EPOS 2020 - New Classification and Rhinosinusitis Treatment Guidelines

The European Position Paper on Rhinosinusitis (EPOS 2020) will be the latest in the EPOS series of guidelines on rhinosinusitis from an international cohort of experts in the field. The first European Position Paper on Rhinosinusitis and Nasal Polyps (EP3OS) was published in 2005, and the latest European Position Paper on Rhinosinusitis, EPOS 2012 was hugely successful and widely cited worldwide. It delivered a comprehensive review of the key topics in an accessible format with clear research priorities. The core objective of the EPOS 2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations using guidelines, algorithms and schemes for the management (diagnosis, treatment and follow-up) of rhinosinusitis (acute and chronic, adult and paediatric). The document provides an update on the literature published and studies undertaken in the eight years since the EPOS 2012 position paper was published and aims to address areas not fully covered in the previous documents. It involves new stakeholders including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition used over the counter treatments. The evidence-based medicine (EBM) methodologies included randomized controlled trials (RCTs), observational studies (surgery) / real-life studies and network analysis and meta-analysis of systematic reviews were combined with the results from clinical trials. The new EPOS document presents a new classification of chronic rhinosinusitis dividing it into primary and secondary rhinosinusitis, and further into localized or diffuse disease, expanding from the previous phenotyping based only on the polyp presence or absence. The new classification also includes endotyping and etiology, primarily related to the absence of eosinophilic (Type 2 response) inflammation presence. The new evidence based treatment guidelines include a stepwise approach in the treatment of partly controlled and uncontrolled rhinosinusitis. New guidelines for the management of acute viral and postviral, acute bacterial and chronic rhinosinusitis are presented. The indication for the use of biologicals in the treatment of chronic rhinosinusitis is clearly defined

EPOS 2020 - New Classification and Rhinosinusitis Treatment Guidelines

The European Position Paper on Rhinosinusitis (EPOS 2020) will be the latest in the EPOS series of guidelines on rhinosinusitis from an international cohort of experts in the field. The first European Position Paper on Rhinosinusitis and Nasal Polyps (EP3OS) was published in 2005, and the latest European Position Paper on Rhinosinusitis, EPOS 2012 was hugely successful and widely cited worldwide. It delivered a comprehensive review of the key topics in an accessible format with clear research priorities. The core objective of the EPOS 2020 guideline is to provide revised, up-to-date and clear evidence-based recommendations using guidelines, algorithms and schemes for the management (diagnosis, treatment and follow-up) of rhinosinusitis (acute and chronic, adult and paediatric). The document provides an update on the literature published and studies undertaken in the eight years since the EPOS 2012 position paper was published and aims to address areas not fully covered in the previous documents. It involves new stakeholders including pharmacists, nurses, specialised care givers and indeed patients themselves, who employ increasing self-management of their condition used over the counter treatments. The evidence-based medicine (EBM) methodologies included randomized controlled trials (RCTs), observational studies (surgery) / real-life studies and network analysis and meta-analysis of systematic reviews were combined with the results from clinical trials. The new EPOS document presents a new classification of chronic rhinosinusitis dividing it into primary and secondary rhinosinusitis, and further into localized or diffuse disease, expanding from the previous phenotyping based only on the polyp presence or absence. The new classification also includes endotyping and etiology, primarily related to the absence of eosinophilic (Type 2 response) inflammation presence. The new evidence based treatment guidelines include a stepwise approach in the treatment of partly controlled and uncontrolled rhinosinusitis. New guidelines for the management of acute viral and postviral, acute bacterial and chronic rhinosinusitis are presented. The indication for the use of biologicals in the treatment of chronic rhinosinusitis is clearly defined

