Учебники / Rhinosinusitis - A Guide for Diagnosis and Management 2008
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led to a heterogeneous group of pathological processes defined as either rhinitis or rhinosinusitis. The diagnosis of rhinosinusitis is made by a wide variety of practitioners, including primary care physicians, otolaryngologists, allergy specialists, and pulmonologists. The defining CRS patient, for each of these groups, has traditionally been subtly, but importantly, different. A more structured diagnostic process for the patient with chronic nasal symptoms will often lead to greater accuracy in classification and less ambiguity in treatment decisions.
Rhinitis Versus Rhinosinusitis
Rhinosinusitis is a more accurate term to discuss the pathophysiological changes within a common physiological unit.
Rhinosinusitis is an inflammatory condition of the respiratory mucosa of the nasal cavity proper and paranasal sinuses. The traditional discussion of rhinitis and rhinosinusitis as separate entities is rarely applied in modern otolaryngology practice. The mucosa of both the nasal cavity and paranasal sinuses are exposed to common inflammatory triggers, have a similar histology, and represent a single physiological unit. Thus, the term rhinitis is commonly replaced by rhinosinusitis to define this pathophysiological unit [6]. A continuum also exists between the common mucosa of the upper and lower respiratory tracts. This continuum accounts for the high prevalence of lower respiratory tract pathology, such as asthma, within chronic rhinosinusitis suffers [7]. Current concepts of rhinosinusitis define the difference between perennial intermittent rhinosinusitis, or allergic rhinitis, and CRS by the evidence of persistent inflammation of the nasal cavity and paranasal sinus mucosa. While histopathological assessment of the respiratory mucosa from these areas may represent the definitive test for chronic inflammatory changes, these are usually inferred by computed tomography (CT) or nasal endoscopy in the clinical setting. Those patients without chronic mucosal changes, despite chronic symptomatology, are not considered to have CRS but may have other forms of allergic (extrinsic), vasomotor (intrinsic), and occupational rhinosinusitis or even a nonsinogenic origin of their symptoms.
CRS as a Multifactorial Disease
The inflammatory changes of CRS (including nasal polyps) represent a common endpoint of several, potentially coexisting, pathological factors.
What mediates this prolonged inflammatory mucosal response? Even though allergy has always been implicated, evidence that atopy predisposes to chronic or acute rhinosinusitis is still lacking [8,9]. Other pathological etiologies in chronic rhinosinusitis include ciliary dysfunction, immune deficiency, ostial obstruction, bacteria, fungi, superantigens (i.e., exotoxins), leukotriene abnormalities, biofilms [10],
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osteitis, and environmental factors [8,11]. The concept of a single unifying pathological process is unlikely. There is significant heterogeneity between individual immune responses. The clinical spectrum of disease may partly be the result of individual diversity in the CD4+ helper T-cell response to antigens [12], the Th1and Th2-mediated immune responses [12]. CRS, as a clinical entity, defining a common chronic inflammatory endpoint from a range of pathogenic mechanisms, is a popular concept [11].
The Sinonasal Symptoms
Nasal obstruction and discharge are the defining symptoms of CRS.
Local Symptoms
Many symptoms have been attributed to CRS (Table 4.1). Chronic mucosal edema and inflammatory exudate often accompany the inflammatory changes that define CRS. Thus, obstruction and discharge are considered to be the cardinal symptoms of CRS. The symptoms of facial pain, pressure, or headache along with reduction or loss of smell are considered less consistent. These complaints constitute the four major symptoms of CRS. Questions on allergic symptoms (i.e., sneezing, watery rhinorrhea, nasal itching, and itchy watery eyes), although not diagnostic for CRS, should be included to identify concurrent pathological processes. Nasal symptoms may be secondary to CRS, but the physician must keep in mind the differential diagnoses for these common symptoms, as discussed later in this chapter.
