Publications
Popovich VI, Ryzhik VM,
Modern methods for the diagnosis and non–invasive treatment of acute maxillary rhinosinusitis.
National University of Medicine of Ivano–Frankovsk (NUMIF), Ukrainian Ministry of Public Health (200)
Ukrainian Ministry of Public Health
Ukrainian Centre for medical–scientific information, patents and licenses
«Approved»
Director, Department for the Promotion
of Medical Care
Ukrainian Ministry of Public Health
Modern methods for the diagnosis and non–invasive treatment of acute maxillary rhinosinusitis
Methodological recommendations
Kiev–2009
Institution:
National University of Medicine of Ivano–Frankovsk (NUMIF), affiliated to the Ukrainian Ministry of Public Health
Authors: Prof. V.I. Popovich, MD (0342) 528–086
Prof. V.M. Ryzhik, MD
F.M. Dudy, MD
V.M. Vanchenko, MD
I.V. Koshel
M.I. Derevyanko
R.M. Fischuk
Reviewed by:
Prof. A.S. Zhuravlev, MD
Prof. V.V. Kischuk, MD
President of the Ministry of Public Health’s Otorhinolaryngology Commission and Ukrainian Academy of Medical Science
Prof. D.I. Zabolotny, Member of the Ukrainian Academy of Medical Science
CONTENTS
List of abbreviations 2
Introduction 3
Etiology, pathogenesis, classification of ARS 5
Symptoms and diagnosis 6
Treatment 9
Conclusions 17
Recommended literature 19
LIST OF ABBREVIATIONS
Paranasal sinuses PNS
Rhinosinusitis RS
Maxillary rhinosinusitis MRS
Computerized tomography CT
Spiral computerized tomography SCT
Acute viral respiratory infection AVRI
Osteomeatal complex OMC
Chronic rhinosinusitis CRS
Acute rhinosinusitis ARS
International Classification of Diseases ICD
INTRODUCTION
In recent years, nasal and paranasal sinus diseases have increased considerably both in absolute terms and in relative terms within the category of ENT diseases. In the Ukraine, the number of patients with rhinitis, rhinosinusitis and rhinopharyngitis has grown to 489.9 cases per 100,000 inhabitants. In Russia, the prevalence of sinusitis per 1,000 inhabitants grew from 4.6 to 12.2 during the period 1981–1990.
A similar trend is also seen in other countries. К. Albegger (1982) reports that between 5 and 10% of the population suffers from sinusitis. In Germany, during a one–year period (2000–2001), sinusitis was diagnosed 6.3 million times. Of these, 2.3 million cases were chronic sinusitis. Similar data were recorded in the USA; in 1997, sinusitis affected 15% of the population.
If we examine the patient typologies hospitalized in ENT centers, the number of patients with inflammatory conditions of the nose and sinuses has been growing at an annual rate of 1.5–2%, attaining 52%. At the NUMIF’s ENT clinic, the proportion of patients with rhinosinusitis was 50–52% in 2004. Consequently, rhinology in general and rhinosurgery in particular have become the main areas of activity of the ENT hospital.
And within the category of rhinosinusitis, the maxillary sinuses are affected more commonly than other locations, accounting for 73% of the total.
As a general rule, treatment of acute maxillary rhinosinusitis (AMRS) does not require hospitalization and is performed as an outpatient treatment. Traditionally, treatment can only be effective when it acts on all of the links of the disease process. In these cases, an array of preparations are used to treat the etiology, pathogenesis and symptoms. However, most treatments only act on some of the links of the etiopathogenic process – and not always the main links – and, consequently, treatment success is often only partial.
The main reason for this situation is to be found in certain statements that are not totally true about the key links in the disease’s etiology and pathogenesis. Thus, the mistaken conviction that the bacterial flora is a primary factor in ARS leads to the unjustified prescription of a large quantity of antibiotics; this is the most common mistake. As a result, the number of antibiotic–resistant germs increases, requiring extending the duration of the recommended antibiotic therapy from 3–5 days to 2 weeks. Some authors recommend prolonging it to 14–16 weeks (even with the availability of very modern antibiotics). Prolonged antibiotic therapy accounts for up to 25–35% of all drug–induced side effects.
