Breathe Easy: Innovations and Expert Perspectives on the Management of Chronic Rhinosinusitis Without Nasal Polyps

Monday, November 4^th, 2024

Breathe Easy: Innovations and Expert Perspectives on the Management of Chronic Rhinosinusitis Without Nasal Polyps

Anatomy and Physiology of the Sinuses

[00:08:37]

Anatomy

All right, so first thing we'll do will be just a brief review of the anatomy and physiology of the sinuses. So, this is a CT scan in a coronal plane bone window, fairly anterior and going through the frontal sinuses, as you can see here superiorly. And then you've got the nasal septum, which is the divider between left and right. And then we can also see our inferior turbinates. When we're looking at sinuses on a CT scan, we're not necessarily looking at size and symmetry, although that, you know, sometimes is relevant. We're more looking at what does the interior of the sinus look like. And on a CT scan, it should be filled with air, which, as I'm sure most of you know, is black, on a CT scan. If it was filled with gray, you know, that would indicate some potential abnormality, mucosal thickening, obstruction, you know, infection, things of that nature.

And a little bit further back, this is now at the level of the ethmoid sinuses that you can see here, in between the eyes, you get the left and right orbit in the brain. The septum here, which you can see, has a little bit of a deviation or a spur. You can see the middle turbinates as well as the inferior turbinates. And then we've got our maxillary sinus here. And this osteomeatal complex, which is essentially a region where if there is obstruction, that can set patients up for sinusitis. It's where, you know, the maxillary sinus, the anterior ethmoid, and the frontal sinus, that is a region where all those sinuses drain into. And so that's what the – if you hear that terminology, that's what we're referencing.

Within the ethmoid sinus, you can see there are several partitions, septations, which essentially result in somewhat of a labyrinth. And, you know, each of these little partitions can be obstructed alone or altogether, depending on disease severity. And then further back in the sphenoid sinus, or at the level of the sphenoid sinus, you can see the sphenoid sinus on either side, here, Again, we don't necessarily worry about size or symmetry, but these sphenoid sinuses look very normal as they're nicely aerated. And then you can see some surrounding anatomy. The optic nerve here, as well as the carotid artery, which sits in the cavernous sinus, which sits on either side of the sphenoid sinus.

[00:11:35]

Physiology

Physiology, the normal nose produces anywhere from 600-1800 mL of mucus daily. That mucus is propelled by mucociliary movement, which is a very coordinated movement out the natural ostium, which is very important when we're doing sinus surgery. Historically, individuals just thought that this was a plumbing problem, and you just needed to make a hole in the sinus. It didn't really matter how big or where. Now, we know that it's critically important to incorporate the natural ostium with a surgical opening to ensure that we don't have things such as mucostasis or recirculation. So, certainly, note not all sinus surgery is the same. And certainly, we want to do sinus surgery that's functional. And so, it's important to understand this physiology.

While a lot of this mucus is used to humidify air that goes through the nose into the lungs, a lot of this also just goes down the back of our throat. And when everything is working normally, we don't really notice this happening.

Acute Sinusitis

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Acute Sinusitis

So we'll dive right into acute sinusitis, certainly something that we see frequently in both pediatric and adult population. You know, our guidelines are very similar, so we can essentially, you know, talk about both together throughout this talk.

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Viral URI

We'll go ahead and begin with discussing viral upper respiratory infection, or an acute viral rhinosinusitis would be the other terminology. Classic symptoms involve nasal congestion, rhinorrhea, which is a medical term for runny nose. It certainly could be clear, but purulent rhinorrhea is also possible with a viral process. It's not the bacteria that makes rhinorrhea purulent. It's the neutrophils and the acute inflammatory process which results in discolored rhinorrhea, and then also just the metabolism of the neutrophils that can result in the various colors. Sore throat is common, cough, low grade fever. And children, they can be fussy, maybe adults too, poor sleep. And then, as many of you know, symptoms typically peak within the first few days and then improve over time.

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Viral URI – Education

A little bit on the expected frequency. You know, anybody who has kids probably experienced this. You know, it's not unusual for kids to have 5 to 6 viral upper respiratory infections per year. Certainly could be, you know, more or less. If you send your kids to daycare, you know, it's a kind of a breeding ground for viruses, so that your kids might experience more than the 5 to 6. On the adult side, it tends to be 1 to 2. But if you have kids bringing home – bringing home viruses like I do, it certainly can feel like a lot more.

In terms of the typical symptoms and course, you can see here symptom prevalence. On this graph you have symptom prevalence on the Y-axis and days of illness. You can see, as mentioned before, symptoms tend to peak Day 2 through 4. You've got nasal discharge, which is certainly the most prevalent. You've got cough, fever, not necessarily super prevalent, headache, nasal obstruction or congestion. You can see that some of these symptoms can persist for quite some time beyond 2 weeks. And so, what we'll get into here, is subsequent slides. What's a viral sinusitis versus a bacterial sinusitis? Again, discolored drainage. While the layperson might think that that is what indicates viral versus bacterial, that's not really how we define it medically. And even if symptoms persist for beyond the ten-day time frame, it can still be a viral upper respiratory infection.