Uloga otalgija u diferencijalnoj dijagnostici temporomandibularnih poremećaja

Otalgia (earache) is pain presented in the ear, which does not necessarily originate from the ear (primary otalgia). In the differential diagnostics of (secondary) otalgia cervicocephalic syndrome, temporomandibular disorders, odontogenic pathology, parotitis, tonsillitis, pharyngitis, epiglottis, oesophagitis and malignant tumours infiltrating trigeminal, vagal or auricular (cervical) nerves branches from oesophagus inferiorly and skull base cephalad, should be considered. Primary otalgia is usually confined to external otitis or acute otitis media, while it is rarely found as a symptom of chronic otitis media, except in exacerbations. In the chronic otitis media earache is usually a sign of complication and expansion of inflammation to the dura and cranial nerves. In the differential diagnostics of primary otalgia otoscopy and otomicroscopy are necessary, as well as radiologic work-out, where CT and MRI scans are replacing former conventional x-.ray Schuller and Stenvers views. If otalgia is associated with hearing or balance disorders without clinical manifestation of otitis, the etiology is most commonly viral neuritis of temporal bone nerves, and otoneurological diagnostic workout should be considered. If (secondary) otalgia is associated with dysphagia or odinophagia, the most common etiology would be tonsillopharyngitis, but quinsy, epiglottitis, tongue base abscess, parapharyngeal abscess, and tumours of pharynx, tonsill or tongue base or epiglottis should be considered. Eagle syndrom or elonged styloid process syndrom is also characterised by painful swallowing and referred otalgia. Earache can be caused by temporomandibular disorders, where otalgia is usually increased by mastication and joint palpation. The role of otorhinolaryngologist is to exclude otogenic and pharyngogenic otalgia, and the differential diagnostics should include workout considering cervicogenic otalgia (cervical spine x-ray or MRI), temporomandibular disorders (TMJ x-ray, dentist consultation), or odontogenic otalgia (dentist consultation). The diagnostic workout of otalgia should include radiologist, dentist, reumatologist, and neurologist.Otalgija je bol koja se prezentira u području uha, međutim to ne uključuje nužno otogenu etiologiju. U diferencijalnoj dijagnostici otalgije dolaze u obzir cervikocefalni sindrom, artralgija temporomandibularnog zgloba, odontogeni procesi, parotitis, tonzilitis, faringitis, epiglotitis, ezofagitis te maligni tumori s infiltracijom grana trigeminusa, vagusa i auricularis magnusa, koji se inferiorno šire do područja jednjaka, a kranijalno do lubanjske baze. Otogena bol najčešće se susreće u upalama vanjskog i srednjeg uha, dok je rijetka u kroničnim upalama, osim u fazama egzacerbacije. Kod kroničnih upala srednjeg uha, bol je znak komplikacije i širenja bolesti prema duri ili kranijskim živcima. Za diferencijalnu dijagnostiku otogene boli nužna je otoskopija, katkad mikrootoskopija, te radiološka dijagnostika, ranije konvencionalne snimke temporalne kosti po Schulleru i Stenversu, koje danas sve više zamjenjuje CT i MRI. Ako je bol povezana s ispadom sluha ili ravnoteže, što je najčešće rezultat virusnog neuritisa u temporalnoj kosti, a bez kliničke manifestacije otitisa, u obzir dolazi i audiovestibulološka dijagnostika. Ako je otalgija povezana s disfagijom ili odinofagijom, najčešće je riječ o tonzilofaringitisu, ali u obzir dolaze i peritonzilarni apsces, epiglotitis, apsces korijena jezika, parafaringealni apsces, tumor ždrijela, tonzile, korijena jezika ili epiglotitis. Eaglov sindrom, sindrom elongiranog stiloidnog nastavka, također uključuje bolno gutanje i refleksnu bol u uhu. Bolovi u uhu mogu biti uvjetovani temporomandibularnim poremećajima, s time da se otalgija pojačava žvakanjem ili palpacijom zgloba. Uloga otorinolaringologa jest isključiti otogenu ili faringolaringogenu otalgiju, a potom se diferencijalno dijagnostički uključuje obrada u smjeru cervikogene otalgije (radiološka obrada vratne kralježnice), artralgije temporomandibularnog zgloba (radiološka obrada zgloba, konzultacija stomatologa) ili odontogene otalgije (konzultacija stomatologa). U tome su smislu u obradu uključeni radiolog, stomatolog, reumatolog i neurolog