The mistaken idea that local decongestants can improve the mucosal edema in the openings and sinuses gives rise to exaggerated expectations concerning the effectiveness of treatment with these preparations. As a result, there has been an increase in drug–induced rhinitis, patients dependent on decongestants and effects on other organs and systems.
It is a fairly common belief among specialists that the invasive method or puncture is very effective in the treatment of sinusitis, particularly maxillary sinusitis. The studies performed have shown convincingly that non–invasive methods are used for the treatment of acute sinusitis (method of choice), enabling a clinical cure to be obtained and nasal cavity functions to be restored without damaging the maxillary sinus.
The use of 4, 5 and sometimes more preparations in order to act on all of the links of the etiopathogenesis of RS leads to polypragmasia, often accompanied by the development of side effects. This has a series of negative medical and pharmacoeconomic consequences, with adverse effects for compliance – a comprehensive concept that defines treatment convenience.
Thus, current treatment of ARS is based on empirical approaches aimed at influencing the main pathogenic links. Until recently, this approach was justified, as the traditional viewing methods could not guarantee the obtainment of accurate data about the function of the openings, while the pharmacological options available could not produce a complete local (not systemic) action on the nasal mucosa and the paranasal sinuses, including the openings.
In the Ukraine, methodological recommendations were drawn up for the first time concerning the specific therapy of acute rhinosinusitis, with initial monotherapy with Sinuforte, and its subsequent adjustment to take into account the remission of the symptoms and the improvement of the openings’ functional capacity as a main link in the etiopathogenesis.
The methodological recommendations are aimed at otorhinolaryngologists, GPs and family doctors, and doctors specialized in internal medicine.
ETIOLOGY, PATHOGENESIS, CLASSIFICATION OF RS
Nowadays, it is generally accepted that RS is an inflammatory condition. There is a definition which describes RS as an inflammation of the paranasal sinus mucosae. Johnson et al. have pointed out that as the nasal passage and paranasal sinus mucosae form a continuum, inflammation within the nasal cavity is usually associated with inflammation of the sinus mucosa. There is a broad agreement among researchers that the term "Rhinosinusitis" is more precise than "Sinusitis". This consensus is based on the fact that sinusitis normally does not develop without a previous rhinitis and there is virtually never an isolated involvement of the sinuses without rhinitis (except perhaps for odontogenic rhinitis), while the two main symptoms of sinusitis (difficulty in nasal breathing and nasal secretions) are associated with rhinitis (Lund VJ et al., 1995).
According to the ICD 10, the classification of RS is based on the location of the sinus involved and symptom duration.
The location of the inflammatory condition is defined by diagnostic imaging methods (X–ray, CT, MRI).
Symptom duration is defined as follows:
Acute RS: the condition has an acute onset with symptoms lasting less than 12 weeks and ending with a complete cure;
Recurrent RS: more than 1 but less than 4 acute RS events over a one–year period. The patient is fully cured between events and the symptom–free period is equal or greater than 8 weeks;
Chronic RS: symptom duration is more than 12 weeks with signs of inflammation visible in the X–rays for 4 or more weeks;
Acute exacerbation of chronic RS: worsening of existing symptoms or appearance of new symptoms, with complete disappearance of the non–chronic acute symptoms between events.
Acute RS is considered to be an inflammatory process during which paranasal sinus drainage and ventilation is impaired as a result of a bacterial or viral infection. It is currently considered that the mucosal edema and subsequent blockage of the osteomeatal complex and paranasal sinus ostia caused by the viral infection is the cause of the bacterial infection of the paranasal sinuses by local germs forming part of the saprophytic flora (conditionally pathogenic) which have acquired pathogenic features. This in turn leads to acute RS with a symptomatic inflammatory infiltration of the mucosae.
