CBD: Chronic Rhinosinusitis
Clinical scenario
A 38-year-old man presents with a two-year history of worsening bilateral nasal blockage. The blockage is constant and does not vary throughout the day or year. He does not have rhinorrhoea or any allergic symptoms.
On further questioning, he has entirely lost his sense of smell over the same period. He has a history of asthma: over the last six months he has needed to take his salbutamol inhaler more frequently. He has never had nasal surgery and is otherwise well; however his sleep quality has suffered recently. He works in an office and does not smoke. He has tried antihistamines bought over the counter, and took a nasal steroid spray for two to three weeks, to little effect.
On examination, the nose is externally normal. The nasal mucosa is slightly erythematous. Multiple silvery polyps fill both nasal cavities. Auscultation of the chest shows good air entry with a very mild polyphonic wheeze.
His GP prescribes a week of oral prednisolone, and a three-month trial of fluticasone nasal spray and saline nasal douching. On review, the patient reports a rapid improvement in all of his symptoms, but a slow increase in his nasal blockage over the following three months.
The patient is referred to ENT for consideration of endoscopic sinus surgery due to failure of medical management. Following surgery he reports his nasal blockage is much improved (although his sense of smell is still relatively poor). He is prescribed regular fluticasone nasal drops and saline nasal douching, to be continued in the long term.
Pathology
Chronic rhinosinusitis (CRS) is a clinical syndrome characterised by chronic inflammation of the musosa of the nasal cavity and paranasal sinuses. It is estimated to have a prevalence of 5-15% and It is separated into two distinct forms – with and without nasal polyposis – these forms are increasingly thought of as two distinct disease entities. It has a complex pathogenesis with no clear defined cause.
In chronic rhinosinusitis with nasal polyposis (CRSwNP), inflammatory mucosal swellings (polyps) form in the paranasal sinuses and prolapse into the nasal cavity. When large, they cause nasal blockage. It is important to realise that “nasal polyps” is not a pathology in itself, but a manifestation of the chronic inflammation in CRSwNP. In the same way, the surgical removal of polyps improves the symptoms, and the efficacy of regular medication. However, it does not cure the condition and does not alter the need for intranasal steroids to control the underlying inflammation. Surgery is commonly required on more than one occasion, but the interval between surgery varies significantly between individuals. The inflammation in CRSwNP is typically characterised by tissue eosinophilia and a TH2-mediated response.
Patients with a triad of CRSwNP, asthma and NSAID intolerance (known as Samter’s triad) have severe symptoms, and tend to require surgery more frequently despite the use of regular intranasal medication.
In chronic rhinosinusitis without nasal polyposis (CRSsNP) is typified by inflamed nasal mucosa and mucopurulent discharge from the paranasal sinuses. In contrast to CRSwNP, patients are more likely to complain of anterior or posterior rhinorrhoea, and an unpleasant smell in the nose (cacosmia).
Chronic rhinosinusitis is strongly associated with respiratory disease; in particular asthma. The prevalence of asthma is at least doubled in patients with CRSsNP, and roughly quadrupled in CRSwNP, where it is strongly associated with adult-onset asthma. Nasal polyps can also form as a result of ciliary disorders such as cystic fibrosis and primary ciliary dyskinesia, which should be suspected if a child presents with nasal polyposis.
The interaction between the bacterial flora of the paranasal sinuses and CRS is not well understood. The presence of bacterial biofilms and a dysfunctional mucosal immune response are thought to contribute to the pathogenesis. However, it is a misconception to regard CRS as a chronic infection. Macrolide antibiotics have some effect on CRS symptoms whilst being taken, and are used in selected patients in a specialist setting, mostly for their anti-inflammatory effects. However, this is not felt to have a significant effect on the course of the disease. Similarly, CRS is not primarily an allergic disease, and the evidence of a direct pathological link between CRS and sensitisation to airborne allergens is inconclusive at present.
Clinical features
Chronic rhinosinusitis is primarily a clinical diagnosis. Radiological investigations (non-enhanced CT of the paranasal sinuses) are used selectively in the diagnosis of the disease, as a large proportion of the normal population will have incidental opacification of the sinonasal air spaces on CT even when asymptomatic. CT is requested when a patient is planned for endoscopic sinus surgery (ESS), to visualise the variable anatomy of the paranasal sinuses and plan the surgical approach. Plain sinus X-rays are now obsolete. Microbiological investigations are rarely indicated, as the condition is not treated with antibiotics, and it is impossible to differentiate colonisation from pathogenic infection.
CRS is defined in the EPOS 2012 Position Paper as more than twelve weeks of two or more of the following symptoms:
1. Nasal congestion
2. Rhinorrhoea
3. Reduced sense of smell
4. Facial pain/pressure
(at least one of the symptoms MUST be 1 or 2)
The diagnosis of CRS should also be supported by examination findings of polyposis or mucopurulent discharge, or CT evidence of sinusitis.
However, it is important to remember that facial pain is not in itself indicative of CRS. Although it is a popular self-diagnosis, “sinus headaches” are rarely due to sinonasal disease. Any patient presenting with a primary complaint of facial pain should be asked about the other cardinal symptoms of CRS. If these are not present, CRS should not be suspected, and a diagnosis of midfacial segment pain or another headache variant should be considered.