RHINITIS IN ADULTS

Rinitis je upala nosne sluznice različite etiologije, uključujući infekciju, alergiju ili hiperreaktivni odgovor na raznovrsne podražaje iz okoline. Praćen je simptomima opstrukcije, hipersekrecije, kihanja ili svrbeža nosa. Klasifikacije rinitisa se oslanjaju na etiologiju i težinu simptoma. Iako je s epidemiološkog gledišta najčešći virusni rinitis u sklopu obične prehlade, javnozdravstveno se značenje prvenstveno fokusira na kronični rinitis, alergijski i nealergijski. Alergijski rinitis se etiološki dijeli na sezonski i perenijalni, a prema trajanju simptoma na intermitentni i perzistentni (do 4 tjedna ili do 4 dana u tjednu, odnosno dulje od 4 tjedna ili više od 4 tjedana). Nazalni simptomi kod nealergijskog hiperreaktivnog rinitisa mogu biti izazvani samo kratkotrajno, nosnom iritacijom samo u trenucima ekspozicije okidaču refleksnog odgovora. Zbog odsutnosti značajnijih razina upalnih elemenata u nosnoj sluznici, u nekim oblicima nealergijskog neinfektivnog rinitisa, takav se odgovor nosne sluznice na iritanse svrstava u kronične rinopatije, koji se u posljednje vrijeme definira najčešće kao idiopatska rinopatija. U takvim rinitisima ključna je uloga proteina koji reguliraju ionske kanale u nosnoj sluznici, te neuralnih refleksa, koji dovode do kongestije, hipersekrecije ili kihanja. Terapija kroničnih rinitisa, alergijskih i nealergijskih, temelji se na izbjegavanju alergena, odnosno okidača te na primjeni toalete nosnih šupljina, antihistaminika, topikalnih kortikosteroida, antikolinergika i imunoterapije.Rhinitis is a very common disorder caused by inflammation or irritation of nasal mucosa. Dominant symptoms are nasal obstruction; however, in some patients, runny nose, excessive sneezing or nasal itch may be the most bothersome symptoms. The most common causes of nasal inflammation are viral infections and allergic response to airborne allergens. Response to irritants may cause similar symptoms, although signs of inflammation may not always be present. Viral rhinitis is lasting up to 10 days and it is part of the common cold syndrome. In short-lived rhinitis, lasting for 7 to 10 days, sometimes it is not easy to differentiate between the potential causes of the disorder, if general symptoms of infection like fever and malaise are not present. In long-living rhinitis, it is important to differentiate between infectious, allergic, non-allergic non-infectious rhinitis, and chronic rhinosinusitis. Itch and ocular symptoms are more common in allergic rhinitis, while other symptoms like nasal obstruction, rhinorrhea and sneezing may affect patients with allergic and non-allergic rhinitis. Patients with allergic rhinitis often have symptoms after exposure to irritants, temperature and humidity changes, like patients with non-allergic rhinitis, and such exposure may sometimes cause more severe symptoms than exposure to allergens. Sensitivity to a non-specific trigger is usually called non-specific nasal hyperreactivity. Allergic rhinitis occurs due to immunoglobulin E (IgE) interaction with allergen in contact with nasal mucosa in a sensitized patient. Sensitization to certain airborne allergen, like pollens, dust, molds, animal dander, etc. usually occurs in families with allergy background, which is helpful in making diagnosis in patients who have rhinitis in a certain period of the year, or aggravation of nasal symptoms occurs in the environment typical of certain allergen. The diagnosis is clinically confirmed by proving sensitivity to certain allergen on skin prick test, and by proving specific antibody IgE in patient serum. Allergic rhinitis is categorized according to sensitivity to allergens that occur seasonally, like pollens, or to allergens that are present all year round, like house dust mite, molds and animal dander, into seasonal and perennial allergic rhinitis. Allergy to pollens causes the same mechanism of inflammation in response to allergens, which is the result of allergen binding to specific IgE antibody; however, patients with pollen allergy usually complain more of sneezing and runny nose, whereas patients with allergy to perennial allergens more often complain of obstruction, with the episodes of sneezing and runny nose occurring only when exposed to higher concentrations of allergens (house cleaning, around pets). Treatment includes avoidance of allergens, medical treatment and immunotherapy (allergy vaccines, tablets with allergens). Avoidance of allergens means reduction of environmental allergen load to the respiratory system including workplace, which is not easy to accomplish. Medical treatment is usually necessary to control symptoms, and it includes antihistamines, nasal or in tablets, and nasal glucocorticoids (steroids). Antihistamines should be second generation, which do not cause sedation, and such treatment shows more efficacy on runny nose, sneezing and nasal itch than on nasal stuffiness. Nasal steroids are more potent in improving nasal patency than antihistamines, and are at least as potent in the control of all other nasal and ocular symptoms. Nasal patency may be improved by nasal or oral decongestants, but such treatment should be reduced to as short period as possible, since after several days of using nasal decongestants rebound congestion may occur and patients will need nasal decongestants to improve nasal airways even when allergens are not around anymore