Most acute RS start from the nasal passages. One of the main causes is the inflammation–driven increase in edema (usually caused by a viral infection), which blocks the openings of the paranasal sinuses. This leads to reduced pneumatization and development of a negative pressure on them. The sinus gradually fills with transudate. The accumulation of the viscous secretion is accompanied by increased pressure within the sinuses, which in turn leads to pain. Disruption of the ciliary epithelium and the increased viscosity of the secretion significantly impairs the effectiveness of the mucociliary system and leads to mucostasis. With the increasing mucosal edema, paranasal sinus drainage is impaired and this, in addition to impeding mucus flow, also creates suitable conditions for a secondary bacterial infection, the development of a complex cascade of links that follow one after the other and closes the disease’s vicious circle. Thus, in virtually all cases of AVRI, the inflammatory process arises in the nose and paranasal sinuses, and RS is one of the typical manifestations of AVRI.
SYMPTOMS AND DIAGNOSIS
Acute maxillary rhinosinusitis can be defined as any inflammation of the nasal and sinus mucosa, leading to the appearance of clinical signs and symptoms .
The basic clinical symptoms of acute MRS are the following:
- blocked nose;
- nasal secretions;
- headache;
- pain or an oppressive feeling above the maxillary sinus;
- impaired sense of smell;
- bad breath (halitosis).
The clinical signs are:
- edema (probably hyperemia) of the nasal mucosa;
- secretions shown by anterior and/or posterior rhinoscopy.
The basic diagnostic methods are traditional ones such as rhinoscopy and X–rays of the paranasal sinuses in the Waters projection (sinuses darkened, liquid level, increased thickness of the mucosa) and modern methods such as endoscopy of the nasal cavity and computerized tomography.
Endoscopic study
The endoscopic study of the nasal cavity is normally carried out using a rigid endoscope, which has different angles of inclination of the optic axis. The standard examination basically consists of three stages. First, the endoscope is inserted in the lower nasal passage, paying attention to the type of mucosa in the inferior nasal turbinate and the nature of the secretions at the rear of the nasal cavity. Upon advancing into the nasopharynx, the dimensions of the posterior part of the inferior nasal turbinate are measured and the condition of the tonsils and openings of the auditory tube is assessed.
In the second stage of the examination, the endoscope is inserted into the middle nasal passage. The anterior part of the middle turbinate and the uncinate process are examined. Subsequently, when passing through these formations, the ethmoidal infundibulum and bulla are examined, that is, the lumen of the middle nasal passage or osteomeatal complex (OMC), which plays a key role in the physiology of the nasal cavity. The changes in the osteomeatal complex are key links in the pathogenic chain of the development of sinusitis. Examination of the middle nasal passage is complemented by observation of this area when the endoscope is withdrawn after examining the nasopharynx.
The third stage consists of inserting the endoscope into the upper nasal passage, identifying the superior turbinate and, if possible, the natural openings of the sphenoid sinus and the posterior cells of the ethmoid labyrinth. The sphenoid sinus, the upper nasal passage and the openings of the posterior cells of the ethmoid bone and the sinus together with the superior turbinate can be called the posterior osteomeatal complex. This area, together with the analogous area of the middle nasal passage, requires special attention.
Nasal endoscopy enables variations in the structure of the nasal cavity to be identified, particularly in the middle and rear part of the cavity, which are impossible to examine using conventional methods. With this method, it is possible to detect slight changes in the mucosa at an early stage, particular in the OMC. It is relatively easy to diagnose minor polyps or polypoid processes in the mucosa, which affect all the functions of the OMC, but are virtually inaccessible for diagnosis using classic rhinoscopic methods.
If necessary, endoscopy can be used not only to explore the nasal cavity but also all of the paranasal sinuses, with the exception of the ethmoid sinus. The endoscope is inserted in the sinus through an opening created by trochar. However, this method is rarely used since it requires surgical puncture. If additional information is required about the condition of the paranasal sinuses and the condition of the nasal cavity, it is now possible to use computerized tomography.
Computerized tomography of the facial cranium
Today, computerized tomography (CT) is the “gold standard” for radiological diagnosis of diseases of the nasal cavity and paranasal sinuses.
The goal of this study was to:
– Determine dissemination of the disease process in the sinuses;
– Determine the causes that lead to the occurrence or recurrence of sinusitis;
– Specify the individual features of the structure of the nasal cavity, osteomeatal complex and paranasal sinuses.
The CT’s resolution enables differentiation of tissues, perform their densitometry (determine the density in Hounsfield units) and measure the thickness of the mucosa in the nasal cavity with a high level of precision.
