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Philippe Gevaert , MD, PhDMichael A. Kaliner, MD
Paul Van Cauwenberge, MD, PhDReviewers: Kamal Hanna, Richard F. Lockey, Todor Popov
Chronic Rhinosinusitis and Nasal Polyposis
Updated: June 2011
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Organization (WAO). Its curriculum educates medical professionals
worldwide through regional and national presentations. GLORIA modules are
created from established guidelines and recommendations to address different aspects of allergy-related patient care. .
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Module 10:Chronic Rhinosinusitis
and Nasal Polyposis
Lecture objectives
At the end of this presentation, participants willbe able to:
Discuss the underlying pathology of acute andchronic rhinosinusitis and nasal polyposis
Describe the management of acute and chronicrhinosinusitis and nasal polyposis
Rhinosinusitis
Facts: 14.7% incidence in US population: 31,000,000 cases
per year Incidence increased by 18% over the past 11 years
26 million office visits for sinusitis in 1997 >21 million antibiotic prescriptions in 1997
Third most common diagnosis for antibiotics >70 restricted activity days in 1992 250,000 surgeries per year
Survey IMS Health 2001 USA, 1997 Germany, 7/2000-6/2001
Acute sinusitis Diagnosis: 6.3 millionPrescriptions: 8.5 million
Chronic sinusitis Diagnosis: 2.6 millionPrescriptions: 3.4 million
Nasal polyposis: Diagnosis: 221 000
Prevalence of sinusitis: 14.7%
Prescriptions of antibiotics for sinusitis
985 5.8 million 1992 13 million
Work loss (days)1986 50 million1992 73 million
1. Maxillary sinus2. Ethmoidal bulla3. Ethmoidal cells4. Frontal sinus5. Uncinate process6. Middle turbinate7. Inferior turbinate8. Nasal septum9. Ostiomeatal
complex
Infections induce changes in sinus mucosa
B
MT
MS
I T
The ostiomeatal complex
Key
B: bulla ethmoidalisIT: inferior turbinateMT: middle turbinateMS: maxillary sinus
Ventilationand
Drainage
Inflammationand
Remodeling
Anatomy & physiology
Coronal Axial
Ethmoid sinus
Frontal sinuses
RADIOGRAPHIC ANATOMY OF THE PARANASAL SINUSES
Maxillary sinus
Sphenoid sinus Anterior ethmoid
Posterior ethmoid
Sphenoid sinus
Anterior Posterior
Anatomy and physiologyMUCOSAL IMMUNITY
Anatomical and mechanical factors: Epithelial barrier
Mucus/mucociliary clearance
Mucosal immune system:
Innate immunity: Antimicrobial peptides: Defensins
Receptors: Toll-like receptors
Cells: Macrophages, neutrophils, dendritic cells, NK cells, mast cells
Adaptive immunity: Antigen-presenting cells
T-lymphocytes
B-lymphocytes => IgA
Rapid, non-
specific
Specific, memory
Aetiology of rhinosinusitis Allergy
Seasonal Perennial
Infection Acute Chronic: specific e.g.
Bacterial, fungal or nonspecific
Possible host defense deficency
Structural Ostiomeatal complex:
Deviated nasal septum Hypertrophic turbinates
Others Dental, periapical
abcess Underlying diseases,
cystic fibrosis Occupational irritants
and allergens Drug induced, rhinitis
medicmentosa Irritants induced
rhinitis Atrophic rhinitis
After International Consensus Report on the diagnosis and management of rhinitis. Allergy Suppl 19,49,1994
Anatomy and physiology
COMMON COLD
BACTERIAL SUPERINFECTIONStrep pneu./Haemo inf./Morax
catar.
