Rhinosinusitis, chronic J32.-

Chronic rhinosinusitis CRS is diagnosed when typical complaints or symptoms (nasal breathing obstruction, antero-nasal and/or retro-nasal secretion (also known as postnasal drip: nasal secretion running down the throat), facial pain, headache, olfactory disturbance or facultative symptoms (feeling of illness, pressure pain above the forehead or throat) are present. maxillary sinus, complaints in the area of the teeth and the periodontium, increase in pain when bending forward) that last > 12 weeks or if > 4 episodes of acute rhinosinusitis occur in one year without symptom-free intervals in between. In principle, the symptoms of CRS are similar to those of acute rhinosinusitis, but in an attenuated form. As with the acute form, the severity of the disease of CRS can be classified as mild, moderate or severe. This can be done with the aid of a visual analogue scale (VAS) of 0-10 (10 = maximum interference). From a VAS value of 5, a reduction in quality of life is assumed. A major problem of CRS patients is the indirect consequences of illness such as sleep reduction, concentration disorders, fatigue and general exhaustion.

Ear, nose and throat guidelines (Tokunaga T et al. 2015) distinguish between:

• CRS without nasal polyps (CRSsNP)
• CRS with nasal polyps (CRSwNP) - special form of ASS intolerance syndrome(Santer's disease) and further classification into
• CRSwNP without mucosal eosinophils
• CRSwNP with mucosal eosinophils (ECRSwNP)
• (Non-invasive) Allergic Fungal Rhinosinusitis (AFRS)

The prevalence of CRS is estimated to be between 4.5% and 12% in North America and European countries respectively (DeConde et al 2016).

In chronic rhinosinusitis the causes (in contrast to acute rhinosinusitis) are still largely unexplained. Ignorance of the exact disease mechanisms has so far led to a polypragmatic, decongestant, anti-inflammatory and antimicrobial therapeutic approach.

There is evidence that environmental pollution, active and passive exposure to cigarette smoking, perennial allergic rhinitis, gastroesophageal reflux, immunodeficiencies, play a pathogenetic role.

Microbial factors: The triggers are previous or existing viral (predominantly), bacterial, mycotic infections. Staphylococcus aureus is found in patients with bronchial asthma or ASA intolerance in the nasal vestibule and the main nasal cavity in up to 90% of cases (normal in about 1/3 of the European population). The pathogen can also survive intracellularly (epithelial cells, macrophages, fibroblasts). Under certain conditions, staphylococci can release enterotoxins that act as superantigens and induce a massive Th2 directed local immunological (eosinophilic) response. This pathomechanism seems to play a major role in the development of polyps.

Biofilms: The pathogenetic role of mono- and polybacterial biofilms in CRS is still unclear. These are mainly formed by Staphylococcus aureus, but also by Haemophilus influenza (also Pseudomonas aeroginosa?). These colonise biotic as well as abiotic surfaces, bypass the body's own immune defence and lead to a reduced sensitivity to antibiotics, while retaining the ability to release planktonic bacteria (Foreman A et al. 2009). Bacterial biofilms appear to be associated with increased local lymphocytic inflammation with increased gamma-interferon production and different types of antibiotics (Foreman A et al. 2009). growth factors (Hekiert AM et al. 2009).

Mucociliary transport: Disturbances of mucociliary transport (MT) have been detected especially in IgE-mediated (allergic) chronic rhinosinusitis. To what extent the mucociliary clearance plays a role in the pathogenesis of this disease remains to be seen.

Other: CRS can also occur in bronchial asthma, in anatomical malformations of the nasal cavity, as intolerance reaction against non-steroidal anti-inflammatory drugs (ASA intolerance syndrome - Santer's disease), as toxin-induced rhinitis or in immunoglobulin deficiency: V.a. IgA deficiency (an immunoglobulin deficiency is found in about 13% of patients with therapy-refractory > 4 months persistent CRS - Schwitzguébel AJ et al. 2015)

Determination of inflammation parameters such as CRP, BSG; IgE, specific IgE. In refractory forms of CRS, the determination of immunoglobulin fractions is useful (clarification of an immune defect, especially IgA deficiency).

Microbiological methods: In therapy-resistant RS and in patients with immune deficiency, a smear with an antibiogram and, if necessary, further microbiological tests can be the basis of a calculated therapy. A controlled collection of samples from the middle nasal passage, or (better) from the "pointum maximum" of the inflammation area should be aimed for.

Allergological examination: In case of etiologically unexplained chronic rhinosinusitis and in case of anamnestic/clinical indications of allergic etiology, a subtle allergological diagnosis (prick test, determination of specific IgE from serum) is recommended.

