Chronic Rhinosinusitis (CRS)

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By: Arinda Puteri Pratiwi

Sinusitisis defined as inflammation of the paranasal sinuses, and rhinitisas inflammation within the nasal cavity. Chronic rhinosinusitiscan be diagnosed after the condition has been present for at least 3 months.1 

Chronic rhinosinusitis manifests more subtly than acute rhinosinusitis. The typical symptoms of acute rhinosinusitis (fever and facial pain) are usually absent. Patients may present with nasal obstruction, nasal discharge (of any character from thin to thick and from clear to purulent), post nasal drip, and decreased sense of smell. By physical examination of the nasal cavity, purulent mucus, edema, and polyp can be found. Signs of paranasal sinuses inflammation also can be documented by radiographic imaging.2

Chronic rhinosinusitis is most often caused by bacteria, namely Pseudomonas, Citrobacter, Haemophilus, Propionibacterium, Staphylococcus, and Streptococcus. It is known that the bacterial landscape in chronic rhinosinusitis differs from acute bacterial rhinosinusitis (ABRS), with Staphylococcus aureus, Enterobacteriaceae spp, and Pseudomonas spp (especially Pseudomonas aeruginosa) predominating rather than Streptococcus pneumoniae and Haemophilus influenzae, which are the important pathogens in ABRS. In epidemiology, there is also a relationship between the prevalence of chronic rhinosinusitis with air pollution, active and passive smoking, allergic rhinitis, and gastropharyngeal reflux.3,4,5

Contributing factors to development of CRS are asthma, allergic rhinitis, cystic fibrosis, immune dysfunction, ciliary dysfunction, lost ostia patency, defective mucociliary clearance, and acetylsalicylic acid-exacerbated respiratory disease.4 Other factor which may contribute to the occurence of chronic rhinosinusitis is presence of odontogenic infection. Odontogenic infections are important to note as potential etiology of CRS due to potential differences in microbial flora.6

Chronic rhinosinusitis may also be caused by structural anomalies within paranasal sinuses, the drainage of paranasal sinuses (termed as osteomeatal complex), or nasal cavity. Ostial obstruction caused by septal deviation, scars from previous surgery or trauma, craniofacial anomalies, or foreign bodies may lead to fluid accumulation and stagnation, creating a moist, hypoxemic environment which is ideal for growth of pathogen.6

Diagnosis of CRS is made by adequate history taking, physical examination, and radiographic imaging. The Task Force on Rhinosinusitis sponsored by the American Academy of Otolaryngology – Head and Neck Surgery (AAO-HNS) published a working definition for rhinosinusitis in 1997.1

The Task Force proposed a symptom – based format for the diagnosis of rhinosinusitis, with major and minor symptom categories. Major factor includes facial pain/pressure, nasal obstruction, nasal discharge/discolored postnasal drip, hiposmia/anosmia, purulence in examination, purulence in examination and fever (acute only). The presence of facial pain or pressure without any other major symptoms and signs cannot be used to direct the diagnosis. In addition, the presence of fever in sinusitis or acute rhinosinusitis without any symptoms and signs, cannot be used to direct the diagnosis. While, minor factor includes headache, fever (all nonacute), halitosis, dental pain, fatigue, cough, and ear pain or pressure or fullness. A strong history consistent with rhinosinusitis would require the presence of either two major factors, or one major and two minor factors. When only one major factor or two or more minor factors are present, this constituted a suggestivehistory in which rhinosinusitis should be included in the differential diagnosis.1

With the trend of increasing prevalence of Staphylococcal species, gram-negative bacilli and anaerobic bacteria in chronic rhinosinusitis, the administration of broad-spectrum antibiotics empirically for the treatment of CRS is necessary. Selection of antibiotics is preferably through culture and sensitivity test results, especially if the first-line antibiotics do not result in improvement. Period of the most effective antibiotic treatment is not yet clear, but many experts recommend giving the length of about 4-6 weeks. Other therapies that may be provided include topical and systemic steroids, leukotriene inhibitors, antihistamines, especially if there is an allergic basis, antifungal, decongestants, mucolytics, and irrigation with physiological fluid.5,8

Chronic rhinosinusitis is rarely life-threatening, but complications that can occur especially in those not handled adequately are local complication, orbital complication, and intacranial complication. Local complications include mucocele and osteomyelitis (when occurs in frontal bone, known as Pott’s puffy tumor). Orbital complications are preseptal cellulitis, orbital cellulitis, subperiosteal abscess, orbital abscess, and trombophlebitis cavernous sinus. Intracranial complications are meningitis subdural abscess, epidural abscess, intracerebral abscess, and cavernous sinus thrombosis/venous. 6,7,8

REFERENCE

  1. Bailey BJ, Johnson JT. Head & Neck Surgery-Otorhinolaryngology. 5th ed. Philadelphia: Williams & Wilkins, 2014.
  2. Brook, Itzak, et al. Sinusitis From Microbiology to Management. New York: Taylor and Francis, 2006.
  3. Ballanger JJ. Hidung dan sinus paranasal. Dalam Penyakit Telinga, Hidung, Tenggorok, Kepala dan Leher Jilid 1 edisi 13, Binarupa Aksara 1994; hal 1-27.
  4. Kaplan, A. Canadian Guidelines for Chronic Rhinosinusitis, Clinical Summary, Canadian Family Physician, Volume 59, December 2013, Pages 1276
  5. Kristyono I, Selvianti. Patofisiologi, diagnosis dan penatalaksanaan rhinosinusitis kronik tanpa poli nasi pada orang dewasa, Karya Tulis Ilmiah, 2013.
  6. Saladin K. Saladin: Anatomy & Physiology: The Unity of Form and Function. 3rd ed. New York: McGraw-Hill; 2003.
  7. Vander AJ, Sherman JH, Luciano DS. Human Physiology: The Mechanism of Body Function. 8th ed. New York: McGraw-Hill; 2001.
  8. Fokkens WJ, et al. 2012, European Position Paper on Rhinosinusitis and Nasal Polyps, Rhinology 50; suppl. 23: 1-298.

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