Increasing symptoms after 5 DAYS
No resolution after 10 DAYS
ACUTE rhinosinusitis
MULTIFACTORIAL ETIOLOGY
CHRONIC rhinosinusitis EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: 583-601
Underlying conditions Sinusitis and Immunodeficiencies
Sinusitis and cystic fibrosis
Humoral immunodeficencies frequently associated with sinusitis
Congenital immunodeficencies
Selective IgA deficency, Common variable IgG immunodeficency, Agammaglobulinemia, specific antibody deficency, (rarely IgG Subclass deficency)
Acquired immunodeficencies
Immunosupressive agents, HIV
Classification: chronic rhinosinusitis
with and without nasal polyps2 OR MORE MAJOR SYMPTOMS nasal blockage anosmia/hyposmia purulent nasal discharge/post-nasal drip facial pain/pressure
AND EITHER endoscopic findings of polyps mucopurulent discharge edema or obstructionOR CT scan abnormality: mucosal changes within ostiomeatal
complex or sinus cavity
EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: 583-601
Classification: chronic rhinosinusitis
with and without nasal polyps
DURATION
ACUTE/intermittent < 12 weekscomplete resolution of symptoms
CHRONIC / persistent > 12 weeksincomplete resolution of symptoms
EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: 583-601
Symptoms associated with rhinosinusitis
Major symptoms: Minor symptoms:
Facial pain/pressure HeadacheFacial congestion/fullness FeverNasal obstruction/blockage HalitosisNasal discharge/purulence/postnasal drip FatigueHyposmia/Anosmia Dental painFever Cough
Ear pain/fullness
MicrobiologyNormal sinuses: Free of growthAcute rhinosinusitis:ViralBacterial (Strept. Pneumoniae,H. Influenzae, M.
Catharralis)Chronic rhinosinusitis:Anaerobes: Propionibacterium, Bacteriodes, PeptococcusAerobes: Staphylococcus, Corynebacterium, PseudomonasFungi (Aspergillus fumigatus, Curvularia, Dreschelaria)Dental sinusitis: Microaerophilic strept. species
Nasalpolyps
Imaging of sinsusesMRI: only recommended in tumor diagnosisCT sinuses: current standard imaging- Acute rhinosinusitis: only for possible complications
- Chronic sinusitis: only after 4+ weeks of treatment!
Septal deviation
Dental sinusitis
Chronic Sinusitis
Nasal polyps
The signs and symptoms of acute sinusitis
(>10 days and < 12 weeks): Prerequisite symptoms
Persistent upper respiratory infection (>10 days)
Persistent muco-purulent nasal or posterior pharyngeal discharge
Cough
Supporting symptoms Congestion Facial pain/pressure Post-nasal drip Fever Headache Anosmia, hyposmia Facial tenderness Periorbital edema Ear pain, pressure Halitosis Upper dental pain Fatigue Sore throat
Diagnosis of acute bacterial sinusitis (ABS)
or
Have not improved after 10 days
Have worsened after 5 to 7 days
A diagnosis of ABS is suggested when Symptoms of a viral URI
International Rhinosinusitis Advisory Board. ENT J 1997;76(suppl):1; Lanza and Kennedy. Otolaryngol Head Neck Surg 1997;117:S1.
Association between viral and bacterial sinusitis infections
Viral infections Self-limiting 2 to 3 acute viral respiratory infections per year (6-8
in children) >80% symptoms resolve in 7-8 days Often inciting event for development of sinusitis and
other respiratory tract infections 0.5%–2% of cases complicated by acute bacterial
infection (>20 million cases)
Brook. Primary Care 1998;25:633; Gwaltney. Clin Infect Dis 1996;23:1209; Gwaltney et al. N Engl J Med 1994;330:25.
Acute bacterial rhinosinusitis (ABRS)
Sinus and Allergy Health Partnership, 2000
Copyright permission for reproduction pending
Therapy
Decongestives/pain Saline washes Antibiotics (oral, IV) Corticosteroids (local, oral) Surgery: Adenoidectomy (child) Endoscopic sinus surgery (adult) chronic
acute
Strength of evidence for treatment of
acute rhinosinusitisTherapy Level Recommendation Relevance
antibiotic Ia (49 studies) A yes: after 5-10days,or in severe cases
topical corticosteroid 1b (1 study) A yes
addition of topical steroid toantibiotic
Ib (5 studies) A yes
oral steroid no evidence(1 study)
D no
addition of oral antihistaminein allergic patients
Ib (1 study) B no
nasal douche no evidence(3 studies)
D no
decongestion no evidence(3 studies)
D Yes as symptomaticrelief
mucolytics no evidence (3 studies)
D no
EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: 583-601
An update on acute rhinosinusitis management:
antibiotics in adultsCochrane Review Antibiotics for acute maxillary sinusitis
7330 subjects in 32 studies (10 double blind) antibiotic vs. control (n=5) newer, non-penicillin antibiotic vs. penicillin class
(n=10) amoxicillin-clavulanate vs. other extended spectrum
antibiotics (n=10)
Confirmed radiographically or by aspiration, current evidence is limited but supports penicillin or amoxicillin for 7 to 14 days. Clinicians should weight the moderate benefits of antibiotic treatment against the potential for adverse effects
Williams Jr JW, The Cochrane Library 2003
Evidence for treatment of rhinosinusitis with topical
corticosteroids plus antibiotics - 1Study Drug Antibiotic Number Effect X-ray
Meltzer, 2000
(340)
Momet.furuate
amox/clav 407 Significant effect incongestion, facialpain, headache andrhinorrhea. No significant effect inpostnasal drip
No statistical
difference inCT outcome
Nayak, 2002(341)
Momet.furuate
amox/clav 967 Total symptomScore (TSS) wasimproved(nasal congestion,facial pain, rhinorrheaand postnasal drip)
No statistical
difference inCT outcome
Evidence for treatment of rhinosinusitis with topical
corticosteroids plus antibiotics - 2
Study Drug Antibiotic Number Effect X-ray
Dolor, 2001(342)
FP cefurox 95 Significant effect.
