1. What is chronic rhinosinusitis?What is chronic rhinosinusitis?
SinusitisSinusitis oror rhinosinusitisrhinosinusitis isis
inflammationinflammation of theof the paranasal sinusesparanasal sinuses, which, which
may be due tomay be due to infectioninfection,, allergyallergy, or, or
autoimmuneautoimmune issuesissues..

2.  TheThe EP3OS taskforceEP3OS taskforce (a group of international experts who appraise(a group of international experts who appraise
and report on the available literature)and report on the available literature) developed a clinical definition ofdeveloped a clinical definition of
rhinosinusitis that is based on the Allergic Rhinitis and its Impact onrhinosinusitis that is based on the Allergic Rhinitis and its Impact on
Asthma (ARIA) group guidelines .Asthma (ARIA) group guidelines .
 Clinically, sinus inflammation (ie, sinusitis) rarely occurs withoutClinically, sinus inflammation (ie, sinusitis) rarely occurs without
concomitant inflammation of the contiguous nasal mucosa.concomitant inflammation of the contiguous nasal mucosa.
Regardless, the expert panels that adoptedRegardless, the expert panels that adopted rhinosinusitisrhinosinusitis
acknowledged that the termsacknowledged that the terms rhinosinusitisrhinosinusitis andand sinusitissinusitis should beshould be
used interchangeably, especially because the termused interchangeably, especially because the term rhinosinusitisrhinosinusitis hashas
only come into common use during the past decade.only come into common use during the past decade.
 Recent theories of sinusitis indicate that it often occurs as part of aRecent theories of sinusitis indicate that it often occurs as part of a
spectrum ofspectrum of diseasesdiseases that affect thethat affect the respiratory tractrespiratory tract ((i.e.i.e., the "one, the "one
airway" theory) and is often linked toairway" theory) and is often linked to asthmaasthma. All forms of sinusitis may. All forms of sinusitis may
either result in, or be a part of, a generalizedeither result in, or be a part of, a generalized inflammationinflammation of theof the airwayairway
, so other, so other airwayairway symptomssymptoms, such as cough, may be associated with it., such as cough, may be associated with it.
 Chronic sinusitis is sinonasal inflammation lasting for more thanChronic sinusitis is sinonasal inflammation lasting for more than 1212
weeks, without resolution,weeks, without resolution, and can be cause by multiple factors.and can be cause by multiple factors.

3. EPIDEMIOLOGYEPIDEMIOLOGY
 The 2012 update of the European Position PaperThe 2012 update of the European Position Paper
on Rhinosinusitis and Nasal Polyps (EP3OS)on Rhinosinusitis and Nasal Polyps (EP3OS)
reported that it may affect betweenreported that it may affect between 5% and 15%5% and 15% ofof
the population in Europe and the United States,the population in Europe and the United States,
although high quality epidemiological data isalthough high quality epidemiological data is
scarcescarce
 A multicentre questionnaire survey of adults inA multicentre questionnaire survey of adults in
Europe estimated thatEurope estimated that one in tenone in ten participants hadparticipants had
CRS but with notable geographic variation.CRS but with notable geographic variation.
 Chronic sinusitis affects approximatelyChronic sinusitis affects approximately 12.5%12.5% ofof
people.people.
 One American study analysing a multiemployerOne American study analysing a multiemployer
database from 1991 ranked sinusitis as thedatabase from 1991 ranked sinusitis as the ninthninth
most costlymost costly health conditionhealth condition

4. CLASIFICATIONCLASIFICATION
 acute rhinosinusitis — a new infection that may lastacute rhinosinusitis — a new infection that may last
up to four weeks and can be subdividedup to four weeks and can be subdivided
symptomatically into severe and non-severe;symptomatically into severe and non-severe;
 recurrent acute rhinosinusitisrecurrent acute rhinosinusitis — four or more— four or more
separate episodes of acute sinusitis that occur withinseparate episodes of acute sinusitis that occur within
one year;one year;
 subacute rhinosinusitis — an infection that lastssubacute rhinosinusitis — an infection that lasts
between four and 12 weeks, and represents abetween four and 12 weeks, and represents a
transition between acute and chronic infection;transition between acute and chronic infection;
 chronic rhinosinusitis — when the signs andchronic rhinosinusitis — when the signs and
symptoms last for more than 12 weeks; andsymptoms last for more than 12 weeks; and
 acute exacerbation of chronic rhinosinusitisacute exacerbation of chronic rhinosinusitis — when— when
the signs and symptoms of chronic rhinosinusitisthe signs and symptoms of chronic rhinosinusitis
exacerbate, but return to baseline after treatment.exacerbate, but return to baseline after treatment.

