[START 265071_01_FR_Sindwani_pt1_030219 (7 min).mp3] Raj Sindwani, MD: [00:00:07] Hello, I am Dr Raj Sindwani from the Cleveland Clinic. Welcome to this program entitled Evaluating the Latest Data in the Medical Management of Chronic Rhinosinusitis. [[delete 00:17- 00:34]] [00:00:17] Today we are going to discuss diagnosing chronic rhinosinusitis, treating patients with chronic sinusitis without nasal polyps, and treating patients with chronic sinusitis with nasal polyps. We will also highlight some of our discussions and discuss future directions. [00:00:34] Let us first discuss the diagnosis of CRS, or chronic rhinosinusitis. Joining me for this segment is Dr Anju Peters from Northwestern University’s Fienberg School of Medicine. Welcome Anju. Anju Peters, MD: [00:00:46] Thank you Raj. [[VPP NOTE: There was no production kit sent with this program so program was filmed with laptops as monitors, stools (no desk), things on boxes etc). Is there anything that can be done they seem to be staring off into space withtheir eyes darting around (they never look like they are looking at each other)]] Burden of CRS Dr Sindwani: [00:00:47] Anju, before we begin discussing diagnosis, let us chat first about the burden of CRS. I think it is worth highlighting that CRS is associated with reduced quality of life, sleep quality, and productivity. We know it is a major health problem effecting 3 to 7% of the total US population, and has an overall societal cost in the range of billions of dollars. [00:01:09] Anju, with that said, how do we diagnose the significant health issue? CRS Diagnostic Criteria Dr Peters: [00:01:14] Raj, as you mention, chronic sinusitis or rhinosinusitis has significant burden. It is worth noting that CRS is now recognized as predominately an inflammatory condition, somewhat similar to asthma. CRS has multiple phenotypes as to how it presents, but typically for diagnosis of chronic rhinosinusitis, it is thought that patients should have had symptoms for at least 3 months or more, and have some symptoms suggestive of chronic rhinosinusitis are drainage either from the front or the back of the throat with posterior nasal drainage. Often it is mucopurulent. There is nasal congestion or blockage. These patients may have facial pressure, pain, fullness, and sometimes have decreased sense of smell. [00:02:05] In addition to the symptoms, the diagnosis of chronic rhinosinusitis needs objective documentation of inflammation either by endoscopy where you may see drainage, you may see edema, or polyps, or by sinus CT scan which shows inflammation of one of the sinuses. CRS Differential Diagnosis Dr Sindwani: [00:02:24] [[delete 2:24-2:25]] Very good. It has always struck me though, Anju, that many of the signs and symptoms for CRS that you just alluded to can be fairly nonspecific. Can you talk to us about the differential diagnosis that we should be considering[[delete2:25-2:39]] when we consider a diagnosis of chronic rhinosinusitis? Dr Peters: [00:02:39] You are right Raj. The symptoms of chronic rhinosinusitis are often nonspecific; headaches, pressure, congestion, drainage. Other conditions that are somewhat similar in symptoms include most commonly allergic rhinitis, which may affect 20% of the population. [[ delete 2:57-3:00]]delete Others that I would think of would be nonallergic rhinitis, which is similarly inflammation in the nasal passages, but does not have allergic triggers, is more often triggered by irritants. [[delete 3:09-3:11]]You may get obstruction or congestion in the nose if there are anatomic deformities such as nasal septal deviation. [00:03:18] Finally, headaches from neurological causes or facial pain may present very similarly to chronic rhinosinusitis. Dr Sindwani: [00:03:27] [[delete 3;27-3:28]]Very good. Anju, how do you evaluate a patient with CRS? CRS Classification Dr Peters: [00:03:30] When I see a patient in my clinic who I think has chronic rhinosinusitis or is referred to me for chronic rhinosinusitis, I think about the different phenotypes of chronic rhinosinusitis presents. Typically, we think of it as chronic rhinosinusitis without polyps, which is about 80% of patients with chronic rhinosinusitis, and then 20% is chronic rhinosinusitis with nasal polyps [[delete 3:55- 4:01]]that you and Dr Han will talk about later on in these segments. [00:04:01] Other forms of chronic rhinosinusitis worth mentioning including allergic fungal rhinosinusitis or ARD or aspirin exacerbated respiratory disease. When I see these patients with the clinical symptoms, I think of other contributing factors of comorbid conditions such as allergic rhinitis [[delete4:28-4:31]] I would also…, so one of the first things I would do is consider testing them for allergies to treat their allergic rhinitis. Stepwise Evaluation of CRS [00:04:28] Here is a good time to say that asthma is very common in patients with chronic rhinosinusitis, so