Effect measuredAs clinicalsuccess depending onPatient’sself-judgment of symptomatic improvement
Not done
Evidence for treatment of rhinosinusitis with topical
corticosteroids plus antibiotics - 3Study Drug Antibiotic Number Effect X-ray
Barlan, 1997 (343)
Bud amox/clav 89 children
Improvement incough and nasalsecretion seen atthe end of thesecond week of treatment in theBUD group
Not done
Meltzer, 1993 (344)
Flunisol. amox/clav 180 Significantsympt: overall score for global assessment of efficacy wasgreater in thegroup with flunisolide
No effecton x‑ray
J Allergy Clin Immunol. 2005 Dec;116(6):1289-95.
Copyright permission for reproduction pending
Community-acquired acute sinusitis
Inflammatory component:Topical corticosteroidsSymptomatic treatment
Infectious bacterial component:
Antibiotic treatment
If unsuccessful, prolonged,
or primary signs
Primary signs of bacterial infection:Localized severe headachePus in the middle meatusComplications (orbital, skin, etc.)
Surgical intervention
If unsuccessful on
several trials,or complications
Considerations in antibiotic selection
Cost/ Formulary Status
Considerationsin Antibiotic
Selection
Activity Against Likely PathogenPharmacokinetics (PK)/ Pharmacodynamics (PD)
Medication Allergy
Adverse Effects
Ease of Dosing
Adapted from Kennedy et al. Ann Otol Rhinol Laryngol Suppl 1995;167:22; Sinus & Allergy Health Partnership. Otolaryngol Head Neck Surg. 2000;123:S1.
Resistance Patterns
Conditions for effective antibiotic treatment
Appropriate spectrum Appropriate penetrance and local activity Minor side-effects Good tolerance Liklihood of no resistence Affordable Available
Antibiotic therapy for sinusitis 2007
AmoxicillinAmoxicillin/clavulanate
CephalosporinCefuroximeCefopodoximeCefiximeCefprozilCefdinir
Erythromycin/sulfisoxazoleClarithromycinAzithromycin
MiscellaneousKetolidesQuinalonesMetronidazole Trimethoprin/sulfamethoxazoleClindamycin
Penicillin Macrolide
Recommended antibiotic choices - 2007
First choice: Amoxicillin/clavulante or cephalosporin Good second choice: Clarithromycin
Back-ups: QuinalonesUse metronidazole plus one of the above or clindamycin when gram negative is suspectedTopical mupiricin very useful in select cases
An update on acute rhinosinusitis management: Antibiotics in acute
rhinosinusitis? Don’t treat viral common cold with antibiotics Use symptomatic treatment in mild acute rhinosinusitis
saline decongestant NSAID
Use topical steroids in acute and chronic sinusitis (evidence)
Reserve antibiotics for severe acute presumably bacterial
rhinosinusitis Prescribe antibiotics based on local resistance patterns
Sinusitis - conclusions
Sinusitis is common and over-looked Causes are complex Treatment requires appreciation of causes and careful
follow-up Medical management is effective in most cases Functional endoscopic surgery is helpful in resistant
sinusitis after adequate medical management
Definitions and classificationCLINICAL DEFINITION OF RHINOSINUSITIS/NASAL
POLYPS
2 OR MORE MAJOR SYMPTOMS nasal blockage smell dysfunction nasal discharge/post-nasal drip facial pain/pressureAND EITHER endoscopic findings of polyps mucopurulent discharge edema or obstructionOR CT scan abnormality: mucosal changes within ostiomeatal
complex or sinus cavity
EAACI Position Paper on Rhinosinusitis and Nasal Polyps, Allergy 2005: 60: 583-601
The signs and symptomsof chronic sinusitis (symptoms persisting >12 weeks):
Prerequisite symptoms Purulent nasal and
posterior pharyngeal discharge
Plus: Facial pain/pressure Persistent nasal
obstruction Cough/post-nasal
drip/throat clearing
Supporting symptoms Hyposmia, anosmia Sore throat Malaise Fever Headache, facial
pressure, dental pain Halitosis Sleep disturbance Fatigue
Diagnosis of chronic rhinosinusitis
