Chronic Rhinosinusitis Presented by Sasikarn Suesirisawad, MD

1. Sasikarn Suesirisawad, MD

2.  Chronic Rhinosinusitis (with or without NP) in adults
 ≥ 2 symptoms
 one of which should be either nasal
blockage/obstruction/congestion or nasal
discharge(ant/post drip) or
 ± Facial pain/pressure
 ± reduction or loss of smell
for ≥12 weeks
with validation by telephone or interview.
Questions on allergic symptoms (sneezing, watery
rhinorrhea, nasal itching, and itchy watery eyes) should be
included.
EPOS 2012

3.  CRSwNP: bilateral, endoscopically visualised
polyps in middle meatus.
 CRSsNP: no visible polyps in middle
meatus, if necessary following decongestant.
EPOS 2012

4.  Symptoms ≥ 12 weeks
 ≥ 2 symptoms one of which should be either nasal
blockage/obstruction/congestion or nasal discharge (ant/post
nasal drip):
 ± facial pain/pressure,
 ± reduction or loss of smell;
 Signs (if applicable)
•nasal examination
•oral examination: posteriordischarge; exclude dental infection.
 Additional diagnostic information
• questions on allergy should be added and, if positive, allergy testing
should be performed.
 Not recommended: plain x-ray or CT-scan
EPOS 2012

5.  Symptoms ≥ 12 weeks
 ≥ 2 symptoms one of which should be either nasal
blockage/obstruction/congestion or nasal discharge (ant/post nasal drip):
 ± facial pain/pressure,
 ± reduction or loss of smell;
 Signs
• ENT examination, endoscopy;
• review primary care physician’s diagnosis and treatment;
• questionnaire for allergy and if positive, allergy testing if it
has not already been done.
EPOS 2012

6.  ≥ 2 symptoms
 one of which should be either nasal blockage/obstruction/congestion or nasal
discharge(ant/postnasal drip) or
 ± Facial pain/pressure
 ± Cough
for ≥12 weeks
with validation by telephone or interview.
 Questions on allergic symptoms (sneezing, watery rhinorrhea, nasal itching, and
itchy watery eyes) should be included.
EPOS 2012

7.  5-15% of general population both Europe and
USA.
 Prevalence of MD-diagnosed CRS was 2-4%
EPOS 2012

8.  Ciliary impairment
 Allergy
 Asthma
 Aspirin sensitivity
 Immunocompromised state
 Genetic factor
 Pregnancy and endocrine state
 Local host factor
 Biofilm
 Environmental factor
 Iatrogenic factor
 H.pylori and laryngopharyngeal reflux
 Osteitis

10.  Defect in barrier and/or innate immune response
of sinonasal epithelium.
 Increase microbial colonization, accentuated
barrier damage.
 Defect in STAT 3(CRSwNP)
 Inappropriated Th2 adaptive response
 Local autoantibody
 Biofilm
EPOS 2012

12. EPOS 2012

13. Comparison of major cells and mediators in CRS vs NP. TGF-β, a key
mediator inducing fibrosis, is increased in CRS, but decreased in NP.
Middleton’s Allergy Principle & Practice, seventh edition

14. Mucosa in CRS: BM thickening, goblet cell hyperplasia, subepithelial edema,
mononuclear cell infiltration with few eosinophils
Middleton’s Allergy Principle & Practice, seventh edition

15. Numerous subepithelial eosinophils in luminal compartment
of early-stage polyp.
Middleton’s Allergy Principle & Practice, seventh edition

16. Eosinophils accumulated subepithelially and diffusely
in tissue of mature polyp.
Middleton’s Allergy Principle & Practice, seventh edition

17. Koen Van Crombruggen et al. J Allergy Clin Immunol 2011;128:728-32.

18. Spencer C et al. J Allergy Clin Immunol -

20. Endoscopic view of nasal polyps protruding from middle meatus.
Middleton’s Allergy Principle & Practice, seventh edition

24.  Nasal polyposis
 Fungi on staining
 Eosinophilic mucin without fungin invasion
into sinus tissue
 Type I hypersensitivity to fungi and
 Characteristic radio findings with soft tissue
differential densities on CT scaning
EPOS 2012

26. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

27. CT scans nasal polyps. (A) Central disease, an early stage.
(B) Nearly total ‘white-out,’ a late stage.
Middleton’s Allergy Principle & Practice, seventh edition

30. CT scan of fungal infection of right maxillary sinus: heterogeneous opacification
and calcification with increased attenuation.
Middleton’s Allergy Principle & Practice, seventh edition

31. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

32. EPOS 2012

33. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

36. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

38. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707

45. Daniel L et al. J Allergy Clin Immunol 2011;128:693-707