I would evaluate for that. I would look for an infectious cause, and then I would initiate treatment and see them back for follow up in 6 weeks or so. Depending on how a patient is doing, I may consider a sinus CT scan to make sure to look at the extent of disease to see am I treating the right condition, and then go from there. Dr Sindwani: [00:04:57] That is very good. You like to treat first, and then do the CT scan posttreatment, whether they are doing well or if they are not doing well. Dr Peters: [00:05:05] Yes, most often I would do that. As part of the evaluation, obviously you have a physical exam with endoscopy most often to look for inflammation as well, so you have some idea you are treating chronic rhinosinusitis, but a CT after treatment if someone is not doing better is a great idea. Key takeaways Dr Sindwani: [00:05:22] [[delete 5:23-5:26]]Thank you Anju. Let us summarize with a few takeaway steps. Can you talk a little bit about what some of the key points are that we just discussed? Dr Peters: [00:05:30] Sure Raj. It is important to remember if you see a patient with chronic rhinosinusitis, getting a thorough history, doing a physical examination often with endoscopy is important for the accurate diagnosis and initial treatment of chronic rhinosinusitis. [00:05:45] I would explore and manage comorbidities such as asthma and allergic rhinitis, and then finally imaging with a CT scan of the sinuses for patients who do not do well with the initial treatment. Dr Sindwani: [00:05:57] Thank you Anju. This has been a great discussion. Thank you. Please continue on to the next segment. [END 265071_01_FR_Sindwani_pt1_030219 (7 min).mp3] [START 265071_01_FR_Sindwani_pt2_030219 (8 min).mp3] Raj Sindwani, MD: [00:00:07] Welcome to this segment on the treatment of chronic rhinosinusitis without nasal polyps. My name is Raj Sindwani, and I am again joined by Dr Anju Peters. Welcome back Anju. [[delete 00:17-00:18]] Anju Peters, MD: [00:00:17] Thank you Raj. Classification and Treatment of CRS Dr Sindwani: [00:00:18] Earlier we discussed that CRS is classified by the presence or absence of nasal polyps. Can you tell us Anju, how does that impact treatment? Dr Peters: [00:00:25] Sure. Classification of CRS into CRS with nasal polyps, which is about 20% of CRS, and CRS without polyps, which is majority of CRS, or chronic rhinosinusitis, about 80% does impact therapy, as there may be differences in treatment responses and recurrence. [[VPP delete awkward pause 00:44-00:45]] [00:00:45] We individualize the treatment based on the severity of the symptoms, and based on the presence or absence of polyps. The main treatment option for CRS is topical nasal steroids and saline irrigations. The delivery of topical steroids can be by standardized nasal sprays or we have other ways of delivering nasal steroids. Initial Therapy for CRS without Nasal Polyps Dr Sindwani: [00:01:08]: Let us dive into treatment a little bit more. Can you discuss the types of initial therapy for a patient without nasal polyps Anju? Dr Peters: [00:01:46] Sure. The initial therapy for my patients without nasal polyps with chronic rhinosinusitis I prescribe nasal steroids, as they are the first line treatment option. They decrease inflammation, and they have shown to improve symptoms. In addition, large volume saline irrigations help. They help clean the nasal passages. They decrease inflammation, but are best used as adjunct to nasal steroids. [00:01:41] We do know that penetration of traditional nasal sprays is limited, especially in patients who have not had surgery.[[delete 1:50-1:53]] We have other ways of delivering the nasal steroids. Steroid Delivery Method Dr Sindwani: [00:01:54] Tell me a little bit abut some of those other ways to get steroid into the nose. You mentioned postoperative sinus cavity is a big predicate. What other devices are available? Dr Peters: [00:02:03] Sure, other ways of delivering the nasal steroids, you could do large volume irrigation with squeeze bottle. There are atomizers. There are nebulizers. What is important to know, that the low pressure large volume saline irrigation is more effective than topical nasal sprays. They have shown to improve quality of life, improve symptoms, and decrease disease severity as you see on CT scan and endoscopy. [[VPP delete where Sindwani say ok in the background: 2:28-2:30]] [00:02:29] In addition, I would like to mention that it does work better in patients with surgeries, but there is some data that these large volume irrigations with steroids work in patients who have not had surgery. Finally, there are new devices being studied, one which is an exhalation delivery system with fluticasone, has been approved for nasal polyps, and Jo and you will discuss this further. It is being studied in patients without polyps. Safety of Topical Steroids Dr Sindwani: [00:02:56] Very good. As far as topical steroid