The combination of computerized tomography and endonasal surgery in recent years proved to be ideal and it has become a standard for the diagnosis and treatment of diseases affecting the paranasal sinuses.
Consequently, in modern medicine, endoscopy and computerized tomography should be considered methods to be used obligatorily in the examination of patients with RS. These methods complement each other and offer the possibility of accurately determining the features of the nasal and sinus disorder, variations in anatomic structure, the degree of mucosal hyperplasia and other parameters that enable an accurate clinical–radiological diagnosis to be obtained and a suitable treatment plan to be designed.
TREATMENT OF MAXILLARY RHINOSINUSITIS
130 patients with acute maxillary rhinosinusitis were included in our study. The diagnosis was based on a clinical–endoscopic and radiological examination. Patients with abnormal structures in the area of the osteomeatal complex and which could cause an anatomical obstruction of the openings were not included.
All of the patients were prescribed a comprehensive treatment which included drug–free methods (diet, drinking sufficient liquids, distraction therapy) and initial monotherapy with Sinuforte, a treatment for sinusitis based on a preparation obtained from European cyclamen. The rationale for using this preparation is based on the information concerning the product’s specific action on the upper airway mucous membranes. Briefly, its action on trigeminal nerve endings when administered intranasally facilitates discharge of the goblet cell secretions. Together with the preparation’s cholinergic action, this helps reduce edema and secretion, widen the nasal passages and openings, quickly and effectively clear the paranasal sinuses and restore the function of the mucociliary transport system. Following the preparation’s instructions, each patient self–administered a single daily dose of the product in each nostril.
Treatment efficacy was assessed on treatment days 3, 5, 7 and 10, analyzing the main clinical and endoscopic signs (Table 1). The quantitative evaluation of the treatment efficacy used a symptom scoring system. The symptoms’ severity was rated on the following scale: 0–1 point — no or mild symptoms, 2 points — moderate symptoms, 4 points — severe symptoms (1).
Table 1
Criteria for assessing treatment efficacy
| Subjective criteria | Objective criteria |
| Headache | Reactive phenomena |
| Sinus pain | in the nasal cavity |
| Blocked nose | in the middle nasal passage |
| Nasal secretions | Presence of secretions in the middle nasal passage |
Before starting treatment, all 130 patients had subjective and objective symptoms of AMRS, whose severity was scored with 2 or 4 points.
In order to refine the diagnosis and adjust the treatment, all of the patients underwent a computerized tomography (CT) scan of the nose and paranasal sinuses on the 3rd treatment day using the "Еmotion" (Siemens) spiral computerized tomograph with the «Sinus–Spi» program, in accordance with the recommendations of the «ACR Appropriateness Criteria™». During analysis of the CT and reconstructed images, changes in and densitometry parameters of the nasal cavity, sinus and osteomeatal complex mucosae were determined.
After determining the evolution of the ARS after three days of treatment, the patients were distributed to one of three groups. In the first group, the initial schedule was continued as a monotherapy; in the second group, the treatment was supplemented with systemic decongestants; and, in the third group, the schedule was supplemented with systemic decongestants, antibiotics and, if necessary, catheterization of the maxillary sinuses.
73 patients (56.1%) were included in the first group. These patients showed a significant remission of the subjective and objective symptoms compared with the baseline situation.
Only insignificant reactive phenomena were recorded, with the presence of secretion in the middle nasal passage and, consequently, in the nose. The study of these patients’ spiral computerized tomograms showed the presence of all the symptoms of sinusitis. However, the opening’s function was maintained (Fig. 1).
Fig. 1. Spiral computerized tomograms of patients with ARS and functioning opening (shown with the arrow)
The patients in this group continued monotherapy with Sinuforte until completion of the 7–day period. On the 7th day, the clinical and endoscopic evaluation did not show any symptoms of ARS and it was considered that the treatment outcome was a cure.