[00:16:17]

Acute Bacterial Sinusitis vs Viral Upper Respiratory Infection

So differentiating between the two, there's essentially 3 ways that we make the diagnosis of acute bacterial sinusitis. And this is a clinical diagnosis. It's – and it's based on essentially symptoms alone. And this is not necessarily 100%, you know, for every single patient that comes in through the door. You know, this is not always 100%. The way that we define it is not 100%, but it's essentially just extrapolation based off of studies that have been performed of, you know, sinus cultures throughout the time course of an upper respiratory infection, and when those cultures tend to transition to being turning positive as well as, you know, best available evidence for, you know, time frames where if there's no improvement, antibiotics are indicated.

So these are just guidelines. It's not, you know, written in stone that you have to necessarily follow these, but this is just kind of best practice for the overwhelming majority of scenarios.

So persistent illness. So, you know, the patients who have greater than ten days of symptoms without any improvement. So, not unlike the graph that I just showed you, where there's tens of improvement. If patients continue to have persistent symptoms beyond the 10-day time frame, you can feel pretty confident that that patient is no longer dealing with a viral upper risk for infection, and that it has transitioned into a bacterial rhinosinusitis

Worsening course, or what's called double worsening, where symptoms initially get better and then they get worse again. That's a good indication that a process was originally viral in origin and then transitioned to bacterial.

[00:18:25]

Diagnosis of ABS

And then severe onset would be the other way that we would diagnose an acute bacterial rhinosinusitis. How is that defined? High fever for several days. And this is more relevant for the pediatric population, where they can't speak up for themselves in terms of how they're feeling. And so, we have a slightly lower threshold to start antibiotics a little bit earlier in the pediatric population, when there is this severe onset scenario.

Interesting, as maybe you all are aware, but it is somewhat interesting. The diagnosis of acute bacterial rhinosinusitis per our guidelines, does not include any physical exam findings. As I mentioned previously, you know, nasal edema as well as mucopurulence can be seen in a viral process. And anterior rhinoscopy, which is what most, you know, physicians, providers dealing with an acute upper respiratory infection or acute rhinosinusitis, what they're going to be limited to, is also somewhat limited in terms of what the information can give you to differentiate a viral versus a bacterial process.

The diagnosis also does not include any sort of imaging, plain x-rays really, I would say don't have a role with this or really any disease process of the perinasal sinuses. CT scan of the sinuses, also not indicated. It's not specific and so, nor is it necessarily, yeah, just not – not specific, and it's just not necessary from the perspective of radiating patient. You can diagnose this clinically.

[00:20:21]

Possible Courses

So we made a diagnosis, what are the potential – and it's either resolved on its own, or we've treated it. What are the possible courses? For certain patients, they can – and majority of patients, they return back to baseline or normal, and that's the ideal scenario. But for other patients, they end up going back to baseline but then have a recurrence. And so, we think about the diagnosis of recurrent acute rhinosinusitis.

Recurrent Acute Bacterial Sinusitis

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Recurrent Acute Bacterial Sinusitis

We'll talk about that real quick. And what we're talking about is recurrent acute bacterial rhinosinusitis, not recurrent viral infections.

So, diagnostic criteria is that for each episode we need to meet the criteria for an acute bacterial rhinosinusitis. You know, an acute sinusitis should be of less than 30 days of duration, and there should be greater than ten days of symptom free, greater than ten days without symptoms in between the episodes. And to meet the criteria of recurrent acute, you need four more episodes per year treatment.

Treatment, you know, you treat each episode the same as you would with just a standalone acute bacterial rhinosinusitis. And in these individuals, you know, while this can be unrelated to an allergy – an allergy issue, or an immune system issue, or some sort of anatomic issue, those are things that you should think about as potential contributing factors to why a patient may be dealing – with an adult patient may be dealing with a high frequency of recurring bacterial infections.

And so then the – and in this situation, you know, if you feel like, you know, one of these issues is a consideration, you can refer to either an allergist, immunologist or an ear, nose and throat doctor for additional assessment.

And so possible courses, the kind of third scenario is that you get this acute infection, and it just never goes away. And so there's subacute rhinosinusitis, which is that 30 to the, sorry, 4‑week to 12-week time frame or kind of the 30 to 90 day time frame, where you know, some of those patients might end up resolving, or some of those patients might end up transitioning to the chronic sinusitis picture which is greater than 12 weeks or you know, give or take 90 days of persistent symptoms.

Chronic Rhinosinusitis (Chronic Sinusitis)

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CRS Diagnosis

So, we'll get into chronic rhinosinusitis. So again, as mentioned, greater than 12-week duration, continuous symptoms. You must have two of the following four cardinal symptoms, nasal obstruction or congestion as well as thick discolored drainage. That's critical. That, the drainage piece is very critical and specifically the fact that it being thicker or discolored because patients can have facial pain and pressure for a variety of reasons. And so, we want to see that coincide with discolored or thick drainage.