Table 4.1 Local, regional, and systemic symptoms of chronic rhinosinusitis (CRS)
Local
Nasal obstruction and congestion
Nasal discharge: anterior or posterior
Facial pain
Facial fullness
Headache
Smell dysfunction
Anosmia (loss of smell)
Regional
Sore throat
Dysphonia
Cough
Halitosis
Bronchospasm
Ear fullness or pain
Eustachian tube dysfunction
Dental pain
Systemic
Fatigue
Malaise
Fever
Anorexia
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Regional and Systemic Symptoms
There is great variation in the intensity and pattern of symptoms of CRS. For some patients, extensive mucosal changes in the nasal cavity or paranasal sinuses can progress largely unnoticed until later in the disease process. Large asymptomatic nasal polyps are not an uncommon finding. A subgroup of these patients may present with regional or systemic symptoms as their chief complaint (see Table 4.1). Regional symptoms, such as cough, may have a sinonasal origin. Laryngeal inlet irritation from inflammatory postnasal discharge has some merit, and subsequent bronchospasm may even occur. The medical management of CRS in asthma patients is often associated with an improvement in these symptoms [13]. At these regional areas, other pathological etiologies, such as laryngopharyngeal reflux, may also be contributory. Careful evaluation as to the significance of CRS in the etiology of these regional symptoms should be undertaken.
Duration of Symptoms
Symptoms that have been present more than 12 weeks define CRS as chronic.
The symptom duration for CRS has been arbitrarily established at 12 weeks. It is unlikely that inflammation from an acute infective rhinosinusitis will still be present at this stage without other predisposing factors. There is typically a variable clinical course in CRS over those 12 weeks to many years. CRS is often characterized by incomplete resolution of symptoms with intermittent exacerbations (Fig. 4.1).
CRS with Polyps
Nasal polyps represent the “ballooning” of inflamed mucosa at discrete areas within the nose (Fig. 4.2). They commonly arise from the lateral nasal wall and middle meatus and are present in up to 4% of the population [14]. The mechanisms as to why the mucosa degenerates into polyps in some individuals and not others
Fig. 4.1 The classic symptom course for chronic rhinosinusitis (CRS). Exacerbations with more acute infective features, such as purulent discharge, are common
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Fig. 4.2 Nasal inflammatory polyps
are unknown. Much research has speculated that individual variations in epithelial structure, inflammatory mediators, and immune responses account for the development of polyps [15–17]. Patients with asthma have a 7% to 15% prevalence of polyps and may represent a group with a predisposition to a strong panrespiratory inflammatory response [18]. Nasal polyps are considered to represent a form of chronic focal inflammatory change and are defined as a subgroup within CRS (Fig. 4.3). Although not all CRS patients have polyps, all polyp patients have CRS even if the symptomatology is very mild. Separating CRS patients based on the presence of polyps has previously been popular but does reflect different etiologic events [19,20]. However, the management of a CRS patient with nasal polyps is often more aggressive and may be reflective of a more exuberant inflammatory/immune response in that individual person [19].
Current Concepts
Rhinosinusitis is a group of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses. Chronic rhinosinusitis is rhinosinusitis of at least 12 consecutive weeks duration. Therefore, chronic rhinosinusitis is a group
Fig. 4.3 The spectrum of chronic rhinosinusitis and nasal polyps [59]. (Reproduced with permission from Fokkens W, Lund VJ, Mullol J. European position paper on rhinosinusitis and nasal polyps. Rhinology Journal, June 2007 [19].)
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of disorders characterized by inflammation of the mucosa of the nose and paranasal sinuses of at least 12 consecutive weeks duration [11]. This early definition by the Rhinosinusitis Task Force of the American Academy of Otolaryngology-Head and Neck Surgery is commonly accepted. However, such a definition has limited clinical utility for the practicing physician. Recently, the European Position Paper on Rhinosinusitis and Nasal Polyps clinically defined chronic rhinosinusitis, including nasal polyps, as listed in Table 4.2. Those patients with the following conditions are generally considered to have sinonasal manifestations of a broader pathology:
1.Cystic fibrosis based on positive sweat test or DNA alleles
2.Gross immunodeficiency (congenital or acquired)
3.Congenital mucociliary problems, i.e., primary ciliary dyskinesia (PCD)
4.Noninvasive fungal balls and invasive fungal disease
5.Systemic vasculitis and granulomatous diseases
6.Cocaine abuse
7.Neoplasia
Although these patients may have chronic sinonasal symptoms that are similar to CRS, the treatment will often be directed toward the management of global condition and will not follow classic CRS management paradigms.
