EVALUATION OF CHRONIC
RHINOSINUSITIS
• Chronic rhinosinusitis (CRS) is a common disease that affects>10% of
adult population . It has been delineated phenotypically into CRS
without nasal polyps and CRS with nasal polyps. Both have a high
disease burden and an overlapping spectrum of symptoms such as
nasal obstruction, olfactory dysfunction, facial pain, pressure, and
nasal discharge. Primary assessment includes evaluation of patient
symptoms and impact on quality of life, nasal endoscopic
examination, and imaging.
• Rhinosinusitis can be defined as acute or chronic based on duration of
symptoms: acute being less than 12 weeks duration and chronic being
greater.
• The European position paper on rhinosinusitis and nasal polyps
(EPOS) has now defined rhinosinusitis as a diagnosis made on clinical
grounds based on the presence of characteristic symptoms, combined
with objective evidence of mucosal inflammation (Table 94.1).
• Once a diagnosis of CRS has been made, assessment should consider
whether this is primary CRS (that is chronic inflammation originating
in and limited to the paranasal sinuses) or secondary CRS, occurring
as part of multisystem disease (eg, as a manifestation of autoimmune
diseases or immunodeficiency
• Clinical history is focused on the duration, frequency, and severity of
sinonasal symptoms and their impact on quality of life (QOL) and
ability to perform normal daily activities.
• Evaluation of a patient’s history should consider comorbid conditions
such as allergic rhinitis and lower respiratory disease such as asthma
and bronchiectasis, and the control of disease, as this is important in
guiding therapy.4 Nonsteroidal anti-inflammatory drug (NSAID)induced congestion or wheeze should also be determined.
• NASAL OBSTRUCTION *Duration* ..acute or chronic rhinitis
• LATERALITY* Ask the patient Whether the nasal obstruction is unilateral or
bilateral or changes side?
• Unilateral due to mass,polyp,DNS
• Bilateral due to conditions like nasal allergy, septal haematoma or
ethmoidal polyposis.
• *LATENCY* It should be asked whether the symptom is constant or
intermittent.. Constant due to some mass
• Intermittent due to some allergy
• SEVERITY..prevent routine work, progressive in case of polyps or
malignancy
• NASAL discharge;
• Nature of discharge
• Allergic has thin Copious
• Bacterial has thick scanty mucopurulent discharge from the middle
meatus or oedema,
• The hallmark of AFRS is the presence of allergic mucin. Grossly, it is
thick, tenacious and highly viscous in consistency.18 Hence, the terms
‘peanut butter’ and ‘axle-grease’ are often used to describe the
characteristic appearance of the mucus.
• Inspection
• ANTERIOR RHINOSCOPY
• Structures to be seen in A/R • Nasal vestibule • Nasal septum •
Colour of the mucosa • Lateral nasal wall • Inferior turbinate • Middle
turbinate • Inferior meatus • Middle meatus • Nasal floor • Nasal
roof (usually not seen). F
• Colour of nasal mucosa Pink—Normal Bright red—Infection Bluish, wetty—Nasal allergy
• • Lateral wall
•
Inferior turbinate: It may get hypertrophied in nasal and sinus infections. It may get enlarged, wetty and bluish in allergic nasal
conditions.
• • Inferior meatus: This is not easily visible unless vasoconstrictor spray is used. . Naso-lacrimal duct opens into it.
•
• Middle turbinate: This is the second largest turbinate in the nose and one has to extend the neck of the patient to have a better
view of the turbinate.
•
• Middle meatus: It lies below middle turbinate. All anterior group of sinuses, i.e. Frontal, maxillary, anterior and middle
ethmoidal open into the middle meatus and hence is the common site where from pus may be seen trickling down. Look for polyp
in this area.
• • Superior turbinate: This is usually not seen in A/R examination. One should not attempt to see superior turbinate except when
patient is under general anaesthesia.
• • Nasal floor: It should be looked for secretions, FB, antrochoanal polyp or malignancy.
•
• Nasal roof: Examination of nasal roof is painful and hence should be done under GA if needed. Abnormalities that are commonly
encountered in anterior rhinoscopy are nasal secretions, nasal mass, foreign body, hypertrophy or atrophy of turbinates.
• SINUS TENDERNESS Tenderness over sinuses may be elicited as
follows: 1. Maxillary sinus: firm pressure is given over canine fossa. 2.
Ethmoid sinus: pressure given medial to medial canthus. 3. Frontal
sinus: pressure given at the roof of orbit, above medial canthus, in the
floor of frontal sinus. 4. Sphenoid sinus: tenderness cannot be
elicited. Sinus tenderness indicates infective pathology in affected
sinus.
• Nasal endoscopy is invaluable in the assessment of CRS and can
informdiagnosisaswellasresponsetotherapy.Itisasimpleandwelltolerated
part of the examination; local decongestion and anesthesia can be helpful
but is often not required depending on the patient.10 Endoscopic
evaluation of the nasal cavity provides important information on the status
of the nasal mucosa (ie, edema or crusting), nasal discharge, anatomical
abnormalities (eg, septal deviation, turbinate hypertrophy), evidence of
visible obstruction of the nasal airway or ostiomeatal complex, evidence of
previous surgery or adhesions in addition to allowing differentiation of the
major phenotypical subgroups, based on the presence or absence of nasal
polyps, which is often used to help inform treatment decisions in lieu of
more detailed endotyping
• Endoscopy scoring. Endoscopy is particularly attractive for repeated
assessments over time. There are a number of endoscopic scoring
systems that have been described and used in CRS. The most
common is the Lund-Kennedy Endoscopy Scale, which rates each
sinus for edema, discharge, nasal polyps, crusting, and scarring to
arrive at total score from 0 to 20
• Imaging is an important tool in CRS, used to confirm the diagnosis when
endoscopy is equivocal, assess the severity or extent of disease, and guide
treatment decisions. CT is the gold standard investigation for CRSwNP,
usually without contrast..
• Description of disease burden on CT-based assessment is one objective
method to assess disease severity. This typically includes a quantification of
the opacification of individual sinuses and an overall total score. The LMS is
the most commonly used of these systems due to its simplicity and
reproducibility, and it assigns a “0” for no involvement, “1” for some
opacification, and “2” for complete opacification of each of the 5 sinus
groups on either side, with an additional score for the ostiomeatal complex
as unobstructed “0” or obstructed “2” (giving a total range 0-24