And then you do need – to diagnose chronic rhinosinusitis, unlike acute bacterial rhinosinusitis, you need an objective sign of inflammation. So, that's either edema or purulence, polyps or in either of those seen on anterior rhinoscopy or nasal endoscopy, if you have that tool in the office, or some sort of radiographic changes. So, but symptoms of greater than 4 weeks, plus an objective finding of inflammation. The reason that we add this subjective component is that symptoms alone, while that can be very sensitive, it can lack specificity. So you know, is it just, you know, without inflammation, could this person be having for instance some sort of primary headache condition as well as, you know, allergies or you know, some sort of combination of, of comorbidities.

CRS Epidemiology

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CRS Epidemiology: US CDC Report From 2018

So CRS, epidemiology. So US CDC report from 2018, number of adults diagnosed with sinusitis, not necessarily chronic sinusitis, 28.9 million. Percentage of adults diagnosed with sinusitis is 11.6%. This was a patient report of a physician diagnosis. So, not the – maybe not the best reporting. But certainly, you can see that sinusitis is a big component of our healthcare system. And I think anybody who is actively treating patients, either in the primary care world, allergy world or ENT world, certainly seeing a lot of patients with sinusitis.

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CRS Epidemiology: US

A little bit more about US epidemiology. You can see here in this first column, number of visits in thousands for chronic sinusitis. In the US, there were almost 12 million visits in 2009. And you can see how this stacks up with some of the other diagnoses. And so you can see it's, you know, on par with ischemic heart disease, psychoses. Not too far off from other, you know, heart disease that are nonischemic in nature, benign neoplasms. So certainly, a high prevalence and equating to about 1% of all visits in the office visits in the United States. So, very common.

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A little bit more on epidemiology. You can see that it affects various races and ethnicities, some with a higher, you know, prevalence than others.

CRS Impacts

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Burden of Disease

So, CRS impacts. So, what's the burden of disease? This is, I think, you know, certainly, I think very relevant to my practice. But you know, for a lot of people, they might be, they might say, what's the big deal about little chronic sinusitis? You know, this isn't heart failure, this isn't COPD, this isn't diabetes, this isn't kidney failure. You know, real medical conditions, you know, nothing that's, that's life threatening. And well, I think, you know, to some, you know, laypeople or even providers that might be the way that they feel to the patients, it's a bit different.

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Utility Values

And so, there's this concept of health utility, and it's a score of 0 to 1.0. Zero being death, perfect health being 1.0. US norm being right around 0.8. These utility values are actually used to derive quality adjusted life year analyses to ultimately determine cost effectiveness of treatments. And that's how we ultimate, you know, get certain treatments approved. In today's world, it's not as simple as asking for a number. There is this time trade off that goes into it, and it allows us to comparison – to compare across various disease states.

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Utility Values in CRS

And so, here you can see various disease states, health utility scores, on the far left of the X-axis. You can see death at zero. And on the far right, you can see perfect health, which would be 1.0 US norm, as mentioned, would be 0.81. And then you can see various disease states and the patient reported utility – health utility values. You can see the patients with chronic rhinosinusitis have a health utility value of 0.65. And that's not too far off from moderate asthma or Parkinson's Disease. It's actually a little bit lower than coronary artery disease, requiring a percutaneous intervention, CHF, COPD, hypertension, hearing loss, not too far off from end-stage renal disease with – requiring hemodialysis. And so again, this disease state really affects patients' quality of life. And so much so that it certainly, you know, is very relevant to the person who is experiencing it. I think any of us who have had a sinus infection, you know, we feel pretty miserable for a week, maybe a little bit longer, maybe a little bit less, you know, but it goes away. Patients with chronic sinusitis just imagine feeling like that all the time.

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Burden of Disease

And so, you know, in terms of getting a little bit more into the burden of disease, while we historically focused on the cardinal rhinologic symptoms, we do also know that there are several extra rhinologic symptoms, not necessarily part of the diagnosis, but certainly affects the patient's individual – individual patient's quality of life.

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Sleep Quality and Disease Severity of Patients With Chronic Rhinosinusitis

Some of those extra monologic symptoms would be sleep quality. So PSQI scores, which is the Pittsburgh Sleep Quality Index, you can see that, you know, a higher number indicates, you know, poor sleep. And so, it's not too far off from patients who have obstructive sleep apnea or even narcolepsy. And so, and certainly higher than just kind of general communities. So, sleep quality tends to be effective.

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Fatigue Severity Scale

That kind of coincides with fatigue.

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Simple Reaction Time

And subsequently, reaction time.

