Rhinosinusitis: Global Overview
Introduction
Rhinosinusitis is a global problem.
A survey of allergy and otorhinolaryngology (ear, nose and throat) experts from around the world demonstrates the similarities and differences in diagnostic and management practices that exist currently.
Since rhinitis and sinusitis occur so frequently together and the same mucosal tissue lines both the nose and the sinuses, "rhinosinusitis" is agreed worldwide to be the most appropriate term to describe this condition. Chronic rhinosinusitis is the form of the disease most commonly seen by the experts surveyed, with acute rhinosinusitis the next most common.
Worldwide, patients with rhinosinusitis are usually treated by otorhinolaryngologists (ORL’s) or general practitioners/family doctors. Allergists are the health professionals next most likely to be involved in the management of rhinosinusitis, followed by general physicians. Pharmacists are rarely involved in the management of this condition.
The Diagnosis of Rhinosinusitis
- Nasal examination is routinely performed in patients seen by ORL’s and in 68% of patients seen by allergists.
- Allergy skin tests are performed in 91% of patients with sinusitis seen by a panel of allergists and in less than 10% seen by ORL’s.
- Allergy blood tests are not commonly used but are more likely to be performed by allergists and rarely by ORL’s.
- Allergists are more likely to consider diagnostic measurement of antibodies (IgG, IgA, IgM) and response to immunizations, than ORL’s.
- In South Africa, India, Japan, and Brazil, diagnostic sinus X-rays are performed in 77% of patients. In Europe there is a marked difference in the usage of sinus X-rays between ORL’s (0%) and allergists (100%).
- Diagnostic CT scans are more likely to be recommended by ORL’s than allergists. CT scanning is performed only if initial therapy is unsuccessful (South Africa, USA, Europe, Australia). ORL’s are more likely to request a CT scan if surgery is indicated (India, Japan) or to review the sinuses after an initial course of therapy (UK, USA).
- MRI scans are rarely used by either expert group.
Rhinosinusitis: Underlying or Concomitant Pathologies
Global estimate of prevalence of underlying pathologies when rhinosinusitis is present:
- Allergic rhinitis: 51%;
- Non-allergic rhinitis: 15%;
- Vasomotor rhinitis: 6.3%;
- Aspirin sensitivity: 3.7%;
- Non-allergic rhinitis with eosinophilia symdrome (NARES): 2.3%;
- Abnormalities of sinus outflow tract;
- Septal deviation, 15.7%
- Concha bullosum, 9.2%
- Paradoxical curvature middle turbinate, 3.5%
- Haller cells, 1.5%
- Immunodeficiency: 3.7%;
- Cystic Fibrosis: 2.7%;
- Fungal infection: 5%.
The Management of Rhinosinusitis Worldwide
Allergists would refer the patient to an ORL if initial therapy were unsuccessful or if there were evidence of nasal blockage following initial therapy.
Recommended therapies for acute rhinosinusitis
Antibiotics alone
Recommended therapies for recurrent acute rhinosinusitis
Antibiotics with decongestants
Recommended therapies for subacute rhinosinusitis
Antibiotics - with antihistamines and topical corticosteroids added to treatment by allergists
Recommended therapies for chronic rhinosinusitis
Antibiotics with topical corticosteroids and antihistamines
Additional therapies
Nasal saline washes are used in some countries for acute and chronic rhinosinusitis (USA, Japan and Brazil)
Allergy immunotherapy is not used in the treatment of rhinosinusitis unless the patient has concomitant allergic rhinitis. In Japan and Brazil it is especially used in the treatment of chronic rhinosinusitis when allergic rhinitis is present.
First-line therapies of choice are
Decongestant: oxymetazoline or xylometazoline.
Antibiotics: amoxycillin or amoxycillin and clavulanic acid combined
Antihistamines: cetirizine, clorpheniramine, fexofenadine, loratadine. clorpheniramine and others
Topical corticosteroids: beclomethasone dipropionate, budesonide, mometasone, flunisolide, fluticasone propionate, triamcinolone
Second-line antibiotics of choice: cephalosporins