CRS is usually diagnosed by the clinical symptoms, their duration and severity and by the clinical findings.

The following clinical examination procedures are diagnostic tools:

• general clinical impression, inspection, pressure/tapping pain over maxillary or frontal sinuses
• Rhinoscopy and/or nasal endoscopy.
• By means of nasal endoscopy, inflammatory mucosal changes and polyps can be detected.
• in addition, computer tomographic images can provide an insight into the paranasal sinuses.

A CRS can be a partial or initial manifestation of a systemic disease. The following must be excluded: granulomatosis with polyangiitis (Wegner's granulomatosis), nasal sarcoidosis (rare), eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome),
Cartagenic syndrome.

Serious complications are rare; orbital and intracranial inflammation may occur. Furthermore, involvement of the surrounding soft tissue and bone is possible. In about 50% of patients polyps are also detectable (Bachert C et al. 2008), see below. Classification.

The comorbidity of allergic rhinitis and bronchial asthma is confirmed. It is significantly higher in children than in adults (45% versus 35%).

Alpha-sympathomimetics: Alpha-sympathomimetics (e.g. xylmetazoline, oxymetazoline, tramazoline, tetryzoline) are available for topical application on the nose. They stimulate sympathetic alpha1- and alpha2- receptors and cause a vasoconstriction of the mucosal capacity vessels when applied nasally. They are rapidly and effectively effective (danger of tachyphylaxis with loss of efficacy; with long-term use danger of mucous membrane damage - rhinopathia medicamentosa = privinism).

Topical Glucocorticoids: Topical glucocorticoids show high efficacy on nasal fruit friction in both acute and chronic rhinosinusitis in allergic rhinitis. Improvement of symptoms is not expected immediately but after 2-4 days in seasonal RS and after 2-3 weeks in perennial RS. They should be used regularly according to a prescribed schedule and not only when "needed". Dexamethasone, beclomethasone dipropionate, flunisolide, budesonide, triamcinolone acetonide, momethasone furoate, fluticasone propionate, fluticasone furoate are available for nasal application. The modern glucocorticoids used in local therapy (in particular the C6/C9-halogenated glucocorticosteroids) are characterized by a high lipophilicity, a pronounced tissue binding with high receptor affinity. This is usually expressed as receptor affinity (RRA) with reference to dexamethasone (RRA=100) (Klimek M et al. 2011). The modern nasally applied glucocorticosteroids have a 10-3 times more potent effect than dexamethasone.

Glucocorticoid combinations: The combination of fluticasone propionate and azelastine hydrochloride showed a synergistic effect on nasal fruit friction; the effects were superior to the individual application.

In the European as well as in the German guideline, the combination therapy with topical glucocorticoids (fluticasone, mometasone, betamethasone) alone or in combination with systemic antibiotics - is recommended in acute bacterial rhinosinusitis as well as in the chronic form. In allergic and polyposis forms of chronic rhinosinusitis, locally applied glucocorticoids are the therapy of choice.

Topical anticholinergics: They act by competitively inhibiting muscarinergic acetylcholine receptors, which are found in the nasal mucosa on glandular cells. Their indication is uncontrollable nasal hypersecretion. A representative of this group is ipratropium, which is not approved in Germany. For this preparation there is a positive recommendation of the European guidelines commission (recommendation grade A) for the therapy of a viral infection of the upper respiratory tract.

Topical mast cell stabilizers: The active substance group of the so-called chromones comprises disodium cromoglicic acid (DNCG) and Nedocromil. They are available as local therapeutics and act by inhibiting degranulation and thus mediator release on mast cells. Nedocromil additionally inhibits chemotaxis of neutrophil granulocytes.

Topical H1-blockers: Histamine antagonists have a better effect on hypersecretion, itching and sneezing than on allergic mucosal swelling. Azelastine, levocabastine and ketotifen are available for topical-nasal application. They show a comparable potential as the oral H1-antihistaminkka: As herbal decongestives (decongestant therapeutics), extracts of chamomile blossoms (e.g. Soledum med.® nasal drops, 1-2 sprays several times a day) work. Furthermore, essential oils such as eucalyptus oil, pine needle oil, levomenthol (available as a combination preparation in Pinimethol® cold ointment (dosage: for rubbing in or inhaling 2-3 times a day; for inhaling, a 10 cm long ointment strand is applied to hot water in a small bowl). Also possible as bath additive. In addition, camphor applications should be mentioned.

Secretolysis: Secretolytic effect (especially suitable for children) especially with steam inhalates, e.g. with thyme herba (thyme herb) or chamomile flowers. Use: Pour boiling water over the camomile flowers in a large bowl. Cover the head well with a large bath towel; inhale for 5-10 minutes for children and 10-15 minutes for adults. Cave: Children must be monitored permanently! For older children or adults, the inhalate can be supplemented with 2 drops of tymian oil/eucalyptus oil; alternatively with 1 tablespoon of table salt.