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Productivity Costs in Patients With Refractory Chronic Rhinosinusitis

And so, all of these things play into this concept of productivity loss. So there's absenteeism as well as presenteeism. So, absenteeism is needing to take time off from work. And so, you can see, on average, patients take 18 full workdays. Patients with chronic sinusitis take 18 full workdays from work. Plus there's missed worked work hours totaling up to, you know, 6.5 days on average, you know, for office visits, things like that. And then you have presenteeism, which is where you're – you're at work, but, you know, you don't have the same level of focus or performance. I think anybody who's gone to work a little bit, feeling a little bit under the weather, can, can relate to that. And then there's household absenteeism as well. So, you know, you're talking about 24 days of annual absenteeism and 38 days of annual presenteeism for the average patient with chronic rhinosinusitis. I mean, that's a – that's a big deal.

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Productivity Costs of Patients With Refractory Chronic Rhinosinusitis

And so, you know, we have – you know, there are ways to then kind of translate this into, you know, the lost productivity in terms of dollars. And for chronic rhinosinusitis, we've got about $12.8 billion in productivity costs, and that's not too far off, or that's a little bit higher than individuals with chronic migraine, a little bit less or moderate amount less than patients with severe asthma. And then diabetes certainly takes the majority of the productivity loss in the U.S. And so, and these are the four common chronic diseases after taking disease prevalence into account.

So these are essentially indirect costs to the system. Direct costs like office visits and surgery, things like medication is another. I think last time data were available, maybe 8 years ago, another 8 or 10 billion. So this is $20 billion every year for, for the US.

Classification of CRS

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CRS Diagnosis

So, a little bit more about classification. Again, this is the diagnostic criteria.

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CRS With Nasal Polyps

There's patients, there's kind of 2 general classifications for chronic rhinosinusitis. You know, chronic rhinosinusitis is really a kind of a wastebasket term, just means chronic inflammation of the sinuses. And crudely we've kind of lumped patients into two separate categories. But you know, we're starting to get into phenotypes and endotypes similar to, you know, the asthma world. And so, but one of the kind of broad groups would be patients who have chronic sinusitis with nasal polyps. That's a type 2 skewed inflammatory profile. They've got more of an eosinophilic inflammation, certainly a higher association of asthma and atopy. And there are patients who have, you know, that have AERD as a part of this. So, aspirin exacerbated respiratory disease as well as AFRS or allergic fungal rhinosinusitis. And certain patients with cystic fibrosis. Nasal obstruction and loss of smell are very, very prevalent in these patients. Chronic inflammatory, and this is more unlike maybe chronic sinusitis without nasal polyps, this is more of a chronic inflammatory condition with not a lot of – an infectious component compared to the nonpolyp version.

And then last thing to mention is that this is actually much less common than chronic rhinosinusitis without nasal polyps. It is about maybe 10% of patients who have chronic rhinosinusitis.

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CRS Without Nasal Polyps

And so, chronic rhinosinusitis with nasal polyps, it's kind of a mixed type 1 through 3 inflammatory profile. This does include some unique forms of chronic rhinos sinusitis, including patients who just have a fungal ball or silent sinus syndrome, which is where the maxillary sinus gets kind of involutes on itself or kind of creates like a vacuum, becomes atelectatic. Mucoceles, which is where a sinus cavity just obstructs for whatever reason, and usually in the setting of trauma or prior surgery, but sometimes there's no prior history, as well as odontogenic sinusitis. But there are other, you know, phenotypes of chronic rhinos without nasal polyps. Those are just 4 kind of well-defined phenotypes.

Pressure and fullness as well as discharge tend to be the most common symptoms, as I alluded to at the beginning of the talk with pretest questions. And then chronic inflammatory condition with perhaps more of a frequent bacterial contribution. So, unlike the patients who have polyps, recurring infections or kind of. This chronic infectious type profile is certainly more common in the chronic rhinosinusitis without nasal polyp classification. And then certainly this is much more common. This is 90% of patients with chronic rhinosinusitis.

CRSsNP Medical Treatment

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International Forum of Allergy and Rhinology: International Consensus Statement on Allergy and Rhinosinusitis 2021

So medical treatment, we'll get into that. So in 2021, there was this international consensus statement on allergy and rhinology. It was published by the International Forum of Allergy and Rhinology, and it kind of did an overview of medical treatments and kind of aggregated the evidence. Saline irrigations evidence is B. Their policy level was for recommendation for initiation, given that there is good evidence that there's benefit with minimal harm and minimal cost. And so, a lot of patients who have chronic rhinosinusitis either already irrigate on their own, or have been told to irrigate. And that's certainly a reasonable recommendation based on the evidence.

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ICAR: Rhinosinusitis 2021: Oral Antibiotics Less Than 3 Wk

We have available oral antibiotics less than 3 weeks. There's actually poor evidence for nonmacrolide oral antibiotics. And so the policy level was that can't make a recommendation. Obviously, if there is – you know, if there is an infectious component or, you know, symptoms consistent with an infectious component, then I would say it's very common for patients to have been treated with a course of antibiotics. And so, it's not that you should not use antibiotics, short courses of antibiotics, but it's just that there's actually not a lot of evidence for it, oddly enough. And – but I guess the one thing to take away from this is that, you know, really prolonged courses of antibiotics or like, you know, numerous repeated courses of antibiotics, you know, might be worthwhile thinking about, you know, what are the other treatment options? Does this patient, you know, need to be referred for, you know, surgery, or is there something else going on that we're missing, like a tumor or something like that?