The second group consisted of 27 patients (20.7%). The clinical evaluation of the patients in this group showed a substantial effect on the symptoms, with virtually complete disappearance of the headache, blocked nose and secretions (Table 2). However, local sinusitis symptoms were still fairly obvious: pain in the sinus area and reactive phenomena with the presence of secretion in the middle nasal passage. The study of the computerized spiral tomography images obtained from these patients showed a partial blockage of the openings (Fig. 2). The detailed study of the structure of the osteomeatal complex did not show any anatomical causes for this blockage and all the changes were ascribed to reactive phenomena and mucosal edema in the opening. In the light of the findings, the Sinuforte therapy was supplemented with systemic decongestants. By the 7th treatment day, all of the subjective and objective symptoms had virtually disappeared and a complete cure was achieved by day 10.
Fig. 2. SCT scan of a patient with acute RS and partial blockage of the opening
(showed with the arrow)
The third group consisted of 30 patients (23%). During the analysis of the clinical course, improvements were observed in the patients’ condition. A substantial improvement was observed in symptoms such as blocked nose and pathological nasal secretion (Table 2). However, the headache and the pain in the sinus area were still substantial. During the endoscopic study of the objective symptoms, a decrease in the reactive phenomena in the nasal cavity was observed with little secretion in the middle nasal passage, which, however, showed fairly substantial reactive phenomena. These patients’ SCT scans showed total blockage of the opening with radiological signs of the underlying sinusitis (Fig. 3). The detailed study of the structure of the osteomeatal complex did not show any anatomical cause for this blockage and, therefore, it was ascribed to inflammatory changes in the mucosa. In the light of this situation, the Sinuforte therapy was supplemented with systemic decongestants and antibiotics.
Fig. 3. SCT scan of a patient with acute RS and complete blockage of the opening
(shown with the arrow)
Following the recommendations, the efficacy of the complete treatment prescribed for the patients in the third group was assessed once again after 2 days. Most of the patients (16 of 30, 12.2%) showed a positive evolution. The severity of the headache and the pain in the sinus area decreased considerably. However, the quantity of secretion both in the nasal cavity and in the middle nasal passage increased substantially. In our opinion, these symptoms were a sign of restored function of the opening. By the 7th treatment day, these symptoms were considerably less severe and a clinical cure was obtained by day 10 or 11.
In 14 of the 30 patients (10.7%), the supplementary prescription of decongestants and antibiotics did not improve the clinical and endoscopic picture. All of the data indicated that the opening remained blocked. Consequently, the sinus was catheterized through the natural opening in order to restore function and clear the sinus.
The sinus was catheterized once under endoscopic control and rinsed with saline solution through the natural opening (Fig. 4).
Fig. 4. Endoscopic view of the nasal cavity during catheterization and rinsing of the sinus through the natural opening
- Catheter
- Middle turbinate
- Edema of the mucosa of the middle nasal passage
During rinsing of the sinus, a small quantity of pus and mucus was removed. A few hours later, the quantity of secretion in the middle nasal passage and nasal cavity suddenly increased. We believe that this is evidence of restoration of the opening’s functional capacity and mucociliary transport in the sinus. The active exudation continued for several days and then sharply dropped. By days 10–12, the clinical and endoscopic symptoms had virtually disappeared and the patients were considered cured.
As can be seen from the above data, evaluation of the treatment efficiency by stages and adjustment of the treatment in accordance with the speed of remission of the symptoms and restoration of the opening’s functional capacity as key etiopathogenic factor have been shown to be highly effective.
Prescription of Sinuforte, with its trophic action on the upper airway mucosa, as initial therapy was associated with a substantial remission of the subjective symptoms and a clear symptom improvement by the 3rd day of treatment in almost all patients. Among the patients with a functioning opening, a positive evolution was seen both in the symptoms of rhinitis (blocked nose, nasal secretions, reactive phenomena in the nose) and in the symptoms of sinusitis (headache, pain in the sinus area, reactive phenomena and secretion in the middle nasal passage). Continuation of the monotherapy with cyclamen in these patients led to a complete cure by the 7th day.
Among the patients with partial or total blockage of the opening, a clear positive evolution was seen in the symptoms of rhinitis by the 3rd day of treatment with Sinuforte: the blocked nose, the quantity of secretion and the reactive phenomena in the nasal cavity decreased considerably. However, among the patients in these groups, it was common for reactive phenomena to persist in the middle nasal passage, although to a lesser degree than before starting treatment. This indicated that the sinusitis had not been eradicated, with persistence of the pain in the sinus area being a common symptom in the patients in these groups.