6. Features of CRSFeatures of CRS
Key clinical featuresKey clinical features
 Nasal blockage/obstructionNasal blockage/obstruction
 Nasal congestionNasal congestion
 Anterior/posterior rhinorrhoeaAnterior/posterior rhinorrhoea
 Facial pain/pressureFacial pain/pressure
 Anosmia (total/partial)Anosmia (total/partial)

7. Features of CRSFeatures of CRS
Minor symptomatic featuresMinor symptomatic features
 Ear pain/pressureEar pain/pressure
 DizzinessDizziness
 HalitosisHalitosis
 Dental painDental pain
 CoughCough
 Drowsiness/malaiseDrowsiness/malaise
 Sleep disturbanceSleep disturbance
 FeverFever

8. Red flag symptomsRed flag symptoms
 Unilateral symptomsUnilateral symptoms
 BlockageBlockage
 Bleeding/bloodstained dischargeBleeding/bloodstained discharge
 CacosmiaCacosmia
 ProptosisProptosis
 DiplopiaDiplopia
 EpiphoraEpiphora
 Neurological symptomsNeurological symptoms

9. DIAGNOSISDIAGNOSIS
Allergy and Immunology EvaluationAllergy and Immunology Evaluation
-Allergy testing – (-Allergy testing – (skin prick testing)skin prick testing)
should be considered for patients whoshould be considered for patients who
report allergic type symptoms in theirreport allergic type symptoms in their
history. As many as 60% of patients withhistory. As many as 60% of patients with
CRS have substantial allergic sensitivities,CRS have substantial allergic sensitivities,
primarily to perennial allergens, such asprimarily to perennial allergens, such as
house dust mites, cockroaches, pethouse dust mites, cockroaches, pet
dander, and fungi.dander, and fungi.
““If you determine the cause to be allergic,If you determine the cause to be allergic,
for example, you are going to treat CRSfor example, you are going to treat CRS
very differently than if it were anatomical”very differently than if it were anatomical”

10. DIAGNOSISDIAGNOSIS
 Computed tomographyComputed tomography first-linefirst-line
recommendationrecommendation

11. DIAGNOSISDIAGNOSIS
 Magnetic resonance imagingMagnetic resonance imaging
 Active anterior rhinomanometryActive anterior rhinomanometry
 Sino-Nasal Outcome Test, SNOT-22Sino-Nasal Outcome Test, SNOT-22
This “health-related quality of life” questionnaireThis “health-related quality of life” questionnaire
(HRQoL) was originally designed for rhinosinusitis(HRQoL) was originally designed for rhinosinusitis

12. RhinomanometryRhinomanometry
 The word rhinomanometry means “rhino” forThe word rhinomanometry means “rhino” for
nose and “manometry” for measurement ofnose and “manometry” for measurement of
pressure.pressure.
 Rhinomanometry measures air pressureRhinomanometry measures air pressure
and the rate of airflow during breathing.and the rate of airflow during breathing.
These measurements are then used toThese measurements are then used to
calculate nasal airway resistance.calculate nasal airway resistance.