The ICAR guidelines did differentiate. This is actually kind of did differentiate the two time Frames less than three weeks versus greater than three weeks. I kind of already explained this that really antibiotics beyond three time frame there's poor evidence and generally speaking or not recommended, you know, with maybe the exception of, you know, a very unique circumstance or patient.

They did also look at extended macrolide courses. So, this is a little bit more common in the in Europe as opposed to the United States. But you know, some people will use low dose macrolides for patients with chronic rhinosinusitis without nasal polyps, and it's getting more at the – or the use of the macrolide is less for its antibiotic properties, and more so for its intrinsic anti-inflammatory properties. And so this is something that you might come across or hear about, and it's an option for patients but probably best to be done by a specialist of some kind.

Oral corticosteroids, you know, despite the common use there's, there's really not a lot of evidence to support it. It's an option for patients but you know, if you're going to do it, short courses are certainly recommended as opposed to a longer course, just because of the side effects with long courses of corticosteroids and the lack of good evidence to support it use.

In terms of intranasal corticosteroid sprays or intranasal corticosteroids aggregate evidence is A, and so policy level was also for an option. Certainly, I think this is fairly low risk, and I would say first-line treatment for patients who present with symptoms. And although, I'd say many patients might come to you saying, oh, I've tried, you know, nasal steroid of one kind or another. You know, it's oftentimes they haven't used it for long enough, or they maybe aren't using it correctly in terms of how they're aiming it in their nose. So it's important to, you know, if someone's already tried it to make sure that you're – that they've tried to tried it for a reasonable period of time and used it properly. And if not, then educate them and start them on it, as there is good evidence for – level A evidence for intranasal corticosteroids.

New Treatment Since 2021

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Exhalation Delivery System With Fluticasone

And then, since 2021, there's been the introduction of an exhalational delivery system with fluticasone. Essentially, this device is a breath-powered bidirectional drug delivery system. And the way that it works is there's a nozzle that goes in the nose, and then a nozzle that goes in the mouth, and then you – there's a pump here or so you push on the bottle and that, you know, sends the medication out into the chamber and then allows your exhalation to then push the drug into the nasal cavity and distribute it a bit more widely than just a standard nasal spray. And as you exhale the – your soft palate will close off the connection between the nasal pharynx and oropharynx. And so, then that also allows for the sprays not only go in the nostril in an anterograde fashion, but then the contralateral nostril and nasal cavity via retrograde fashion.

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Efficacy of EDS-FLU for Chronic Rhinosinusitis 2 RCTs (ReOpen1 and ReOpen2)

There's been 2 randomized placebo-controlled studies looking at the use of the exhalational delivery system. ReOpen1, ReOpen2.

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ReOpen1: Cardinal Symptoms

And as you can see here, patients who were on the drug, which are the kind of darker blue and lighter blue lines, had a greater reduction in symptom improvement when it comes to congestion, facial pain, nasal discharge, sense of smell, compared to individuals who are on placebo.

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Prior Nasal Steroid Sprays

And for patients who had previously trialed a nasal steroid spray, we still saw, or the study still confirmed that those patients had a reduction in symptoms from baseline. So there was significant benefit in those who had previously quote, unquote failed standard delivery nasal sprays.

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Fluticasone Propionate Nasal Spray Exhalation Delivery System

And so the exhalational delivery system with fluticasone is a drug device combination, the first non-surgical treatment shown to improve symptoms with FDA approval and level 1 evidence and can be used first-line or if symptoms persist despite other over-the-counter intranasal corticosteroid sprays.

Individualized Treatment Options

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CRSsNP Treatment Algorithm

And so, individualized treatment selection is really important. As I alluded to, this is a disease that affects an individual's quality of life and to varying degrees. And it's not anything that's this life-threatening. But again, can have a significant impact. And so really it's the patient who should kind of drive this and their symptom severity that should drive this. But you know, options that are available. So, initial regimen topical nasal steroid sprays, low evidence, but cheap and safe, and certainly would be considered first-line treatment alongside nasal saline irrigations. Consider a short course of an oral antibiotic if there's purulence, or if they've been antibiotic-naive. But remember that the evidence is not great. And so, I certainly avoid extended four-week, six-week courses. And then if you keep on, if you find that you're needing to – the patients aren't getting better, repeated courses could indicate that the wrong antibiotic was selected, but it could also indicate that antibiotics may not be the next best choice, or more antibiotics may not be the next best choice. And it may be reasonable to send that patient on for a specialty evaluation by an ear, nose and throat doctor.

And then also consider short courses of an oral steroid. Again, remember, the evidence is limited. And similar to oral antibiotics, you don't want to do super long courses or repeated courses, unless under the care of a specialist.

