Facial pain is often misdiagnosed as sinusitis, but it is rarely a significant feature of chronic sinusitis. Other causes of facial pain are summarised in Box 3. Treatment of CRS should commence with a trial of topical steroids and nasal irrigation for at least eight weeks. Topical steroids can be delivered as a nasal spray or in conjunction with the nasal irrigation, through addition of diprosone OV cream or budesonide respules to the rinse once a day.
Nasal saline irrigation should be conducted at least twice daily to mechanically lavage the contents of the sinuses. If nasal polyposis is evident on examination, a burst of oral steroids can be used, in the form of oral prednisone. A Cochrane review 13 found that a short course of oral steroids produces a significant reduction in polyp size and subsequent subjective improvement in sinonasal symptoms.
Steroid regimes vary between otorhinolaryngologists. A trial of 25 mg mane for five days then This should be used in conjunction with ongoing topical steroids and nasal irrigation to maintain polyp reduction. Inclusion of macrolide therapy for at least eight weeks has also been shown to enhance mucociliary function, reduce inflammatory cytokines, and may also reduce polyp size.
Allergic rhinitis typically presents with recurrent episodes of sneezing, pruritis, rhinorrhea, nasal congestion and lacrimation.
Acute and Chronic Rhinosinusitis: A Comprehensive Review
These symptoms occur after exposure to the allergen, which stimulates IgE-mediated mast cell degranulation. Allergens can often be clearly identified by history-taking; however, in the absence of clear precipitants, Radio-Allergo-sorbent Test RAST serology may be indicated. Treatment consists of patient education regarding avoidance strategies, and oral antihistamines.
Second-generation, non-sedating oral H1 antihistamines have a quick onset of action with a small side effect profile and can be safely used in children. Referral to an immunologist for desensitisation may be considered in the case of severe allergic symptoms uncontrolled by simple measures. In the event that appropriate medical therapy fails, patients should be referred to an otorhinolaryngologist for consideration of surgical management. FESS involves endoscopic removal of polyposis when present, and ventilation of sinus cells.
Major complications are rare, but include damage to extraocular muscles, loss of vision, cerebrospinal fluid leak and meningitis. It is important for patients to be aware that CRS is an inflammatory condition of the mucosa, and that as such, sinus surgery is not a cure for their condition; rather, it is an attempt to allow better symptom control. Ongoing use of topical steroids and nasal rinses are often required postoperatively to control mucosal inflammation.
Aspirin desensitisation has been shown to decrease polyp recurrence, the number of hospitalisations, and corticosteroid requirements in patients with co-existing CRSwNP. Rhinosinusitis is a common primary care presentation and manifests in a variety of forms. Assessment and management of patients can usually be performed at a primary care level; referral for surgical management is required only for complicated disease or disease that is refractory to medical therapy.
Imaging is not essential for diagnosis, but should be considered if the diagnosis is uncertain or complications are suspected. Given the large quality-of-life burden in patients with CRS, prompt diagnosis and effective management are important. Competing interests: None. Provenance and peer review: Commissioned, externally peer reviewed.
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Downloads Help with downloads. Opening or saving files Files on the website can be opened or downloaded and saved to your computer or device. MP3 Most web browsers will play the MP3 audio within the browser. No competing interests:. I declare the following competing interests:. Yes No. Paired t -test and signed-rank sum test were used for the comparison of symptom scores. General linear and logistic regression model was also used for studying the predictive factors of symptom scores and success of medical therapy.
SAS 9. Eighty consecutive patients with CRS and without exclusions completed the study. There were 50 male and 30 female patients with a mean age of 45 years range, 17—74 years. Within our study group, 2. After 3 months follow-up, Just over one-half Ten patients had incomplete data and were excluded from the analysis. Four patients had inadequate response to medical therapy but because of comorbidities or other extenuating circumstances pregnancy surgery was not offered. After a mean of 5 months of additional follow-up range, 1— Relative younger ages, male gender, European ethnicity, presence of asthma, and positive endoscopic as well as CT findings were factors predictive of a need for surgery.