Symptoms suggestive of chronic rhinosinusitis
Initial evaluation: Medical history: major, minor symptoms General examination Evaluation of underlying disease and co-morbidities Anterior rhinoscopy, Nasal endoscopy CT scan (not in an acute episode)
Special indications (differential diagnosis and underlying
disease) Allergy tests Microbiology (eventually sinus puncture) Challenge test for aspirin sensitivity Nasal cytology
(eosinophils, neutrophils) MRI (if tumor or fungus suspected) Ciliary function studies Biopsy
Biopsy Blood examinations
(Wegener’s, immunodeficencies)
Sweat chloride test Electron microscopy of cilia Genetic analyses Consultations of other specialities
(ophthalmologist, neurologist etc.)
Differential diagnosis of chronic rhinosinusitis - 1
Infectious rhinitis: viral upper respiratory tract infection
Allergic rhinitis: seasonal, perennial, occupational Nonallergic rhinitis: “Vasomotor rhinitis”, NARES,
aspirin- exacerbated respiratory disease Rhinitis medicamentosa Rhinitis secondary to pregnancy, hypothyroidism Anatomical abnormalities: severe septal deviation, foreign body Nasal polyps Inverted papilloma, benign and malignant tumors
Claus Bachert, Allergy: principles and practice.
Differential diagnosis of chronic rhinosinusitis - 2
Cerebrospinal fluid leak, meningoencephaloceles Mucoceles Wegener‘s granulomatosis Cocaine abuse Atrophic rhinitis Specific or tropic infections Fungal sinus disease Ophthalmologic or neurologic diseases
Claus Bachert, Allergy: principles and practice.
Chronic rhinosinusitis: why?
Chronic inflamed (eosinophilic) mucosa Possible superimposed infections
Bacteria Fungi
Superantigens Biofilms Osteitis
Chronic rhinosinusitiswith and without nasal polyps
Chronic Rhinosinusitis Nasal Polyps
Nasal Polyps
The spectrum of sinus disease
Rhinosinusitis - Eosinophils +
Chronic rhinosinusitiswith and without nasal polyps
Chronic Sinusitis
Nasal Polyposis
Facial pain/pressure Yes Sometimes
Facial congestion/fullness Yes Yes
Nasal obstruction/blockage Yes Yes
Nasal discharge/purulence/postnasal drip Yes Yes
Anosmia Sometimes Yes
Blood eosinophils Sometimes Often
Asthma Yes Often
Aspirin exacerbated respiratory disease Rarely 10% of cases
Chronic sinusitis - without nasal polyps
Prevalence of 14.7% in the normal population
Th1 type Inflammation with increased IFN increased TGF and remodeling
Pathogenic role of infections is unclear
Nasal polyposisPrevalence approx. 2- 4%
Asthma in approx. 40-65%
Aspirin sensitivity in 10-15%
Mixed cellular infiltrate withprominent eosinophilia in 90%
Inflammation with local IgE production increased IL-5, eotaxin, cys-LTs and ECP
Superantigens or superallergens
Bacterial Superantigens Staph aureus enterotoxins: SEA, SEB, SEC, SED,
SEE, TSST-1 Strep. pyogenes, Mycoplasma arthritidis, Yersinia pseudotuberculosis ……
Highly potent immune stimulators Interact with T-cell R
and MHC class II 20% of all T-cells are activated by SEA
SAg
T-Cell
V V
MHC II
TCR
APC
S. aureus colonization and IgE antibodies to
S. aureus enterotoxin mix in mucosal tissue
T. Van Zele, P. Gevaert et al. JACI 2004
Copyright permission for reproduction pending
Nasal polyposis: aetiology and pathogenesis
Chemokines
TB
Cytokines Hyper IgE
Eosinophils ( apoptosis)
SuperantigensIL-5
ECP
Albumin
Eotaxin
Polyclonal IgE
Epithelial damage (barrier dysfunction)
chronic microbial trigger
S. Aureus enterotoxins: disease modifiers
Recommended approach to the treatment of chronic rhinosinusitis
2007 Hydration (6 - 8 glasses of water per day) Antibiotics X 14-21+ days (until asymptomatic +7 days)
Choices: cephalosporin, amoxicillin/clavulanate, clarithromycin, quinalone
Long-acting nasal decongestant, BID X 7 days (oxymetazoline)
Nasal saline applied with nasal irrigation device, BID Topical nasal CCS:
2 sprays BID, until symptoms resolved Reduce to lowest effective dose, to maintain remission Aim towards the eye and away from the nasal septum
Next recommended approaches
Switch antibiotics CT scan; limited cut, coronal plane
Treat bacterial rhinitis rarely MRI – fungal or possible tumors
Add metronidazole or clindamycin (especially with foul smell)
Consider fungal Rx (itraconazole, amphotericin) Oral CCS (Daily followed by QOD) Topical antibiotics (tobramycin, mupirocin nasal
ointment)
Evidence-based treatment of CRSTherapy Level Grade of
Recommend.Relevance
oral antibiotic therapyshort term < 2 weeks
III (4) C no
oral antibiotic therapylong term ~ 12 weeks
III (6) C yes
topical steroidswithout significant systemic absorption
II (2) B yes
oral steroid no dataavailable
- no
nasal douche III C yes, forsymptomrelief
decongestion topical/oral no data in single-use
- no
Evidence-based treatment of CRS
Therapy Level Grade ofRecommend.
Relevance
mucolyticssystemic antimycotics
IV (1)VI
DD
nono
topical antimycotics III D no
oral antihistaminein allergic patients
Ib (1) B no
allergic therapyin allergic patients
Studies includepatients withNP
D yes
allergen avoidancein allergic patients
Studies includepatients withNP
D yes
proton pump inhibitors III (3) D no
Evidence-based long-term antibiotics in CRS
Study Drug Number Time/Dose Effect onsymptoms
Evidence
Hashiba et al,
1996(379)
clarithromycin 45 400mg/dfor 8 to 12weeks
clinical improvement in71%
III
Nishi et al,1995 (381)
clarithromycin 32 400mg/d pre- and post-Therapyassesment ofnasal clearance
III
Gahdhi et al,1993 (382)
Prophylaticantibiosis details notmentioned
26 Notmentioned
19/26 decrease Of acuteexacerbation by50%7/26 decrease ofacute exacerbation byless than 50%
III
Evidence-based long-term antibiotics in CRS
Study Drug Number Time/Dose Effect onsymptoms
Evidence
Ichimura et
al, 1996(18)
roxithromycin
Roxithromycin
and azelastine
20
20
150mg/dfor at least8 weeks
1mg /d
clinical improvement and polyp-shrinkage in52%
Clinicalimprovementand polypshrinkage in68%
III
Strength of evidence for treatment of CRS/NP
Intervention Chronic rhinosinusitis Nasal polyps
Corticosteroids Topical A A Systemic / C
Antibiotics Oral short term < 2w C DOral long term >12w C C
Antimycotics Topical / Systemic D DAntihistamines D BAnti-leukotrienes / C Nasal saline douche C D Decongestants D DAllergen avoidance D D
Treatment options for polyposis
Treat underlying sinusitis High dose nasal CCS Oral CCS Chronic/prophylactic antibiotics, systemic and/or
topical Anti-fungal, systemic and/or topical Anti-IL5
Nasal corticosteroid spray in nasal polyposis
Lund V, et al. Arch Otolaryngol Head Neck Surg 1994; 124: 513-8
Copyright permission for reproduction pending
Nasal corticosteroid drops in nasal polyps
Aukema, Mulder, Fokkens; JACI 2005
Copyright permission for reproduction pending
Budesonide use, 2007
Dilute budesonide solution (Pulmicort Respules), 500-1000 ug in 2-4 Oz saline and irrigate the sinuses BID
Have head positioned to the side so that gravity helps get washings into the sinuses; turn head as if to put the ear on knee
Has resolved polyp resistant to nasal fluticasone sprays
Topical anti-fungal treatment in nasal polyposis
A Richetti et al. 2002 J Laryngology & Otology
Copyright permission for reproduction pending
Topical anti-fungal treatment in nasal polyposis
Open study: - with 4 w Amphotericin B + nasal GCS
- in 74 patients with NP 48% improvement of NP (>> small polyps)
13 13
27
48
5
13
Before treatment
After treatment
0% cured
42% cured
62% cured
Stage I Stage II Stage III
n
50
40
30
20
10
Nasal lavages with Amphotericin B is in 2 DBPC studies:
- Ebbens F & Fokkens W J Allergy Clin Immunol. 2006 Nov;118(5):1149-56.