16. Historic perspectiveHistoric perspective
 The first attempt at objectively measure nasal airflow was probably performed byThe first attempt at objectively measure nasal airflow was probably performed by
ZwaardemakerZwaardemaker in the Netherlands inin the Netherlands in 18891889. He placed a cold mirror beneath the. He placed a cold mirror beneath the
nose and measured the size of the resultant condensation spots (Zwaardemakernose and measured the size of the resultant condensation spots (Zwaardemaker
1889).1889).
 GlatzelGlatzel improved Zwaardemakers method inimproved Zwaardemakers method in 19011901 by using a metal plate insteadby using a metal plate instead
of a mirror (Glatzel 1901). These hygrometric methods were physiologicallyof a mirror (Glatzel 1901). These hygrometric methods were physiologically
perfect because there was no deformation of the nostrils, and no artificialperfect because there was no deformation of the nostrils, and no artificial
airstream was used. But, they had numerous disadvantages in clinical use sinceairstream was used. But, they had numerous disadvantages in clinical use since
they were dependent on environmental factors such as temperature andthey were dependent on environmental factors such as temperature and
humidity etc. Further modifications of these methods were described by Jochimshumidity etc. Further modifications of these methods were described by Jochims
in 1938 by the fixation of the condensed pattern with Gummi Arabicum (Jochimsin 1938 by the fixation of the condensed pattern with Gummi Arabicum (Jochims
1938).1938).
 The first rhinomanometric procedures inThe first rhinomanometric procedures in 19581958 were of the passive typeswere of the passive types
((Seebohm & HamiltonSeebohm & Hamilton). But it was difficult for patients to hold their breath and). But it was difficult for patients to hold their breath and
not to swallow when air was being blown through their nose. These methodsnot to swallow when air was being blown through their nose. These methods
have rarely been applied clinically. Sometimes they have even required generalhave rarely been applied clinically. Sometimes they have even required general
anesthesia.anesthesia.
 In 1984 came the first report from the International Standardization Committee ofIn 1984 came the first report from the International Standardization Committee of
Rhinomanometry (ISCR) lead by Clement from Belgium (Clement 1984Rhinomanometry (ISCR) lead by Clement from Belgium (Clement 1984).).
 Acoustic rhinometryAcoustic rhinometry was added in the earlywas added in the early 1990s1990s as a method to measure theas a method to measure the
cross-sectional area and volume of the nasal cavity (Hilberg et al 2000).cross-sectional area and volume of the nasal cavity (Hilberg et al 2000).
 A new report from ISCR came in 2005 to try to resolve all controversies toA new report from ISCR came in 2005 to try to resolve all controversies to
achieve a mutual understanding of clinicians, surgeons, scientists andachieve a mutual understanding of clinicians, surgeons, scientists and
manufacturers (Clement et al 2005).This report included recommendations formanufacturers (Clement et al 2005).This report included recommendations for
acoustic rhinometry and four phases rhinomanometry.acoustic rhinometry and four phases rhinomanometry.

17.  Active anterior rhinomanometry is todayActive anterior rhinomanometry is today
the most commonly used method ofthe most commonly used method of
rhinomanometryrhinomanometry..
--We use a transparent airtight facemaskWe use a transparent airtight facemask
with one nostril sealed off with adhesivewith one nostril sealed off with adhesive
tape.tape.
-A hard plastic tube is passed through the-A hard plastic tube is passed through the
tape to measure the nasopharyngealtape to measure the nasopharyngeal
pressure.pressure.
-This is a dynamic test that studies nasal-This is a dynamic test that studies nasal
ventilation, and shows the nature of the airventilation, and shows the nature of the air
stream.stream.

19. Indications for rhinomanometryIndications for rhinomanometry::
Rhinomanometry can be usedRhinomanometry can be used to differentiateto differentiate if the nasal obstruction isif the nasal obstruction is
structurally mucosal in nature by conducting the test before and afterstructurally mucosal in nature by conducting the test before and after
topical decongestion.topical decongestion.
Objective testing is useful in theObjective testing is useful in the quantitative assessmentquantitative assessment of theof the
benefit of medical and surgical therapy. It can be used to assess thebenefit of medical and surgical therapy. It can be used to assess the
effectiveness of septoplasty and/or turbinoplasty in alleviating nasaleffectiveness of septoplasty and/or turbinoplasty in alleviating nasal
obstruction.obstruction.
In nasal physiology research it providesIn nasal physiology research it provides quantitative informationquantitative information on theon the
response of the nasal mucosa to intranasal challenges withresponse of the nasal mucosa to intranasal challenges with
allergens and other types of physical and chemical stimuli (Malmallergens and other types of physical and chemical stimuli (Malm
2000).2000).