Presence of polyps was not a predictive factor Table 1. It is generally accepted that CRS is treated initially with medical therapy with the aim of reducing symptoms, improving quality of life, and preventing disease progression or recurrence. The medical therapy prescribed for an individual patient may be influenced by previous treatments, patient referral patterns, and local bacterial sensitivities. Other combinations of medical therapy have yielded variable results.
In a retrospective study of 40 patients, symptoms and CT changes were assessed after oral prednisone for 10 days, 40 mg daily for 5 days followed by 20 mg daily for 5 days , broad-spectrum antibiotics for 4—8 weeks, nasal saline irrigation, and intranasal steroid. A relapse rate of A more recent study reported patients treated with 4 weeks of clarithromycin or amoxicillin-clavulanate, a tapering course of oral steroids over 12 days, nasal saline irrigation, intranasal steroid, and topical decongestants.
Several factors may contribute to the difference seen in our series and that of existing studies. The majority of our patients were referred by their primary care physicians, often with a long history of symptoms that had been resistant to previous trials of medical therapy. In this preselected group, the failure of medical therapy would be expected to be higher than self-referred patients.
Direct comparison between studies is challenging because of different study design variables including doses, duration, and inclusion of additional agents; follow-up period; and definitions of what constitutes failure of medical therapy. The majority of American Rhinologic Society members surveyed Nasal polyposis has been previously reported to be an important predictor of sinusitis relapse.
Our study has some limitations. Compliance with medical therapy was not measured, and poor compliance would presumably reduce efficacy. The decision to proceed to surgery was largely based on the patients' perspective that their response to medical therapy was not adequate. It is very difficult to objectify the basis of this decision, and it is vulnerable to patient and surgeon biases.
However, the framework of the consultation was similar in all cases and the patients were asked how they wished to proceed in an open manner. A longer period of follow-up especially in patients whose symptoms have improved sufficiently after the medical therapy so that surgery was not indicated, would offer a superior insight into the longevity of the medical therapy effect.
For practical reasons we were limited to a period of several months to maximize completeness of follow-up. The majority of the study patients with Samter's triad had not been desensitized at the time of their taking medical therapy. Aspirin desensitization has been shown to improve nasal congestion, sense of smell, and reduction in sinus infections.
This effect is independent of maximal medical therapy, and may confound the result. The majority The combination of medical therapy and surgery shares a synergistic relationship in providing long-term disease control.
The challenge is to offer a medical therapy regimen that is effective while remaining safe and well tolerated by patients. Medical therapy for CRS will continue to evolve as our understanding of the disease process and pharmacotherapy advances.
After a follow-up at 3 months, those patients who showed good symptomatic response to medical therapy were maintained on intranasal steroid sprays and saline irrigation. The beneficial effect of the medical therapy was persistent up to an average of 8 months follow-up. Endoscopic findings and a history of asthma were a prognostic factor for failure of medical therapy.
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Demographic factors including being older and of female gender were associated with favorable response. The authors thank Jasmin O'Sullivan for her effort in facilitating access to clinical records. The authors have no conflicts of interest to declare pertaining to this article. National Center for Biotechnology Information , U.
Journal List Allergy Rhinol Providence v.
Allergy Rhinol Providence. Published online May Lee C. Young , M. Stow , M. Douglas , M. Nicholas W. Richard G. Author information Copyright and License information Disclaimer. Corresponding author. Address correspondence and reprint requests to Richard Douglas, M. Any use of the work other then as authorized under this license or copyright law is prohibited. This article has been cited by other articles in PMC. Abstract Uncomplicated chronic rhinosinusitis CRS is generally treated with medical therapy initially and surgery is contemplated only after medical therapy has failed.
Keywords: Antibiotics, chronic rhinosinusitis, corticosteroid, intranasal steroid, macrolides, maximal medical therapy, medical therapy, prednisone, saline irrigation, symptom. Table 1 Factors associated with outcome of surgery. Open in a separate window. Lund VJ. Maximal medical therapy for chronic rhinosinusitis. Pharmacologic management of chronic rhinosinusitis, alone or with nasal polyposis.