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CRSsNP Treatment: Ongoing Disease

So ongoing disease, if symptoms persist, despite standard natal sprays, it would be reasonable to consider a trial of exhalation delivery system, XHance being the brand name of that. As alluded to, there's grade 1 evidence, and there's efficacy in those who have failed standard sprays. And it works for all forms of CRS patients without, or – sorry, patients without nasal polyps as well as patients with nasal polyps. So, you know, if you don't have the benefits of, you know, a nasal endoscope in the office to identify, you know, smaller nasal polyps, certainly you can see larger nasal polyps on anterior rhinoscopy. But you know, for some of the smaller nasal polyps, you know, you don't have to worry about which subtype a patient has if you're going to prescribe them an exhalational delivery system of fluticasone. And then, you know, since this is relatively new, most patients have not tried it. So it's a reasonable kind of intermediary step.

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When to Refer to ENT

When referring to ENT red flag symptoms, meaning you know, there's some sort of complication of chronic rhinosinusitis or, you know, there's something else going on like a sinusal tumor which sometimes can masquerade as chronic rhinosinusitis. You know, unilateral symptoms or very asymmetric symptoms should be a red flag, and prompt you to consider a specialty evaluation. Swelling of the face or any vision changes, definitely should prompt you to refer to a specialist. And then bleeding, while, you know, a lot of patients have nosebleeds and that can sometimes be attributable to incorrect use of an intranasal corticosteroid, which should be visible on anterior rhinoscopy. You would see like a raw area, but you know, if it seems to be more significant and there's not a raw area on exam, then it might be reasonable to refer that patient on, just in the event that there's again something going on like a sinus tumor, whether that be benign or malignant.

Certainly, you know, if someone has immunosuppression or poorly controlled diabetes, those patients are a little bit more prone to having complications of chronic rhinosinusitis and/or more of a refractory nature to their disease state. And so, you know, there's good evidence to support earlier surgical intervention for those patients, or the need for culture-directed antibiotics, you know, and someone who's immunosuppressed. You know, as an ENT, you know, we have scopes. We can get cultures from the middle meatus a bit more easily than, you know, general practitioner. And so, those are a couple medical comorbidities that might prompt you to refer on a little bit sooner rather than later. And then, you know, if you've exhausted all medical treatment options, and don't want to, you know, be doing a third, fourth, fifth round of antibiotics or steroids, you know, without having a little bit more information or better understanding of kind of the patient's disease state, reasonable to refer that patient on.

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ENT Evaluation/Management

You know, when the patients are sent to an ENT, they're undergoing to undergo a comprehensive rhinologic history, they're going to have sinonasal endoscopy, which is maybe what separates, you know, our examination process from a non-ENT. And it allows us to get, really get a high-definition view of the entire nasal cavity all the way back to the nasal pharynx and you know, identify the presence of nasal polyps, mucopurulence, ability to take, you know, directed cultures, as well as the ability to exclude a sinonasal tumor. You know, the process says – the decision-making process, as I alluded to, is shared. So you know, we kind of assess symptoms and the impact of those symptoms. What are the goals of the patients? We discuss, you know, what have you tried, what have you not tried in terms of medical treatments? And – but when patients maybe have very severe disease or they've exhausted all their medical treatments, or they're wanting to take the next steps for whatever reason, then we have a conversation about sinus surgery.

[00:51:26]

When to Consider Surgery

And so, when to consider sinus surgery? Obviously, we want them to meet the criteria for chronic rhinosinusitis. There's not a role for sinus surgery in uncomplicated acute bacterial rhinosinusitis, nor is there really a defined role in subacute rhinosinusitis. We want to make sure that they failed an appropriate trial of medical therapy, and that symptoms are bothersome enough to the patient to warrant surgery. So we oftentimes, or at least in my practice, we have patients fill out quality of life questionnaires to determine kind of how severe is it for that patient, and there's good data to help us steer the conversation towards or away from surgery, depending on, you know, their ultimate score on that test. And so ultimately, you know, I tell patients, you know, it's an elective surgery and you know, the decision is up to them and give them all the options and allow them to, you know, with their families, make a decision for surgery.

[00:52:38]

Defining Shared Decision-making

And this just gets into, you know, a little bit more of what I've been talking about. So, we'll skip over that, in the interest of time.

[00:52:47]

We Can Empower Patients

You know, obviously, we want to empower patients by providing them clear, concise and unbiased information. You know, it's a process. We certainly, you know, I usually see patients sometimes it's very clear early on, patients have tried everything, and you know, my initial visit, we might move forward with surgery. There's other patients where – a lot of patients where I'll see them a few times, before we might make that leap. And so, it's an ongoing conversation over the course of time.