- Weschta M & Riechelmann H. , Arch Otolaryngol Head Neck Surg. 2006 Jul;132(7):743-7
Oral antifungal terbinafine is ineffective:
- Kennedy DW, Laryngoscope. 2005 Oct;115(10):1793-9
Long term antibiotic treatment in nasal polyposis
DBPC study in 90 patients: 3m low-dose erythromycin, nasal douche, nasal GCS vs. sinus surgery 50% Improvement of symptoms no difference vs sinus surgery
Mupiricin use Use mupiricin with
Recurrent crusting, particularly anterior Congestion, headache, green secretions & normal CT
– contact points, spurs Polyps
Mupiricin (Bactroban 2%) anteriorly with finger or Q tip, blot nose
Dissolved in saline, irrigate nose and sinuses with sinus rinse, along with budesonide
Polyp treatments - 2007 Anticipate 25+% improve with sinus Rx + nasal CCS Another 25-50% improve with sinus Rx + high dose nasal
CCS (FP drops or MDI, or nasal lavages with budesonide) The remainder improve with oral CCS + FP or nasal
lavages with budesonide solution Overall medical treatment can get close to 100%
success Mupiricin appears to help prevent regrowth, especially
with crusting Surgery, properly done, is successful short-term but
polyps can and do recur and repeated surgery gets progressively more difficult and dangerous!
Polyps – recommended treatment - 2007
Treat underlying sinusitis High dose nasal CCS
Fluticasone (FP), either nasal drops (EU) or MDI (USA) through nasal adapter (such as a baby bottle nipple)
Prednisone 20-30 mg Daily x 3-4 weeks, then QOD, then taper to 0
Budesonide solution (Pulmicort Respules) dissolved in sinus lavage Wash with the head positioned with ear turned to the knee
Mupiricin ointment topically or dissolved in sinus lavavge Consider careful surgery if polyps are persistent, resistant or
recur Consider oral or topical anti-fungal treatment
Conclusions - 1
Lack of controlled studies in Chronic Rhinosinusitis/Nasal Polyps!!
Current standard treatment for CRS: Nasal douche with saline Topical corticosteroidsBUT in NP: reversible effect, no resolution of NP Surgery: endoscopic sinus surgeryBUT in NP: high recurrence rate!!
Conclusions - 2Treat associated diseases: Allergic rhinitis
Combinations? Nasal douche Topical steroids (drops) Antibiotic ointment (mupiricin) Long term antibiotics (macrolides or doxycycline)
Anti IgE
Anti-IgE?
Antibiotics? Anti-fungal?
IL-5
ECP
Eotaxin
IgEAnti
IL-5
Anti-IL-5?
Corticosteroids? Anti-LTs?
Anti-CCR3?
Tacrolimus?
Future therapies in nasal polyposis
Summary - chronic rhinosinusitis
CRS is common; nasal polyposis occurs in about 25% CRS
Nasal polyposis is a complex disease to treat and few etiologic answers are known
Polyposis is nearly always associated with CRS and makes treating underlying sinusitis more difficult
Treat for sinusitis plus high dose nasal corticosteroids, particularly in solution. Consider topical antibiotics
Surgery may be beneficial, especially when combined with good medical care
Nasal polyps recur – this is a chronic, relapsing disease
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