20. There are two occasions when anteriorThere are two occasions when anterior
active rhinomanometry is not possible toactive rhinomanometry is not possible to
useuse::
 11. If the nasal cavity that transmits the. If the nasal cavity that transmits the
pressure from the nasopharynx ispressure from the nasopharynx is totallytotally
obstructedobstructed no measurement is possible.no measurement is possible.
 22. In. In septal perforationseptal perforation the flows andthe flows and
pressures recorded are not representativepressures recorded are not representative
of the nasal cavity being studied.of the nasal cavity being studied.

21. How is chronic rhinosinusitis managed?How is chronic rhinosinusitis managed?
Most patients will respond to conservative treatment; allergy treatment ifMost patients will respond to conservative treatment; allergy treatment if
they are allergic, intranasal corticosteroids for most patients, and salinethey are allergic, intranasal corticosteroids for most patients, and saline
nasal irrigation in some cases.nasal irrigation in some cases. Conservative treatmentConservative treatment is usually veryis usually very
effectiveeffective
 There is level 1 evidence (randomised controlled trials) to support the useThere is level 1 evidence (randomised controlled trials) to support the use
ofof intranasalintranasal corticosteroidscorticosteroids (sprays or drops). The effect of(sprays or drops). The effect of
corticosteroids may be mediated by a reduction in eosinophil activity incorticosteroids may be mediated by a reduction in eosinophil activity in
the mucosa.the mucosa.
 Short term use ofShort term use of decongestantsdecongestants may have a role in the treatment ofmay have a role in the treatment of
acute rhinosinusitis, but there is no evidence to support their use for CRSacute rhinosinusitis, but there is no evidence to support their use for CRS
 AntibioticsAntibiotics are sometimes necessary for sinusitis if you have a bacterialare sometimes necessary for sinusitis if you have a bacterial
infection.the use of long term (12 weeks)- macrolide antibiotics in patientsinfection.the use of long term (12 weeks)- macrolide antibiotics in patients
with CRS. However, chronic sinusitis is usually caused by somethingwith CRS. However, chronic sinusitis is usually caused by something
other than bacteria, so antibiotics usually won't help!!!other than bacteria, so antibiotics usually won't help!!!
 ImmunotherapyImmunotherapy -If allergies are contributing to your sinusitis, allergy-If allergies are contributing to your sinusitis, allergy
shots (immunotherapy) that help reduce the body's reaction to specificshots (immunotherapy) that help reduce the body's reaction to specific
allergens may help treat the condition.allergens may help treat the condition.

22. Side effects of treatmentSide effects of treatment
Potential, common side effects of localPotential, common side effects of local
corticosteroid use may includecorticosteroid use may include epistaxis andepistaxis and
nasal irritationnasal irritation, although these are generally, although these are generally
mild and well tolerated by most patientsmild and well tolerated by most patients

23. Disease that accompany Chronic RhinosinusitisDisease that accompany Chronic Rhinosinusitis::
 The relationship betweenThe relationship between allergy, asthma, and CRSallergy, asthma, and CRS is ais a
complex one that is not clearly understood, but thesecomplex one that is not clearly understood, but these
conditions commonly coexist and treatment of one canconditions commonly coexist and treatment of one can
influence the other: for example, successful treatment ofinfluence the other: for example, successful treatment of
CRS can improve asthma control.CRS can improve asthma control.
 Nasal polyposisNasal polyposis is also found in a high proportion ofis also found in a high proportion of
patients withpatients with aspirin sensitivityaspirin sensitivity. When accompanied by. When accompanied by
asthma, this group of conditions is calledasthma, this group of conditions is called Samter’s triadSamter’s triad..
 One retrospective study of CRS patients undergoingOne retrospective study of CRS patients undergoing
functional endoscopic sinus surgery found thatfunctional endoscopic sinus surgery found that 5.9%5.9% ofof
adults had Samter’s triad.adults had Samter’s triad.

