Jurding Rhinosinusistis

UPDATE ON THE MANAGEMENT
OF CHRONIC RHINOSINUSITIS
Pembimbing :
dr. Afif Zjauhari, Sp. THT-KL
dr. Agus Sudarwi, Sp. THT-KL
Oleh:
Fitrian Hanif Zulkarnain / 30101407191
Liana Indri Shantika / 30101306974
Lynda Jully Novitayanti / 30101306980
Abstract
Chronic rhinosinusitis (CRS)
is a common disorder
characterized by mucosal
inflammation of the nose and Current understanding supports
paranasal sinuses with inflammation, rather than
sinonasal symptoms infection, as the dominant
persisting for greater than 12 etiologic factor
weeks.
This paper provides a

succinct review of the
evidence supporting Antibiotics are the most
or refuting common commonly prescribed medication
therapeutic agents in for CRS, but their role in
the management of management is not strongly
CRS. supported by high-level studies
Diagnosis CRS
In addition,,,
 Nasal endoscopy or imaging must also be

used to confirm the presence of sinonasal
disease to increase the specificity of diagnosis.
 Endoscopic findings, include mucopurulent
discharge, nasal polyps or polypoid change,
and/or mucosal edema obstructing the middle
meatus.
 the addition of endoscopic findings to
symptom-based criteria significantly
improved diagnostic accuracy of CRS.
Gold Standart...
 Computed tomography (CT) is considered

the gold standard for imaging in CRS.
 Findings ; isolated or diffuse mucosal
thickening, bone changes, or air-fluid levels.
 Magnetic resonance imaging (MRI) does not
pose a radiation risk and has improved soft
tissue definition over CT scan, but is more
expensive.
Epidemiology...
 CRS is estimated to result in over 18 million

physician visits in the United States each
year and is self-diagnosed in one in seven
adults. It is also the fifth most common
diagnosis for an antibiotic prescription.
Etiology...
CRS differentiation by
inflamatory mediators...
Standard treatment
 there is no such standardized therapy for
CRS
 This is in part due to the heterogeneity of
the disease, which includes CRSwNP,
CRSsNP, allergic fungal rhinosinusitis
(AFS), and CRS associated with other
systemic diseases such as atopy, asthma,
cystic fibrosis, and aspirin-exacerbated
respiratory disease (AERD).
“maximal medical therapy,”
 Is: given individual is treated with a combination

of medical strategies best suited for that patient
 treatment strategies include topical and systemic

medications. Surgery is performed for recalcitrant
disease refractory to medical therapy
Topical medical therapy
 topical solution to the unoperated sinuses
is limited, with less than 2% of the total
irrigation volume attaining sinus
penetration in the setting of CRS with
mucosal edema.
 Similar findings apply to nebulization,
with less than 3% sinus penetration.

 Pre-surgery nasal sprays with, ESS is essential to
allow effective topical distribution to the sinuses
 Head position was found to effect penetration of
the frontal sinus, with less penetration seen with
the head in neutral position versus a forward-
angled position.
Intranasal saline
 saline nasal irrigation is beneficial in
relieving symptoms of CRS when used as
the sole modality of treatment, as well as a
treatment adjunct.
 Overall, saline nasal irrigations are well
tolerated. Side effects; nasal discomfort,
drainage, epistaxis, headache, and otalgia.
 Most studies suggest symptom and health-
related quality of life improvement with
usage
Topical steroids
 Steroids reduce eosinophil viability and

activation, and may indirectly reduce the secretion
of chemotactic cytokines by nasal mucosa and
polyp epithelial cells
 Conventional FDA-approved solutions available
by metered-dose, low-volume topical sprays
include fluticasone proprionate, mometasone
furoate, ciclesonide, budesonide, flunisolide,
fluticasone furoate, beclomethasone dipropionate
monohydrate, and triamcinolone acetonide
the efficacy of conventional topical
steroid therapy in both patients with
CRSsNP and CRSwNP, with
improved symptoms, endoscopic
appearance, and reduced polyp size.
Side effects are uncommon, but
include epistaxis, dry nose, nasal
irritation, headache, and cough.
Topical antibiotics...
 The goal of topical antibiotic therapy is local

delivery of high drug concentrations while
reducing systemic effects
 But, topical antibiotics have potential efficacy;
however, there is currently a low level of
evidence for their use.
Systemic medical therapy
Oral steroids
 Systemic corticosteroids have a significant side
effect profile, which increases with dose and
duration of treatment. Patients should be
counseled regarding the possible negative effects
on bone mineral density, hyperglycemia, weight
gain, early cataract formation, pituitary–
hypothalamic axis suppression, sleep disturbance,
and exacerbation of psychiatric conditions.Given
the natural history of CRS requiring ongoing
treatment over long periods of time, the short-
lived benefits of systemic steroids must be
balanced with the long-term potential side effects
Oral antibiotics
 Long-term, low-dose antibacterial treatment presents the

