinus aeration and adequate mucociliary
clearance.
• Macrolides : anti-inflammatory with antibacterial effects.
• A recent evidence- based review recommended against the use of
intravenous antibiotics for uncomplicated CRS

Medical Therapy for Chronic Rhinosinusitis: Antibiotics
• Amoxicillin 50 - 90 mg/kg/day
• Amoxicillin-clavulanate : cover B-lactamase organisms,H influenzae
• Alternative : quinolones or clindamycin with a 2nd or 3rd gen cephalosporins

LONG TERM MACROLIDE THERAPY FOR
CHRONIC RHINOSINUSITIS
• Clinical studies showing beneficial effects are quite limited.
• These studies do not clearly differentiate effects in CRSsNP or CRSwNP
Roxithromycin 150mg/d 12 wk – change from
baseline at 12 wk
Azithromycin 500 mg/d 3 d then 200mg/wk
11 wk – no significant

Seresirikachornet al.: Predicting Success of Low-Dose Macrolides.Laryngoscope 129:July 2019

Seresirikachornet al.: Predicting Success of Low-Dose Macrolides.Laryngoscope 129:July 2019
• Treatment CRS did not favorable LDMs in improvement of outcomes.
• Data showed no difference between the effects of LDMs and placebo.
• Forest plots from the RCTs did not show the benefit of LDMs therapy.

TREATMENT
Medical Therapy for Chronic Rhinosinusitis: Anti-inflammatory

TOPICAL STEROID
CRSwNP and CRSsNP: Use INS (sprays and aerosols) (StrRec,A)
• Reduce symptoms of blockage, rhinorrhea, occasionally hyposmia
• Recurrent within weeks to months of discontinuation of treatment.
Children:
• no RCTs evaluating the effect of INSs in children with CRS.
• Treatment as allergic rhinitis (efficacy and safety of INSs).
- Mometasone fuorate 2 yr
-Fluticasone propionate 4 yr

SYSTEMIC GLUCOCORTICOID
CRSsNP
short course of oral steroids for treatment of (Rec, C)
 CRSwNP
short-term treatment with oral steroids (decreases polyp size and
alleviates symptoms.(StrRec,A)
• medical polypectomy
• Prednisolone 30 mg/day then stepwise reducing dose
during a 14 - 20 days

TREATMENTS OF CRS
 Anti-IgE :Omalizumab for treatment of CRSwNP
Annals of Otology, Rhinology & Laryngology 2017, Vol. 126(11) 739 –747
• prospectively SNOT-22 and the ACQ-7 scores
• Omalizumab (n =13) or Surgery (n = 24)
• significant decrease in total nasal endoscopic polyp scores after 4,16 weeks
• effective for severe CRSwNP comparative after surgery
-Anti-IgE therapy reduces nasal polyp score in patients with severe comorbid
asthma T. Bidder.Rhinology 56-1: 42-45, 2018

 omalizumab is an effective treatment for CRSwNP
 improvements are greater with eosinophilic disease.
 Significant reduction of polyp size and QOL ,reduced need for surgery
1: 147 - 153, 2018 http://doi.org/10.4193/RHINOL/18.077
Gevaert P. Omalizumab is effective in allergic and nonallergic patients with nasal polyposis and
asthma. J. Allergy Clin. Immunol. 2013;131:110–116. doi: 10.1016/j.jaci.2012.07.047.

IMMUNOTHERAPY
 Am J Rhinol allergy 28, 145–150, 2014; doi: 10.2500/ajra.2014.28.4019)
• Weak evidence to support use of immunotherapy
• Adjunctive treatment in CRS patients .

TREATMENTS OF CRS
 Anti-Cytokine therapy :treatment of CRSwNP
Annals of Otology, Rhinology & Laryngology 2017, Vol. 126(11) 739 –747
- efficacy therapy in patients with CRSwNP.
- anti-IL-5 (reslizumab and mepolizumab) and anti-IL-4/IL-13 (dupilumbab)
- Reduce nasal polyp size, reduce need for surgery in CRSwNP patients
J AllergyClin Immunol 2017;140:1024-31.

