Update on the management of chronic rhinosinusitis

Infection and Drug Resistance Dovepress open access to scientific and medical research R e v ie w Open Access Full Text Article Infection and Drug Resistance downloaded from https://www.dovepress.com/ by 5.135.15.0 on 12-Jul-2018 For personal use only. Update on the management of chronic rhinosinusitis This article was published in the following Dove Press journal: Infection and Drug Resistance 22 January 2013 Number of times this article has been viewed Rachel B Cain Devyani Lal Department of Otorhinolaryngology, Mayo Clinic, Phoenix, AZ, USA Introduction Correspondence: Devyani Lal Department of Otorhinolaryngology, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA Tel +1 480 342 2928 Fax +1 480 342 2626 Email submit your manuscript | www.dovepress.com Dovepress http://dx.doi.org/10.2147/IDR.S26134 Powered by TCPDF (www.tcpdf.org) Abstract: Chronic rhinosinusitis (CRS) is a common disorder characterized by mucosal inflammation of the nose and paranasal sinuses with sinonasal symptoms persisting for greater than 12 weeks. The etiology of CRS is incompletely understood. Current understanding supports inflammation, rather than infection, as the dominant etiologic factor. CRS significantly impacts patients’ quality of life and health care expenditure. There is no standard management of CRS. Treatment strategies differ based on divergent etiologies of the various CRS subclasses. Both systemic and topical agents are used. These interventions differ in CRS with nasal polyposis (CRSwNP), CRS without nasal polyposis (CRSsNP) and specific situations such as allergic fungal rhinosinusitis or aspirin-exacerbated respiratory disease. Antibiotics are the most commonly prescribed medication for CRS, but their role in management is not strongly supported by high-level studies. This paper provides a succinct review of the evidence supporting or refuting common therapeutic agents in the management of CRS. Novel and emerging strategies will also be discussed. Keywords: review, evidence-based, sinusitis Chronic rhinosinusitis (CRS) is diagnosed when specific sinonasal symptoms lasting 12 or more weeks are confirmed by nasal endoscopy or radiographic imaging (Figure 1).1 CRS is best considered as a group of heterogeneous disorders from a multitude of causes that result in mild to severe symptomatic inflammation of the sinonasal mucosa (Figure 2).2 The management of this complex and diverse disease is therefore a challenge. Much ongoing research is being directed toward the investigation of treatment strategies, as well as developing criteria for diagnosing the various CRS subsets. The most simplified classification divides CRS into those patients who have nasal polyps (CRSwNP) and those without (CRSsNP) (Figure 3).3 Medical therapy of CRS is a key strategy, with surgery playing a vital adjunctive role. Medical therapy is directed toward treatment of the underlying etiology, as well as the resultant inflammation. A variety of systemic and topical therapeutic agents are commonly employed. These include corticosteroids, antimicrobials, and immune modulating medications. As CRS is a chronic disease, there are concerns related to the use of systemic agents over prolonged periods. Long-term use of corticosteroids and antibiotics may lead to adverse effects, drug interactions, and antimicrobial resistance. The development of topical therapy delivered directly to the sinonasal cavity has created an alternative treatment strategy to help potentiate these concerns. Many therapeutic agents Infection and Drug Resistance 2013:6 1–14 © 2013 Cain and Lal, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. 1 Dovepress Cain and Lal • American Academy of Otolaryngology – Head and Neck Surgery criteria ≥12 week duration of ≥2 of following: Infection and Drug Resistance downloaded from https://www.dovepress.com/ by 5.135.15.0 on 12-Jul-2018 For personal use only. • Mucopurulent drainage • Nasal obstruction • Facial pain/pressure/fullness • Decreased sense of smell AND Inflammation by one or more objective criteria • Endoscopy: pus, mucosal edema or polyps • Imaging showing inflammation of the paranasal sinuses Figure 1 Diagnosis of CRS. Note: © 2007 Sage Publications. Reproduced with permission from Rosenfeld RM, et al. Clinical practice guideline: adult sinusitis. Otolaryngol Head Neck Surg. 2007; 137(3 Suppl)S1–S31. can now be delivered into the sinonasal cavity by a variety of delivery methods, such as irrigations, sprays, and aerosols. This paper will provide a succinct summary of current and emerging evidence-based strategies to treat CRS. Epidemiology CRS is estimated to result in over 18 million physician visits in the United States each year4 and is self-diagnosed in one in seven adults.5 It is also the fifth most common diagnosis for an antibiotic prescription.6 Despite its prevalence, there is a surprising paucity of accurate epidemiologic data for CRS, especially CRSsNP. Patient surveys in the United States have found a 15%–16% prevalence of CRS;7,8 however, a prevalence of only 2% was found using ICD-9 (International Classification of Diseases, Ninth Revision) codes as an identifier.9 In studies from Canada, Korea, Scotland, Europe, and Sao Paulo, prevalence of CRS ranges from 1%–11%.10–14 Population-based studies of CRSwNP from Sweden, Korea, Finland, and France report the prevalence of CRSwNP to lie between 0.5% and 4.3%.15–18 Autopsy studies reveal a higher prevalence between 2% and 42%, with more polyps found in dissected naso-ethmoidal blocks and endoscopic sinus surgery (ESS) than with anterior rhinoscopy alone.19,20 Men and women are both affected by CRSwNP, with some discordance in the literature as to which sex is more frequently affected. In general, nasal polyps occur in all races and become more common with age, with the average age of onset being 42 years.18 Etiology Regarding the etiology of CRS, numerous hypotheses have been proposed with a great deal of overlap, supporting a multifactorial basis. One classification method separates potential contributing entities into host and environmental factors (Figure 2).2 Although comprehensive, this scheme fails to illustrate causal relationships and host–environment interactions. The heterogeneous nature of CRS is important to understand when planning treatment for this diverse group of patients whose disease may have arisen from very different underlying etiologies. In a broad generalization, CRSwNP in the Caucasian population is associated more closely with high tissue eosinophilia and increased T helper (Th)-2 cytokine expression (interleukin [IL]-5 and IL-13) as well as nasal obstruction and smell loss. Meanwhile, CRSsNP may have more Th-1 polarization and less eosinophilic infiltration (Figure 3).3 However, these characterizations may not hold true for other ethnic populations. (...truncated)