The <SinoNasal Outcome Test (SNOT-22)> is a validated patient-reported outcome measure which is widely adopted for the assessment of CRS symptoms. Patients score their symptoms from 0 (no problem) to 5 (as bad as it can be) in 22 domains, with a maximum score of 110. There is evidence that patients with a score of >30 have the best chance of benefiting from surgical intervention.
Management
Chronic rhinosinusitis is a long-term inflammatory disease which is managed primarily with the long-term use of intranasal medication, chiefly fluticasone and mometasone. Surgery is used as an adjunct for patients in whom medical treatment is not giving sufficient symptomatic relief. For some patients, regular intranasal steroid spray and/or saline nasal douching is sufficient for long-term symptomatic control, and may result in them never requiring surgical intervention.
Conversely, in patients who present with severe symptoms, or those with recalcitrant symptoms after a trial of medical therapy, it is best to refer promptly to an ENT surgeon. There is evidence that early surgical intervention results in the best long-term outcomes, and that delaying necessary endoscopic sinus surgery leads to poorer outcomes and greater healthcare utilisation.
1. In a patient presenting with symptoms of CRS, commence regular use of a fluticasone or mometasone-based intranasal spray or drops. This should be prescribed as a regular prescription, and the patient advised that they may need to continue the medication in the long term. The patient should also be advised to use twice-daily high-volume nasal douching.
2. Advise the patient that they should not expect significant benefit until 6-8 weeks after commencing the spray. One of the most common reasons for failure of medical treatment is that the patient feels little immediate benefit from the spray, and therefore stops it because their expectations were not managed at the beginning.
ENT surgeons refer to CRS as “asthma of the nose”. This underscores the pathological link between the two diseases, but also can be helpful in explaining to patients the need for long-term suppressive therapy for an incurable inflammatory disease (like asthma). A patient on an intranasal steroid spray should not stop it without clinical justification, just as a patient who stops their daily preventer inhaler for asthma can expect their symptoms to worsen.
In cases where symptoms are severe, it is reasonable to commence treatment with a 7-10 day course of oral prednisolone (with appropriate clinical caution). In polyp-related disease, this can perform a “medical polypectomy”, shrinking polyps enough to improve the access of topical medications to the sinonasal mucosa.
In patients where a prolonged trial of intranasal medication (with good compliance) has failed to give sufficient symptomatic improvement, refer to ENT for further assessment and consideration of endoscopic sinus surgery. It can help to explain to the patient at this point that surgery is aimed at improving the symptoms and longer-term control of the disease, but does not cure it.
Patients with CRS who smoke should be strongly encouraged to stop.
Concerns about nasal steroid sprays
Long term use of intranasal steroids is frequently a cause of concern among patients and clinicians.
· Fluticasone and mometasone-based intranasal sprays and drops have negligible systemic absorption. There is therefore no concern of suppression of the adrenocortical axis from their long-term use.
· This is in contrast to beclomethasone and betamethasone-based products, which are substantially absorbed and should not be prescribed in the long term (e.g. Beconase has 44% absorption).
· There is also no evidence of “thinning of the nasal lining” from their use as is the case with skin.
· They are safe for use in children: mometasone is generally licensed from the age of 4, and fluticasone is licensed from the age of 6-12 depending on preparation.
The most common side effect from the use of intranasal steroid sprays is epistaxis. This is primarily felt to be due to incorrect administration technique, whereby the patient pushes the tip of the spray nozzle against the nasal septum and sprays, leading to direct physical irritation. This can be avoided by advising the patient to administer the spray with the nozzle pointing backwards, not upwards, and angled slightly outward toward the ear on each side.
The available (level IA) evidence does not support a link between the use of intranasal steroid medication and increased intraocular pressure, whether the patient has a history of glaucoma or not. (NB intranasal ipratropium bromide is contraindicated in glaucoma).
Endoscopic sinus surgery (ESS)
ESS, which is also known as FESS (functional endoscopic sinus surgery), consists of a set of endoscopic procedures, which aim to enlarge the natural ostia of the paranasal sinuses, or in the case of the honeycomb-like ethmoid sinuses, completely exenterate the wafer-thin sinus lamellae, up to the medial wall of the orbit and the skull base.
At the same time, any polyps are removed. The operation improves the patient’s symptoms, and crucially, improves the penetrance of intranasal steroids. Once the sinuses are laid open and obstructive polyps are removed, topical medications can access the sinonasal mucosa more effectively, and will control the patient’s symptoms better than before surgery. Patients still require long-term intranasal steroids after ESS.
ESS is usually a day-case procedure. The patient can expect a congested nose with some headache/facial pain, and blood-stained nasal discharge. Small nosebleeds are common after ESS, but larger persistent bleeds should be seen in A&E. Postoperative nasal douching and steroids should be continued as long-term medications unless directed otherwise – stopping the medications because the patient feels better will lead to more rapid recurrence of symptoms and the need for further surgery.
Further reading
EPOS European Position Paper on Rhinosinusitis and Nasal Polyps 2020
Author: Mr Thomas Jacques, Consultant Rhinologist/ENT Surgeon, St. George’s Hospital, London