Complications in rhinosinusal

disease
Livije Kalogjera
 Complication
• Medical complication
is an infrequent and
unfavorable evolution
of a disease, a health
condition or a medical
treatment

• Severe symptoms
• Non-responsiveness
to standard or any
treatment
• Evolution towards a
life threatening
condition
 Severe nasal symptoms
• Total nasal
obstruction
• Permanent
rhinorrhea
• Severe facial
pain/headache
• Facial swelling
• Anosmia
 Staging and outcome measures in
rhinitis/rhinosinusitis
HRQL OBJECTIVE DIAGNOSTIC TOOLS
SYMPTOMS

brain-nose axis

Objective?
 HRQL
• generic
• disease specific
Petersen KD et al, Allergy 2008

• commorbidities
Magnan A et al, Allergy 2008

• lifestyle, stress
• mental status
Mosges, Klimek; Allergy 2007
Stewart MG, Am J Rhinol 2005
 Objective measures
• imaging
• measurement of nasal patency
• secretion
• reflexes
• MC transport
• olfaction
• inflammation
• nasal NO
• lavage
• scraping
• biopsy
 Why objective measures?
• discrepancy between
patient’s score and
rhinoscopic/endoscopic
evaluation
• intraindividual variability
• follow-up after treatment
• provocation tests
• medicolegal reasons
• research
 CT severity scoring system

• I-IV staging systems

(Kennedy, Levine and
May, Friedman,
Harward)
• Lund-Mackay staging
system (0-2 per sinus
system, ostiomeatal
complex) – max. 12
points per side
• CT severity – disease
severity?
 Incidental CT scores
• Incidental mean Lund-MacKay
score - adults 4.26 (95% CI, 3.43
to 5.10) (Ashraf, Otolaryngol Head
Neck Surg 2001)
• Incidental mean Lund-MacKay
score - children – 2,81 (95%
confidence interval, 2.40 to 3.22),
in 19,3% score 0 (Hill, Otolaryngol
Head Neck Surg 2004)
Endoscopy vs. CT in CRS
n=78

22%

44% CT+ endoscopy+

CT+ endoscopy-
CT- endoscopy+
CT - endoscopy -
26%
8%

Adapted from Stankiewicz, Chow. Otolaryngol Head Neck Surg 2002

• Endoscopy showing purulence, nasal polyps, or watery

congested mucosa correlated well with CT results
• Negative endoscopy correlated with CT results in 65% of
patients.
 Nasal patency measures
• imaging
• endoscopy
• rhinomanometry
• acoustic rhinometry
• PNIF
• No correlation with
subjective obstruction,
airflow sensation
Clarke JD, Am J Rhinol, 2006
Nathan RA et al, JACI, 2005
 Olfaction assesment
• tests for odour threshold (n-
butanol)
• odour discrimination
• odour identification
• multiple forced choice from a few
verbal items per test odorant

1. subjects should be familiar with all odor-

describing items used in the test;
2. odorants included in the test should be Smell testing is an
similar with regard to both intensity and important non-invasive
hedonic tone; and
3. the successful identification of individual outcome measure in
odorants from a list of four descriptors
should be > 75% in healthy subjects.
clinical trials
 Inflammation
What are normal
values?

Correlation between
inflammation and
subjective symptoms
and HRQL scores is
often not significant,
more so for RS than AR.

Radcliffe, MJ et al., Do skin prick and

conjunctival provocation tests predict
symptom severity in seasonal allergic
rhinoconjunctivitis? Clinical & Baroody et al. Am. J. Resp. Crit. Care Med., Volume
Experimental Allergy, 36/ 157, Number 3, March 1998, 899-906
 At any point
EPOS: Acute immediate referral/
Dg/ symptoms
rhinosinusitis hospitalisation

for GP Periorbital oedema•

Displaced globe•
Double vision•
Symptoms > 10 or worse Ophthalmoplegia•
Symptoms till 5 days or after 5 days Reduced visual acuity
improved
moderate severe
Severe unilateral or
Viral rinosinusitis bilateral frontal
Topical Antibiotic + headache•
steroid topical
steroid Frontal swelling•
Th symptomatic
Effect in Signs of meningitis
No effect in
48 h
48h
No effect in 14 Sever
days headache,
Th further 7- Referral fever <38C
14 days ORL
Think of ORL
 Symptoms,
endoscopy, previous Sinister signs
unilateral symptoms
treatment, VAS,
Chronic alergy, asthma
bleeeding
rhinosinusitis significant crusting
kakosmia
Moderate to severe
orbital symptoms
VAS 4-10 visual problems
Mild VAS
0-3 frontal headache
Topical steroid nasal frontal edema
lavage bacteriology
Topicalni long-term AB neurological or
steroid, nazal systemic signs
Failure 3
lavage
months
Failure 3 months