If the above symptoms are present, the basic symptoms that enable the differential diagnosis to be performed are the absence of headache and the presence of secretion in the middle nasal passage among the patients with partial blockage of the opening, and headache without secretion in the middle nasal passage in the case of total blockage. These symptoms fully match the data obtained in the SCT scan.
Prescription of systemic decongestants as a supplement to monotherapy with Sinuforte enabled a cure to be achieved by the 7th or 8th day in virtually all of the patients with a partially blocked opening.
In our opinion, the total blockage of the opening among the patients in group 3 was caused by severe inflammation of the mucosa as no abnormalities in the structure of the osteomeatal complex that could cause such a blockage were detected. That is why Sinuforte therapy was supplemented with a systemic antibiotic therapy and decongestants. In most of the patients in this group (16 out of 30, i.e., 12.2%), these measures enabled symptom improvement and cure by the 10th day of treatment. However, in 14 of the 30 patients, i.e., 10.7%, with insufficient symptom improvement by the 5th day of treatment, minor invasive treatments were given (drainage through the middle nasal passage). Restoration of sinus patency and aeration a few hours later led to a considerable improvement in secretion discharge and active physiological clearing of the sinus, enhanced by the effects of Sinuforte’s action. By the 10th or 11th day, these patients showed minimal reactive phenomena in the middle nasal passage and the treatment effect was rated as a cure.
CONCLUSION
By way of conclusion, it can be said that prescription of Sinuforte, a preparation with trophic effects on the upper airway mucosa, even when administered as monotherapy, as initial treatment of the ARS contributes to rapid symptom improvement. The detailed analysis of the evolution of the clinical signs directly related with the opening’s function and which exactly match the CT data, enables an individualized approach to be made to the treatment, based on the individual features of the clinical course of the sinusitis. This approach has the following advantages:
• the treatment initially starts with a product known to have a trophic effect on upper airway mucosa;
• the treatment is subsequently adjusted on the basis of the function of the sinus opening, as this is one of the basic etiopathogenic factors of rhinosinusitis;
• the use of smaller numbers of preparations enables polypragmasia, with all its negative consequences, to be avoided;
• the acceptable tolerability and the early onset of the clinical effect contribute to a rapid improvement of the patient’s quality of life and assures a high treatment efficacy;
• in the case of patients with ARS, the initial treatment and evaluation of its effectiveness by clinical stages can also be carried out by general practitioners and primary care physicians.
Thus, treatment of the acute forms of rhinosinusitis with initial monotherapy with European cyclamen has been shown to be highly effective. The product’s action on nasal cavity and sinus mucosa contributes to a rapid remission of the symptoms and an improvement of the patients’ condition by the third day of treatment. This treatment guarantees restoration of the opening’s function in more than half (56%) of the patients, enabling a clinical cure to be obtained with the use of Sinuforte monotherapy alone.
The evaluation by stages of the remission of the clinical symptoms and the treatment’s effectiveness among patients with insufficient improvement brought to light a partial obstruction of the sinuses in 20.7% of the patients. If reactive phenomena are seen in the mucosa, the local monotherapy with Sinuforte should be supplemented with systemic decongestants. Antibiotics can only be recommended for the 23.2% of patients with total blockage of the sinus opening.
The approaches proposed using conservative therapy have provided a cure rate of 89.3%. Insufficient efficacy of the conservative treatment in 10.7% of the patients was associated with long–term blockage of the opening. The use of minor invasive procedures such as catheterizing the sinus through the natural opening contributed to eliminating this blockage, with rapid restoration of the mucociliary transport system within a few hours. Supplementing the conservative treatment with this minor invasive procedure also enabled these patients to be cured.
The proposed treatment approach consisting of initial monotherapy with Sinufоrte and subsequent adjustment depending on efficacy, which determines the functional capacity of the sinus openings, guarantees a high therapeutic efficacy and convenience in use, avoids polypragmasia and unjustified antibiotic therapy. It can be implemented successfully not only by otorhinolaryngologists but also by the primary care physicians who are the first professionals contacted by these patients.
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17th November 2011
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