treatment for CRS, Anju, are there any safety concerns over the long-term for using these medications for years? Dr Peters: [00:03:05] As we have talked about it, CRS by definition is a chronic process, so long-term treatment is needed. Long-term treatment with topical steroids, it is recommended. These are very safe long-term, occasionally there may be nasal irritation or epistaxis, but you can really limit this by teaching proper technique for the use of these steroids. Dr Sindwani: [00:03:25] Tell me about that. That is a really important point that I think everyone needs to take away. How do you use a traditional nasal steroid spray effectively from a technique standpoint? Dr Peters: [00:03:34] What I tell my patients is look down, put the nasal steroids spray in your nasal pharynx, aim it a little bit laterally. You do not want to spray it towards the septum or you will get irritation. Aim it laterally, spray it, and then breathe in gently. You do not want to sniff it up hard, or it just goes down your throat. Dr Sindwani: [00:03:54] Very good, we also teach the right hand to spray the left nostril out to the ear. Go on, what else were you going to tell us about the safety of steroid sprays? Dr Peters: [00:04:02] I think I want you guys, and you know it, but people to note that at the way the doses we use the topical steroids, steroid rinses, steroid sprays, there is really no evidence for adrenal suppression at these doses. It is important to know that we need long-term therapy with these steroids. The Role of Antibiotics in CRS without Polyps Dr Sindwani: [00:04:18] Very good. What about the role of antibiotics in chronic sinusitis without nasal polyps Anju. This has really gone over a lot of change in our thought process. You mentioned CRS is now considered an inflammatory disease, so then why should we, or do we give antibiotics? [[delete 4:33-4:35]] Dr Peters: [00:04:33] Sure, Raj, that is actually a very good comment. We think of CRS as being an inflammatory disease. We do not know the exact role of bacteria in CRS without polyps. However, we do think that infection may play a role, especially in some patients. The way we use antibiotics is we use it for 2 to 3 weeks, courses of oral antibiotics often in conjunction with a short course of oral steroids. [00:05:00] Typical antibiotics would be amoxicillin, clavulanate, and doxycycline. Sometimes we may consider a longer course of antibiotics, especially macrolides, which in some studies have shown improvement in quality of life. [[delete 5:14-5:20]]This may actually be more of an antiinflammatory mechanism. Strategy for Treatment-Refractory CRS Dr Sindwani: [00:05:19] Okay Anju, what about those patients that fail the response to this initial therapy? What do you do next? Dr Peters: [00:05:24] Sure, if patients do not respond to initial therapy, then I would reevaluate them, looking for other things including comorbid conditions such as immunodeficiency, but first I would do a sinus CT scan to assess the extent of disease, and also to confirm that I am treating chronic rhinosinusitis. [00:05:43] If a patient continues also to have infectious exacerbations, and then I may consider endoscopic guided culture that an appropriate antibiotic is used. Finally, I do want to mention that we do not typically use long courses of oral steroids, as they increase risk of steroid induced adverse effects. Finally, if medical management fails, then eyes and allergist would recommend evaluation by an ENT for possible surgical options. When to Consider Endoscopic Sinus Surgery Dr Sindwani: [00:06:13] Excellent. To add the ENT perspective then, when a patient fails appropriate therapy, is not doing well from a symptom standpoint, and third point, a CT scan done after treatment shows significant disease, that is indeed when we consider endoscopic sinus surgery, or functional endoscopic sinus surgery known as FES. [00:06:32] This minimally invasive surgery is very well tolerated, and has been shown to significantly improve quality of life in chronic sinusitis, both with and without polyps. Key Takeaways [00:06:43] Anju, can you summarize by sharing a few key takeaway points for us? Dr Peters: [00:06:46] [[delete 6:45-6:48]] Sure Raj, I would be happy to. Important to remember that medical treatment of chronic rhinosinusitis without polyps includes topical steroids and saline irrigation, which are long-term therapies that reduce inflammation and improve symptoms and quality of life? We often use antibiotics with or without short courses of oral steroids, and use them for acute exacerbations. [[delete7:09-7:11]] Finally, also important to remember to treat comorbid allergic rhinitis and asthma, and if there is an immunodeficiency. Dr Sindwani: [00:07:18] Thank you Anju, this has been a great discussion. Thank you. Please continue on to the next segment. [END 25071_01_FR_Sindwani_pt2_030219 (8min).mp3]