URGENT
Follow-up WORK-UP AND
CT
steroid, lavage, SURGERY
ev. long-term AB
surgery
 Total/subotal nasal obstruction
• Massive nasal
polyposis
• Tumors
• Choanal atresia
• Nasopharyngeal
stenosis
• Adenoids
• Nasal valve
disfunction
• Severe rhinitis
 Severe/permanent rhinorrhea
• WATERY
• Skier’s nose
• CSF leak (rhinoliquorrhoe)
• PURULENT
• CF
• PCD
• Biofilm
• HAEMORRHAGIC
• Tumor?
 Nasal/facial pain
• Pain in nasal tip – furuncle –
complicated with facial cellulitis
and meningitis
• Nasal pain – external ethmoid
nerve – usually dental, not related
to rhinosinusitis
• Facial pain – rhinosinusitis,
trigeminal neuralgia, dental pain,
temporomandibular disorder,
stress related (PTSD), TENSOS
(the empty nose syndrome)
 Severe headache
• CT pathology related to
type of headache
EXCLUDE
Migraine
Trigeminal neuralgia
Sluder’s headache
Cluster headache
 Facial swelling
• Frontal swelling –
Pott’s puffy tumor
• Orbital cellulitis
• Acute maxillary
sinusitis
• Odontogenic
sinusitis
• Quincke
angioedema
 Ocular complication
• Inflammation – EPOS – sinister
ethmoiditis in children, signs - ocular
sphenoiditis in adults complications

• Nasal and sinus tumors Periorbital oedema

•Displaced globe
• Orbital process
• Double vision
• Allergy
• Ophthalmoplegia
• Hereditary angioedema
• Reduced visual
acuity
 Anosmia
• Viral olfactory neuritis
• Nasal polyps
• Chronic rhinosinusitis
• Olfactory neuroblastoma
• REAHOC
 Can the same bacteria cause acute
and persistent infection?
detectability
virulence
type of inflammation
regulation
route of entry
site of infection
symptom severity
prone to recurrence Staphylococcus aureus

response to treatment a) small colony variants

b) normal phenotype
Furukawa et al. J. Bac 2006; 188/4:1211-1217
 Chronic inflammation – role of infection
vs. colonization – Fungal revolution
• <90% prevalence of fungi cultivated
from nasal and sinus fluid in CRS and
healthy individuals (Ponikau, 1999)
• Is eosinophilic mucin RS immune
response to fungal antigens?
• fungi in secretions, rarely in mucosa
• 6,5 % in CRS mucosa by PCR (Rao et
al., Otolaryngol Head Neck Surg 2006)
• In lavage cultivating+ PCR 50% -
complementary techniques (Polzehl D
et al)
 Bacterial superantigens

• Staph. aureus enterotoxins

(SAE) induce increased
airway hyperreactivity (Herz,
Eur J Immunol 1999) steroid
resistance (Hauk, JACI 2000)
and anergy of T-cells following
initial proliferation (Mac
Donald, Eur. J. Immunol.
21:1963.)
• High prevalence of increased
levels of specific IgE to SAE,
in nasal polyp tissue in severe
asthma and aspirin intolerant
asthmatics, compared to non-
asthmatic polyps and control
mucosa (Zhang et al,
Rhinology, 2005)
 Biofilm in CRS

• FISH analysis
– biofilm from 14 of
18 CRS patients
– Biofilm from 2 of
5 control patients
Sanderson AR et al.
Laryngoscope
116(7), 1121-6, 2006 Biofilm formation in situ
Intracellular niche
• Low metabolic consumption, slow
growth, antimicrobial resistance +
poor penetration of antibiotic
intracellulary, lower toxin production,
may revert to wild type
• Small colony variant of Staph. aureus
important for recurrent rhinosinusal disease
(Sendi P, Cell, 2009)
• very low incidence, poor detectability, lower
virulence, but persistence (Garzoni C et al,
Cell, 2009)
• PCR may identify virulence factors
 PCR – highly sensitive
• detection of 16S rDNA – bacteria
dead or alive - highly sensitive in
detection of any bacteria Houston, we have a
• growth and number – real time problem
PCR
• Ubiquitious nature of pathogenic
and minimally pathogenic bacteria
• New genera detected, non-
cultivable and unkown as human
or animal pathogens
environmental bacteria
• Random amplification effect
• Clinical relevance

Repetitive sampling suggested to exclude contamination

random amplification effect
How to deal with complications?
• Recognize early (check
vision, objective pain, facial
swelling, neurological signs,
smell, BT, CBC, radiology)
• Think of comorbidities

• Start treatment immediately

(parenteral antibiotics,
steroids)

• ENT referral