[00:53:24]

Endoscopic Sinus Surgery

And there's a lot of myths, maybe with sinus surgery. What is it not? It's not scraping, it's not rotor-rooting. You hear that a lot. It's not really. Also, with some exceptions, it's not unanimously, certainly not unanimously considered a cure. There is the need for ongoing medical therapy to a degree and that vary depending on the specific, you know, subtype of chronic rhinosinusitis. But the goals are to allow mucus to drain properly and physiologically as well as to allow, you know, our topical medications to actually reach the disease sinus mucosa. You know, I tell patients our natural openings are only a millimeter or two. If you throw inflammation on top of that, you know, the openings tend to close off and mucus can't drain out. But, you know, it's a 2-way street. And so, rinses or nasal sprays aren't really able to get in either. So, it's a targeted opening of the natural ostia, removal of ethmoid partitions with disease mucosa, correction of anatomic abnormalities, whether that be a subtle deviation of large turbinates, and it allows for improved control of crocodile sinusitis, and then occasionally cure depending on certain subtypes.

And last thing I'll say is not all sinus surgery is the same. You might hear of someone having had sinus surgery and they weren't better, or they were worse. It's certainly not a perfect solution for every patient. But a lot has changed in terms of the way that we do sinus surgery over the past, you know, 10, 20 years. And so, it's reasonable to get a patient into a specialist and in particular a fellow trained rhinologist to determine whether or not, you know, even if they've had prior surgery, whether or not revision surgery may be a benefit.

[00:55:24]

A few more details about sinus surgery. It's outpatient. Depending on the extensiveness of surgery, it can be anywhere from an hour and a half to three hours. It's usually a week of downtime. They have mild to moderate discomfort, usually prescribed 10 pain pills. They do have some bloody drainage for a few days. There's obviously some fatigue associated with surgery and the healing process.

Risks, the most common risk would be a nosebleed. There's like a 1% to 3% risk of a postoperative surgical nosebleed. There are reports of CSF leak and orbital injury. Knock on wood, thankfully, I've never had an orbital or intracranial injury or CSF leak in any of my patients who have had sinus surgery. And then there's a follow-up period to assist in patients and their healing process which is pretty standard.

[00:56:13]

Postsurgical Management

Postsurgical management goals, again, allow mucus to drain properly, and allow topical medications actually reach the disease mucosa. So on the right side, you can see what – this is a right nasal cavity. You can see the middle turbinate, the uncentered process, the ethmoid bola versus postoperatively. You can see the maxillary sinus kind of on the bottom left-hand side of the image. You can see your sphenoid sinus just right in the center of the image. Your frontal sinus kind of at 12 o'clock. Your ethmoid sinuses kind of in between the sphenoid and the frontal, and then middle turbinate there as before. And you can see how much larger you can actually see into the sinuses. You can see how these sinuses would be, you know, able to drain more easily and how nasal sprays and rinses would have more direct access to get in there.

Outcomes of Sinus Surgery

[00:57:10]

Long-term Outcomes for Nasal Polyposis and Chronic Rhinosinusitis

Outcomes of sinus surgery, long-term outcomes for nasal polyposis and chronic rhinosinusitis. So baseline, it's not 22, that quality life score that I was mentioning. And you can see for all types as well as patients without polyps, patients with polyps, we do see improvement in their SNOT-22 scores that is durable for up to five years and beyond. There's a concept of MCID which is a minimum clinically important difference. So, you can show a statistically significant improvement. But is it clinically significant, and so for the SNOT-22, a difference in about 9 points is considered clinically significant. And so, we know that we can really make an impact in these patients. And these are patients who have already failed medical therapy.

[00:58:05]

Utility Change With Treatment

And you know, what is the utility change? We talked about those health utility scores at the very beginning and where chronic sinusitis stacked up with, you know, other disease states. And so, what is the improvement one can expect with sinus surgery? The MCID for health utility scores is 0.03. And so, again, that's that minimum clinically important difference. And you can see here that endoscopic sinus surgery has an MCI – or sorry has an average utility change of 0.09, which is not too far off from total hip arthroplasty, higher than coronary angioplasty, joint replacement, ankle arthroplasty, CPAP and revision sinus surgery. Also, not too far off from some of these other conditions that are maybe expected to have more of a significant impact. Even bariatric surgery, it's in between that 0.09 to 0.12. Sinus surgery is not too far off from that in terms of what that can do for a patient.

[00:59:13]

Take-home Messages

So, take-home messages. There's 30 million Americans who suffer with CRS. We've got our cardinal symptoms of chronic rhinosinusitis, but there are some extra rhinologic symptoms that certainly play a role in the patient's experience as well as productivity losses. Saline irrigations and intranasal steroid sprays are common first-line treatments. But there is good evidence to support the latter. Sorry, I should say that there is good evidence for, well, not great evidence for sprays. But on the fourth bullet point, there is good evidence for the extra – sorry – the exhalational delivery systems of intranasal corticosteroids. And so for, you know, while it's reasonable to start patients on an intranasal steroid spray because of cost and you know, ease of getting it, you know, if someone fails, consider switching to an exhalational delivery system and/or referring to an ENT for, you know, failure of appropriate medical therapy, or certainly any red flag symptoms.

[01:00:32]

Posttest 1: When evaluating a patient with frequent nasal discharge, which of the following characteristics would be most indicative of chronic rhinosinusitis without nasal polyps vs other upper respiratory conditions?