24. Efficacy of theEfficacy of the
fluticasone furoatefluticasone furoate
nasal spraynasal spray
in the treatment ofin the treatment of
perennial allergic rhinosinusitisperennial allergic rhinosinusitis

25. BackgroundBackground
 There are many potential causes for nasal obstruction. Some of theThere are many potential causes for nasal obstruction. Some of the
most common causes are allergic rhinosinusitis.most common causes are allergic rhinosinusitis. Allergic rhinosinusitis,Allergic rhinosinusitis,
occurs when immune system overreacts to particlesoccurs when immune system overreacts to particles that, causingthat, causing
symptoms such as sneezing and a runny nosesymptoms such as sneezing and a runny nose.. Nasal obstruction isNasal obstruction is
typically diagnosed by a patient’s subjective complaint of nasaltypically diagnosed by a patient’s subjective complaint of nasal
discomfort.discomfort.
 Rhinomanometry is one of objective tests that has been attempted toRhinomanometry is one of objective tests that has been attempted to
assess nasal airway patency.assess nasal airway patency. RhinomanometryRhinomanometry is measurement of theis measurement of the
airflow and pressure within the nose during respiration. Nasalairflow and pressure within the nose during respiration. Nasal
resistance or obstruction can be calculated from the figures obtained.resistance or obstruction can be calculated from the figures obtained.
 The goalThe goal of perennial rhinosinusitis treatment is to prevent or reduceof perennial rhinosinusitis treatment is to prevent or reduce
the symptoms caused by the inflammation of affected tissues. Avoidingthe symptoms caused by the inflammation of affected tissues. Avoiding
the allergen is measure which is effective but intranasal corticosteroidsthe allergen is measure which is effective but intranasal corticosteroids
are the preferred treatment.are the preferred treatment.

26. Materials and methodsMaterials and methods
 30 pts. aged 18 to 40 years were evaluated with symptoms30 pts. aged 18 to 40 years were evaluated with symptoms
of perennial allergic rhinosinusitis. In our study we usedof perennial allergic rhinosinusitis. In our study we used
Fluticasone furoate nasal spray and patients took sprayFluticasone furoate nasal spray and patients took spray
once a daily, two sprays in each nostrila, and were followedonce a daily, two sprays in each nostrila, and were followed
10 minutes later. Pts. maintained10 minutes later. Pts. maintained daily symptom anddaily symptom and
adverse-experience diariesadverse-experience diaries and were evaluated by theand were evaluated by the
investigators allergolgists .investigators allergolgists .
 Nasal resistance and/or obstruction have been measuredNasal resistance and/or obstruction have been measured
byby rhinomanometryrhinomanometry
 Patients were evaluated before the study medications werePatients were evaluated before the study medications were
started ( First day) , after one month of treatment and sixstarted ( First day) , after one month of treatment and six
months for nasal and eye symptoms.months for nasal and eye symptoms.
 Rhinomanometry was performed on day 1, after oneRhinomanometry was performed on day 1, after one
month of treatment and six months of the study.month of treatment and six months of the study.

27. RESULTSRESULTS
 Topical fluticasone furoate nasal spray was rapidlyTopical fluticasone furoate nasal spray was rapidly
effective in decreasing mean nasal obstruction, rhinorrhea,effective in decreasing mean nasal obstruction, rhinorrhea,
sneezing, and itching symptoms as well as mean eyesneezing, and itching symptoms as well as mean eye
symptoms.symptoms.
 Nasal airflow increasedNasal airflow increased
 Rhinomanometry significantly correlated with subjectiveRhinomanometry significantly correlated with subjective
nasal obstruction scoresnasal obstruction scores..
 Most patients (79%) preferred the fluticasone furoate nasalMost patients (79%) preferred the fluticasone furoate nasal
spray for the treatment because of administration of nasalspray for the treatment because of administration of nasal
spray for the treatment once a day.spray for the treatment once a day.

28. ConclusionConclusion
 There were no major adverse effects.There were no major adverse effects.
 Nasal congestion, as a symptom and asNasal congestion, as a symptom and as
reflected by rhinomanometric assessment,reflected by rhinomanometric assessment,
was the least improved parameter.was the least improved parameter.
 Most patients (92%) preferred theMost patients (92%) preferred the
fluticasone furoate nasal spray for thefluticasone furoate nasal spray for the
treatment because of administration oftreatment because of administration of
nasal spray for the treatment once a day.nasal spray for the treatment once a day.