Nasal rinsing with saline solution: For the symptomatic local therapy of CRS, the consistent use of nasal rinsing with saline solutions (possibly applications with seawater), e.g. as voluminous (≥150 ml), iso- to slightly hypertonic solutions in the form of a nasal douche, is useful. However, they should not be used as the sole measure.

Antihistamines: Modern antihistamines, which have anti-inflammatory properties in addition to their H1-blocking effect, are mainly used in acute and chronic allergic rhinosinustitis. With Fexofenadin, Levocetericin and Desloratidin highly effective therapeutics are available. Rupatidine is an antihistamine with peripheral antihistamine activity and PAF receptor antagonizing properties. Bilastine is another modern antihistamine available.

Antibiotics: In the case of non-complicative ARS or acute exacerbation of recurrent ARS, the administration of antibiotics is generally not necessary. Antibiotics are indicated in patients with special risk factors. These include chronic inflammatory lung diseases, immunodeficiencies or drug or disease-related immunosuppression.

Antibiotic therapy is recommended for ARS or in the case of acute exacerbation of recurrent ARS or chronic RS with considerable pain and increased inflammatory values (CRP > 10 mg/l or significantly increased BSG and/or fever > 38.5 °C. The first choice is amoxicillin (dosage: 3x500mg/day p.o.) or a cephalosporin derivative (e.g. cefuroxime 2 x 250mg/day p.o.). Alternatively macrolides (e.g. azithromycin 500mg/day p.o.) or doxycycline or co-trimoxazole or amoxicillin in combination with clavulanic acid.

Analgesics/non-steroidal anti-inflammatory drugs (NSAIDs): A meta-analysis from 2013 (1069 patients), concludes that NSAIDs such as ibuprofen effectively relieve symptoms such as fatigue, cold pain (headache, sore throat, earache, limb pain), sneezing attacks in acute RS. Similar results are available for paracetamol and acetylsalicylic acid. The German guideline also mentions diclofenac as an alternative to ibuprofen as comparably effective.

Virustatics: In addition to the symptomatic therapy approaches, virustatics (neuraminidase inhibitors) are also considered. The inhibitors oseltamivir and zanamivir are possibilities for the treatment of risk patients.

If the drug measures do not sufficiently improve the chronic complaints, the guideline of the ear, nose and throat physicians at CRS recommends surgical treatment. This is usually done endoscopically through the nasal opening. The nasal septum can be straightened by surgical intervention. Furthermore, polyps can be removed or the chronic inflammatory mucosa can be ablated.

A CRS may be associated with a history of years or even a lifetime.

Phytotherapeutics: Phytotherapeutically proven in practice is secretolysis with a combination preparation containingverbena (Verbenae Herba): together with Gentianae radix (gentian root)+ Herba Rumicis acetosae (garden sorrel)+ Sambuci flos (elderflower)+ Primulae flos (primula with calyx) as Sinupret forte® (dosage: 1-1-1Drg) or as Sinupret Saft® (7.0ml-7.0ml-7.0ml p.o. - for children from 2-5-LJ: 2.1ml-2.1ml-2.1ml p.o.; for children from 6-11-LJ: 3.5ml-3.5ml-3.5ml p.o.). In the German guideline bromelain is also mentioned. Bromelain in addition to the standard therapy (e.g. antibiotics for bacterial rhinosinusitis) seems to alleviate symptoms.

Phytotherapeutics at elevated temperature with a general feeling of illness (in case of recurrent relapsing activity of chronic rhinosinusitis) may be used in combination with nasturtium (Angocin Anti-Infekt® (dosage: 4-4-4 Filmtbl. p.o. after meals).

Probiotics: The prophylactic effect of probiotics, especially lactobacilli and bifidobacteria, against respiratory tract infections (metaanlayse from 2011) is not proven.

Traditional Chinese Medicine: No recommendation is explicitly made for Traditional Chinese Medicine due to insufficient data. The data situation for preparations containing echinacea is contradictory; their use is not recommended for therapy.

Menthol, camphor and cineol are contraindicated in the treatment of infants and young children or patients with obstructive pulmonary diseases. If infants are to be treated with essential oils, the corresponding preparation should only be dripped onto the pillow or bib!

An adaptive deactivation treatment should be performed in patients with confirmed NERD syndrome (NSAR-Exacerbated Resipratory Disease, Analgesic Intolerance Syndrome) and CRScNP in case of recurrent polyposis.

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