JAMA. 2016;315(5):469-479. doi:10.1001/jama.2015.19330
Tsetsos N. antibodies for the treatment of chronic rhinosinusitis with nasal polyposis. Rhinology. 2018;56:11–21.
Patient CRS with refractory to INS, subcutaneous dupilumab to mometasone
furoate nasal spray compared with mometasone alone reduced endoscopic
nasal polyp burden after 16 weeks

TREATMENT: CRSWNP WITH AERD
 Avoidance of aspirin and other NSAIDs
• Prevent exacerbations but does not prevent progression of disease.
• Selective COX-2 inhibitors (celecoxib, rofecoxib)
 Aspirin desensitization
• relapse of risk in case of noncompliance
• gastrointestinal side effects
 Leukotriene receptor antagonists
 Oral and/or topical glucocorticosteroids
• effective but they cause side-effects in long- term usage.

TREATMENT: CRSWNP WITH AFRS
Antifungals are indicated only for invasive forms of sinus mycosis
or in immunocompromised patients.
 Surgical intervention and use systemic and long-term topical
corticosteroids are recommended.
Follow up : Total serum IgE
• increase in total serum IgE >> need of recurrent surgical
intervention.

SURGERY
 Removing mucosal disease > involved bone ethmoid sinuses and sinus ostia
- Restore sinus ventilation and drainage by opening the key areas
- Preserve sinus mucosa
- Reduce symptoms, increase the quality of life, decrease morbidity

SURGERY IN CHILDREN
If refractory medical management : Adenoidectomy
• Remove infection reservoir, biofilms
• < 7 years with asthma >> prefer FESS
Maxillary antral irrigation
• clear secretion & infection
• provide culture material
Balloon sinuplasty
• Benefit to irrigation
• Combination with adenoidectomy

FUNCTIONAL ENDOSCOPIC SINUS SURGERY
(FESS)
Standard procedure
• Indication : patients resistant to medical treatment.
• Complications
-severe bleeding, orbital trauma and cerebrospinal fluid leaks
-meningitis or cerebral damage
Extensive postoperative care and follow-up
prevent recurrent nasal polyp regrowth.
Decrease morbidity of sinus surgery

US CLINICAL GUIDELINES ON CHRONIC RHINOSINUSITIS IN CHILDREN
History
3 months of at least 2 of the following symptoms purulent rhinorrhea,
nasal obstruction, facial pressure/pain, or cough
Nasal Endoscopy
Nasal endoscopy :mucosal edema, purulent drainage or nasal polyps
Imaging
CT showing ostiomeatal complex or sinus edema
MRI : concern for intracranial or intraorbital complications of sinusitis
Cultures
Endoscopically guided middle meatal cultures : non responded to
empiric therapy within 72 hours, severe illness
Current Allergy and Asthma Reports (2019) 19: 14

US CLINICAL GUIDELINES ON CHRONIC RHINOSINUSITIS IN CHILDREN
EVIDENCE-BASED RECOMMENDATIONS FOR MANAGEMENT
Current Allergy and Asthma Reports (2019) 19: 14
Nasal saline irrigation • First line treatment option
Nasal steroid spray • First line treatment option
• limited evidence in pediatric population
Oral antibiotics • First line treatment option
• Amoxycillin, Amox/clav, Cephalosporin
• Clindamycin for suspicious of anaerobes
• 3rd gen + clindamycin
• Duration 20 days is superior to 10 days
Surgical management • Adenoidectomy +/- Functional Endoscopic
Sinus Surgery(FESS)

COMPLICATIONS
Children and adolescents
Orbital complications
- effect ethmoid , frontal sinus
- first sign : reddish swelling medial upper eyelid (cellulitis),
subperiostial abscess, intraorbital or eyelid abscess.
Orbital phlegmona
-Immediate hospitalization : surgical care ,IV antibiotic
-Lead to a thrombosis of the cavernous sinus, intracranial
infection and complete loss of vision

COMPLICATIONS
Adult
 Empyema frontal sinus : meningitis, an epidural or subdural brain abscess.
 Osteomyelitis of frontal bone
 Recurrent episodes of meningitis
 Fungal disease : penetrate bony structures and the orbit,cheek, and brain.
 Pyomucocele

Chronic rhinosinusitis

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