greatest concern for the emergence of resistant bacterial
strains. In a placebo-controlled RCT exposing oral
streptococcal flora of healthy volunteers to macrolides,
antibiotic use was shown to be the most important driver
of antibiotic resistance. Consideration should also be
given to the well known adverse effects of systemic
antibiotics, including abdominal pain, diarrhea,
Clostridium difficile colitis, anaphylaxis, rash, tendinitis,
and tendon rupture. Some of these effects are exacerbated
with concomitant oral steroid usage.
Antifungals
 Pooled meta-analysis showed no statistically

significant benefit of topical or systemic
antifungals over placebo. Interestingly,
symptoms scores statistically favored placebo
and adverse event reporting was higher in the
antifungal group
Emerging strategies in systemic
therapy
Leukotriene antagonists
 Leukotriene antagonists, such as montelukast,
zafirlukast, and zileuton, have been evaluated in
numerous studies involving patients with
CRSwNP and AERD. Results have been mixed.
Anti-IgE therapy
 In CRSwNP, total IgE levels in nasal

secretions, nasal polyp homogenisates and
blood serum have been shown to be higher
than in controls. Omalizumab is a recombinant
humanized monoclonal antibody that
selectively binds to human IgE and reduces
levels in serum and tissue, which is approved
for patients with moderate to severe or severe
allergic asthma. Further investigation
regarding anti-IgE therapy may be warranted
Anti-IL-5 therapy
 Abundant eosinophilia is also found in the

majority of patients with CRSwNP. IL-5,
produced by Th-2 and mast cells, is a key
player in eosinophil growth, recruitment, and
activation
 Mepolizumab and reslizumab are humanized
anti-IL-5 monoclonal antibodies currently
undergoing investigation in the treatment of
CRSwNP
Aspirin desensitization
 AERD patients to either take 100 mg or 300

mg aspirin daily. After 1 year of therapy, all
patients in the 100 mg group had developed
recurrent nasal polyps, whereas no patient in
the 300 mg group had recurrent nasal polyps
on endoscopy. Risks of oral aspirin
desensitization include severe hypersensitivity,
anaphylaxis, and gastrointestinal side effects.
 no RCTs have been performed.

Endoscopic sinus surgery
 The goals of ESS include eradication of

inflammatory tissue and osteitis,
implementation of adequate drainage and
ventilation pathways, restoration of
mucociliary function, creation of access for
topical medication, reduction of acute
exacerbations and systemic medication usage,
and quality of life improvement
 ESS significantly decreases antibiotic
utilization in CRSwNP and CRSsNP
Conclusion...
 inflammation, as opposed to infection, is the dominant
etiologic factor in CRS.
 While systemic antibiotics and steroids were a mainstay of
treatment in the past, the focus is now shifting toward topical
therapy, improved nasal delivery systems, and novel anti-
inflammatory therapies.
 Potential development of microbial resistance remains a
salutary concern in patients treated with repeated or
prolonged antimicrobial agents.
 Immune modulators, such as anti-IgE and anti-IL5
antibodies, are promising areas of ongoing research.
 Surgery for recalcitrant disease, resulting in quality-of-life
improvement and assisting in aggressive medical
management.
 CRS requires an individualized approach to both medical and
surgical management in a multidisciplinary setting.
ALHAMDULILLAH
TERIMA KASIH

Jurding Rhinosinusistis

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UPDATE ON THE MANAGEMENT

This paper provides a

 Nasal endoscopy or imaging must also be

 Computed tomography (CT) is considered

 CRS is estimated to result in over 18 million

 Is: given individual is treated with a combination

 treatment strategies include topical and systemic

is limited, with less than 2% of the total

irrigation volume attaining sinus

penetration in the setting of CRS with

 Similar findings apply to nebulization,

with less than 3% sinus penetration.

allow effective topical distribution to the sinuses

 Head position was found to effect penetration of

the frontal sinus, with less penetration seen with

the head in neutral position versus a forward-

 Steroids reduce eosinophil viability and

 The goal of topical antibiotic therapy is local

 Long-term, low-dose antibacterial treatment presents the

 Pooled meta-analysis showed no statistically

 In CRSwNP, total IgE levels in nasal

 Abundant eosinophilia is also found in the

 AERD patients to either take 100 mg or 300

 no RCTs have been performed.

 The goals of ESS include eradication of

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