Chronic rhinosinusitis

Chronic rhinosinusitis

CRS is common, a ff ecting around 11% of the population. The aetiology is multifactorial and a number of factors have been linked to CRS, including ciliary dyskinesia, allergy , asthma, bacteria ( Staphylococcus aureus ), fungi and a number of host factors, including anatomical variations (deviated septum, concha bullosa of the middle turbinates). CRS has tradition ally been divided into CRS with nasal polyps (CRSwNPs) and without (CRSsNPs). More recently CRS has been classified into primary or secondary , and local or di ff use disease. Pathology Nasal polyps are benign swellings of the sinus mucosa of unknown origin. Histologically , the polyps contain an oedema - tous stroma infiltrated with inflammatory cells and eosinophils. Inflammatory polyps tend to be bilateral and extend into the middle meatus. A single large polyp arising from the maxillary ). antrum is referred to as an antrochoanal polyp ( Figure 51.52 This usually fills the nose and eventually prolapses posteriorly down into the nasopharynx. Clinical features Patients with CRSwNPs present with nasal obstruction, watery rhinorrhoea, postnasal drip and often hyposmia/anosmia. Pain does not tend to be a significant feature. Polyps are easily identifiable within the nose as pale semitransparent grey masses, which are mobile and insensitive when palpated with a fine probe ( Figure 51.53 ). This allows them to be distinguished from hypertrophied turbinates. In CRSsNPs the middle meatus is often congested, with mucopus present. Malignancy should be considered in adults with unilateral nasal polyps whereas in children such polyps must be - distinguished from a meningocele or encephalocele by high- the anterior cranial fossa. Nasal resolution CT scanning of polyps are unusual in children; however, they do occur in conjunction with cystic fibrosis in 10% of cases.

(b) Figure 51.51 Sagittal (a) and axial (b) computed tomography scans showing complete opaci /f_i cation of the frontal sinus (marked with an asterisk) due to frontal sinusitis. The anterior wall of the frontal sinus is absent owing to infection.

Management Medical treatment of CRSwNPs with systemic steroids will often reduce the size of the nasal polyps and give short-term relief of nasal blockage. Unfortunately , the polyps tend to recur when the treatment stops. Topical corticosteroid drops and sprays are also used along with saline douching. Biological treatments using monoclonal antibodies are a potential new therapy for CRSwNPs. In CRSsNPs, in addition to topical treatments, a long course of low-dose antibiotics (macrolides) can be used in those patients with a normal level of immu noglobulin E. Surgical treatment is indicated in patients who do not respond to medical treatment. Endoscopic nasal polypectomy and functional endoscopic sinus surgery (FESS) is performed follo wing a CT scan that confirms the extent of disease and shows the important bony anatomy preoperatively . Serious complications following FESS include CSF leak and orbital problems, including orbital haematoma, and so it is important to review the level and symmetry of the anterior skull base and the integrity of the lamina papyracea on the CT scan prior to surgery . Endoscopic polypectomy is performed using a powered nasal microdebrider ( Figure 51.54 ). Image guidance can be used in endoscopic sinus surgery and extended endoscopic procedures such as pituitary and anterior skull base surgery to provide real-time feedback of instrument position in the nose based on preoperative CT or MRI scans. Summary box 51.15 Nasal polyps /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Figure 51.52 Antrochoanal polyp. Figure 51.53 Nasal polyp in the right nasal vestibule. Figure 51.54 Powered nasal microdebrider. Polyps are insensitive to touch and are mobile In /f_l ammatory polyps are usually bilateral Unilateral nasal polyps should be removed for histology Bleeding polyps may indicate malignancy Meningocele and encephalocele must be excluded in children with polyps Polyps are removed using a powered microdebrider

Chronic rhinosinusitis

CRS is common, a ff ecting around 11% of the population. The aetiology is multifactorial and a number of factors have been linked to CRS, including ciliary dyskinesia, allergy , asthma, bacteria ( Staphylococcus aureus ), fungi and a number of host factors, including anatomical variations (deviated septum, concha bullosa of the middle turbinates). CRS has tradition ally been divided into CRS with nasal polyps (CRSwNPs) and without (CRSsNPs). More recently CRS has been classified into primary or secondary , and local or di ff use disease. Pathology Nasal polyps are benign swellings of the sinus mucosa of unknown origin. Histologically , the polyps contain an oedema - tous stroma infiltrated with inflammatory cells and eosinophils. Inflammatory polyps tend to be bilateral and extend into the middle meatus. A single large polyp arising from the maxillary ). antrum is referred to as an antrochoanal polyp ( Figure 51.52 This usually fills the nose and eventually prolapses posteriorly down into the nasopharynx. Clinical features Patients with CRSwNPs present with nasal obstruction, watery rhinorrhoea, postnasal drip and often hyposmia/anosmia. Pain does not tend to be a significant feature. Polyps are easily identifiable within the nose as pale semitransparent grey masses, which are mobile and insensitive when palpated with a fine probe ( Figure 51.53 ). This allows them to be distinguished from hypertrophied turbinates. In CRSsNPs the middle meatus is often congested, with mucopus present. Malignancy should be considered in adults with unilateral nasal polyps whereas in children such polyps must be - distinguished from a meningocele or encephalocele by high- the anterior cranial fossa. Nasal resolution CT scanning of polyps are unusual in children; however, they do occur in conjunction with cystic fibrosis in 10% of cases.

(b) Figure 51.51 Sagittal (a) and axial (b) computed tomography scans showing complete opaci /f_i cation of the frontal sinus (marked with an asterisk) due to frontal sinusitis. The anterior wall of the frontal sinus is absent owing to infection.

Management Medical treatment of CRSwNPs with systemic steroids will often reduce the size of the nasal polyps and give short-term relief of nasal blockage. Unfortunately , the polyps tend to recur when the treatment stops. Topical corticosteroid drops and sprays are also used along with saline douching. Biological treatments using monoclonal antibodies are a potential new therapy for CRSwNPs. In CRSsNPs, in addition to topical treatments, a long course of low-dose antibiotics (macrolides) can be used in those patients with a normal level of immu noglobulin E. Surgical treatment is indicated in patients who do not respond to medical treatment. Endoscopic nasal polypectomy and functional endoscopic sinus surgery (FESS) is performed follo wing a CT scan that confirms the extent of disease and shows the important bony anatomy preoperatively . Serious complications following FESS include CSF leak and orbital problems, including orbital haematoma, and so it is important to review the level and symmetry of the anterior skull base and the integrity of the lamina papyracea on the CT scan prior to surgery . Endoscopic polypectomy is performed using a powered nasal microdebrider ( Figure 51.54 ). Image guidance can be used in endoscopic sinus surgery and extended endoscopic procedures such as pituitary and anterior skull base surgery to provide real-time feedback of instrument position in the nose based on preoperative CT or MRI scans. Summary box 51.15 Nasal polyps /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF

Figure 51.52 Antrochoanal polyp. Figure 51.53 Nasal polyp in the right nasal vestibule. Figure 51.54 Powered nasal microdebrider. Polyps are insensitive to touch and are mobile In /f_l ammatory polyps are usually bilateral Unilateral nasal polyps should be removed for histology Bleeding polyps may indicate malignancy Meningocele and encephalocele must be excluded in children with polyps Polyps are removed using a powered microdebrider