The clarification of CRS as a disease from other sinonasal complaints has tremendous benefit both clinically and for research. Sinonasal conditions too broadly defined can lead to a heterogeneous group of patients who clinically may respond poorly to initial treatment and be an unrepresentative group academically. Adoption of the European Position Paper on Rhinosinusitis and Nasal Polyps definition for CRS within clinical practice has the potential to better direct treatment, enhancing patient care, and will help provide a greater understanding of the origins of CRS through better defined research populations.
Table 4.2 The current working definition of CRS (as defined by EPOS [19])
Inflammation of the nose and the paranasal sinuses characterized by two or more symptoms, one of which should be either nasal blockage/obstruction/congestion or nasal discharge (anterior/ posterior nasal drip):
±facial pain/pressure
±reduction or loss of smell and either
•endoscopic signs of:
polyps and/or
mucopurulent discharge primarily from middle meatus and/or edema/mucosal obstruction primarily in middle meatus, and/or
• CT changes:
mucosal changes within the ostiomeatal complex and/or sinuses. These criteria must be combined with:
more than 12 weeks symptoms without complete resolution of symptoms.
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Presenting Symptoms and Differential Diagnoses
CRS can present with significant variability in symptom pattern and intensity. The course of CRS is often characterized by fluctuating symptoms and acute exacerbations. Patient presentations that are dominated by pain or headache, without corresponding nasal obstruction or discharge of similar significance, rarely lead to a diagnosis of CRS as the underlying cause of the presenting complaint. This is true even if there is supporting CT or endoscopic findings of mucosal thickening. Chronic mucosal inflammation is not a classical generator of significant pain. This section describes sinonasal symptoms commonly send in clinical practice and brief differential diagnoses that physicians should keep in mind when evaluating the CRS patient.
Nasal Obstruction/Congestion/Blockage/Stuffiness
Clinical Basis
Nasal obstruction and congestion has a broad interpretability and may encompass a sensation of true mechanical obstruction of airflow to a midfacial fullness. This symptom may be variable and even cyclical. Defining patterns of nasal obstruction with time of day, posture (lying down), during work, or on contact with possible allergens can greatly assist with identifying causes. Chronic inflammation leading to vascular dilatation and narrowed airspace (Fig. 4.4) is likely to account for loss of airflow. Nasal polyps (see Fig. 4.2) and mucosal sensory dysfunction may also be causes.
(a) |
(b) |
Fig. 4.4 Endoscopic assessment of inflamed mucosa (a) compared to normal mucosa (b). Photographs were taken of the middle meatus with the same endoscopic, lighting, and recording equipment from one patient with a chronic left maxillary and ethmoid rhinosinusitis and a normal right paranasal sinus system
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Fig. 4.5 Septal deviation to the right. Endoscopic view of the right nasal cavity
Differential Diagnoses for Nasal Obstruction
1.Septal deviation (Fig. 4.5)
2.Turbinate hypertrophy (Fig. 4.6)
3.Neoplasm (Figs. 4.7, 4.8)
4.Adenoid hypertrophy
5.Rhinitis medicamentosa
6.Nasal valve dysfunction
Objective Evaluation of Nasal Obstruction
Individual perception of nasal obstruction is likely to be highly variable [19]. Thus, intrapatient assessment of airflow generally has a good correlation with subjective
Fig. 4.6 Hypertrophy of the right inferior turbinate
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Fig. 4.7 Nasal tumor. An olfactory neuroblastoma in the left nasal cavity
Fig. 4.8 Computed tomography (CT) scan of the nasal tumor in Fig. 4.7
assessment but has limited value in comparison between patients [21,22]. Nasal peak inspiratory flow (NPIF) is a simple and easily performed measurement. It allows “at home” recordings, and patients can create logs of their flow rate in a similar fashion to peak expiratory flow measurements in asthmatics. It is effort dependent and may give large test–retest variability if not performed correctly. Normal NPIF rates for men are 143 L/min (SD48.6) and 121.9 L/min (SD36) for women [23]. Other measurements of airflow, such as rhinomanometry, show good correlations with patient-recorded symptoms but, due to complexity in use, are reserved for research and academic units only. Measurements of nasal air space or cross-sectional area, while providing a sensitive objective measurement, do not closely correlate with the symptom of nasal obstruction [24,25]. Acoustic rhinometry and rhinosterometry are examples of these investigations.