So, we do have our post test questions that we'll get back to. Wendy, if you don't mind opening up the polls?

Wendy: Absolutely. Okay. Excuse me, I'm sorry. Postpoll 1 has launched now. Please vote. Five more seconds for incoming responses. Thank you for your voting. I'll close the poll and share results.

Dr El Rassi: All right. Better. Better than the pretest. You know, as mentioned, pain or pressure tends to be a little bit more classic in patients without nasal polyps.

[01:01:33]

Posttest 2: A patient with CRSsNP would like to start treatment for symptoms of congestion. Which of the following would be best to share with them regarding treatment options?

We'll do the next posttest question. You go ahead and open up polling.

Wendy: All right, thank you. Thank you, the poll is open. Five more seconds for incoming answers. Thank you for your vote. We'll close the poll and share results.

Dr El Rassi: Right. I think also some improvement compared to the pretest.

[01:02:17]

Posttest 3: How confident are you in your ability to create individualized treatment plans for patients with CRSsNP?

And then the posttest question number 3: How confident are you? Go ahead and open up the polling. I think that was also a good shift towards being more confident. Great.

Q&A

Dr El Rassi: So I will, first off, it looks like there's a few questions in the chat is: If exhalational delivery system fluticasone is more effective, do you ever start with this – start with it as first-line for patients? In my current practice, not necessarily. If they haven't tried an intranasal steroid spray, I usually start with that because I feel like it's a bit easier to obtain and, you know, and so I usually start with that.

Are there specific patient populations in which CRS without nasal polyps is more frequently misdiagnosed? Misdiagnosed meaning, I guess, patient populations – I mean, I would say if someone's immunosuppressed or autoimmune conditions or they've got diabetes. Autoimmune conditions can affect the sinus cavities, and can present clinically, radiographically as chronic rhinosinusitis, the classic one being granulomatosis polyangiitis. But those patients, I would say, are treated much differently. We generally, you know, it's a systemic disease, so it should be treated systemically. And there is really not a role for sinus surgery in those situations. So, you know, you want to get a full history in physical and, you know, if there's immune system issue – immune system issues, or, you know, diabetes or, you know, unilateral asymmetric symptoms, concerns for a sinonasal tumor, cancer, you know, those are the things that you should be kind of, you know, considering or having kind of in the back of your mind.

And then how frequently do you recommend imaging studies to confirm CRS in patients with persistent symptoms? You know, I think if you – I think it's reasonable, like if someone has, you know, the diagnosis of CRS is there's a time frame of two out of the four cardinal symptoms with discolored or thick nasal drainage being, you know, a requirement in addition to one of the other three. You know, if that and you – and if you've tried, you know, antibiotics, you know, if you tried saline irrigations, intranasal corticosteroids, maybe some antibiotics, maybe some oral steroids, and you're wanting to confirm the diagnosis prior to additional treatments or to a referral, I think it's reasonable. Because technically to diagnose chronic rhinosinusitis, you know, you need an objective – some sort of objective assessment of inflammation. That could be anterior rhinoscopy, although, you know, without, you know, excessive signs or excessive disease, you know, someone could just have allergic inflammation, and not necessarily chronic rhinosinusitis. And so, and a lot of people don't have nasal endoscopy in the office to confirm the objective evidence.

And so, yeah, prior to proceeding with additional treatment or referral or to exclude, you know, some sort of other pathology like a sinonasal tumor before continuing treatment, it's very reasonable to consider imaging. I would not image someone in the under, you know, 4-week time frame because that, you know, it's acute bacterial, unless there's a concern for a complication, we wouldn't image in that situation. You know, imaging in the subacute phase, not well understood. But if there's unilateral symptoms, maybe consider that to rule out some sort of, you know, non-inflammatory infectious process. Otherwise, I think it's reasonable if they've, you know, been through that 12-week period and they've tried, you know, appropriate medical therapy to get some imaging.

How often do you see CRS misdiagnosed as a viral or bacterial URI? I mean, I would say not necessarily CRS misdiagnosed, but, you know, acute bacterial rhinosinusitis being misdiagnosed as a viral or bacterial URI. I think if you, you know, it's difficult because we're, you know, we don't – the diagnosis of a viral versus bacterial process is, you know – you know, technically you would want to get cultures, but viral cultures aren't, you know, practical, and nor are bacterial cultures. And so again, we kind of extrapolate, you know, how we diagnose bacterial rhinosinusitis based off of some historical studies. And you know, I think, you know, you're going to – you know, for the general population, excluding patients with immunocompromise, you know, it's reasonable to follow the guidelines that we have set forth. But realize that these are guidelines and that, you know, there's a science to medicine, but there's also an art to medicine. And you want to have conversations with patients, educate them, and have some shared decision-making with patients where there's a question of is this a viral thing or bacterial thing. So, hopefully, that answers your question.

I don't know if there's any other questions, or if there's time for questions, but I'm happy to field any additional ones.