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Nasal Discharge and Postnasal Drip
Clinical Basis
The inflammatory mucus that is produced in CRS is commonly discolored (Fig. 4.9). The exudate can be either an eosinophilicor neutrophilic-dominated process. A constant anterior nasal discharge may be evident by local excoriations around the nasal vestibule from contact and constant nose blowing. Dorsal nasal creases may have also formed from years of handkerchief use and nasal rubbing. There may be a perception of discharge draining posteriorly or “postnasal drip.” Examination of the oropharynx may demonstrate purulent secretions on the lateral and posterior walls. True purulent secretions can produce this symptom, but it can also be a manifestation of changes in mucous rheology with hydration or local pharyngeal inflammation with irritants such as laryngopharyngeal reflux. Unilateral and very malodorous secretions should prompt further investigation for dental infection or a foreign body. Similarly, watery unilateral discharge should raise suspicion of a cerebrospinal fluid (CSF) leak. Examination for the beta-2 transferrin protein will identify CSF.
Differential Diagnoses for Nasal Discharge
Foreign body Allergic rhinosinusitis
Nonallergic rhinosinusitis CSF leak
Rheological changes to normal mucus production with hydration Laryngopharyngeal reflux
Fig. 4.9 Typical thick eosinophilic mucin of chronic rhinosinusitis (CRS). There is also cystic degeneration of the right maxillary sinus mucosa
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Objective Evaluation
Measurements of the amount of nasal discharge are extremely difficult. Subjective recording alone is likely to produce very wide interpatient assessments. Counting tissues or handkerchiefs along with weighing tissues have been used in studies but this method remains of limited use clinically [26]. A sample may be produced for demonstration of color. However, if culture or collection is required, then a direct endoscopic collection from the middle meatus is required. This is currently the gold standard for collecting mucopurulent discharge and replaces previous puncture and aspiration of the maxillary sinus [27].
Facial Pain, Ache, Headache, and Pressure
Clinical Basis
A patient with facial pain alone or as the dominating symptom in the presenting complaint is rarely a consequence of CRS. Minimal production of nociceptive products in CRS has brought the concept of chronic facial pain as a symptom of CRS into question [28]. Discriminative facial pain in response to sinus mucosal stimulation is also unlikely [29]. However, facial pain parameters within disease-specific quality-of-life measures show good content validity and correlation with global changes in health status [30]. Questions that determine the influence of pain on social, professional, and family activities will assist in evaluating the impact of pain on the presenting profile.
Differential Diagnoses for “Sinus” Pain
Dental infection
Migraine
Atypical migraine/midfacial headache
TMJ disorders including bruxism
Trigeminal neuralgia
Obstructive sleep apnoea
Objective Evaluation of Pain
In acute rhinosinusitis, pain may have a good correlation with the presence and site of disease [31]. However, for patients with CRS, pain is neither a good localizing symptom nor a predictive factor [29,32–34]. Subjective recording of pain on visual analogue scales or as Likert scores may be helpful in assessing a cyclical pattern to the symptom or in measuring a response to treatment.