Uloga otalgija u diferencijalnoj dijagnostici temporomandibularnih poremećaja

Otalgia (earache) is pain presented in the ear, which does not necessarily originate from the ear (primary otalgia). In the differential diagnostics of (secondary) otalgia cervicocephalic syndrome, temporomandibular disorders, odontogenic pathology, parotitis, tonsillitis, pharyngitis, epiglottis, oesophagitis and malignant tumours infiltrating trigeminal, vagal or auricular (cervical) nerves branches from oesophagus inferiorly and skull base cephalad, should be considered. Primary otalgia is usually confined to external otitis or acute otitis media, while it is rarely found as a symptom of chronic otitis media, except in exacerbations. In the chronic otitis media earache is usually a sign of complication and expansion of inflammation to the dura and cranial nerves. In the differential diagnostics of primary otalgia otoscopy and otomicroscopy are necessary, as well as radiologic work-out, where CT and MRI scans are replacing former conventional x-.ray Schuller and Stenvers views. If otalgia is associated with hearing or balance disorders without clinical manifestation of otitis, the etiology is most commonly viral neuritis of temporal bone nerves, and otoneurological diagnostic workout should be considered. If (secondary) otalgia is associated with dysphagia or odinophagia, the most common etiology would be tonsillopharyngitis, but quinsy, epiglottitis, tongue base abscess, parapharyngeal abscess, and tumours of pharynx, tonsill or tongue base or epiglottis should be considered. Eagle syndrom or elonged styloid process syndrom is also characterised by painful swallowing and referred otalgia. Earache can be caused by temporomandibular disorders, where otalgia is usually increased by mastication and joint palpation. The role of otorhinolaryngologist is to exclude otogenic and pharyngogenic otalgia, and the differential diagnostics should include workout considering cervicogenic otalgia (cervical spine x-ray or MRI), temporomandibular disorders (TMJ x-ray, dentist consultation), or odontogenic otalgia (dentist consultation). The diagnostic workout of otalgia should include radiologist, dentist, reumatologist, and neurologist.Otalgija je bol koja se prezentira u području uha, međutim to ne uključuje nužno otogenu etiologiju. U diferencijalnoj dijagnostici otalgije dolaze u obzir cervikocefalni sindrom, artralgija temporomandibularnog zgloba, odontogeni procesi, parotitis, tonzilitis, faringitis, epiglotitis, ezofagitis te maligni tumori s infiltracijom grana trigeminusa, vagusa i auricularis magnusa, koji se inferiorno šire do područja jednjaka, a kranijalno do lubanjske baze. Otogena bol najčešće se susreće u upalama vanjskog i srednjeg uha, dok je rijetka u kroničnim upalama, osim u fazama egzacerbacije. Kod kroničnih upala srednjeg uha, bol je znak komplikacije i širenja bolesti prema duri ili kranijskim živcima. Za diferencijalnu dijagnostiku otogene boli nužna je otoskopija, katkad mikrootoskopija, te radiološka dijagnostika, ranije konvencionalne snimke temporalne kosti po Schulleru i Stenversu, koje danas sve više zamjenjuje CT i MRI. Ako je bol povezana s ispadom sluha ili ravnoteže, što je najčešće rezultat virusnog neuritisa u temporalnoj kosti, a bez kliničke manifestacije otitisa, u obzir dolazi i audiovestibulološka dijagnostika. Ako je otalgija povezana s disfagijom ili odinofagijom, najčešće je riječ o tonzilofaringitisu, ali u obzir dolaze i peritonzilarni apsces, epiglotitis, apsces korijena jezika, parafaringealni apsces, tumor ždrijela, tonzile, korijena jezika ili epiglotitis. Eaglov sindrom, sindrom elongiranog stiloidnog nastavka, također uključuje bolno gutanje i refleksnu bol u uhu. Bolovi u uhu mogu biti uvjetovani temporomandibularnim poremećajima, s time da se otalgija pojačava žvakanjem ili palpacijom zgloba. Uloga otorinolaringologa jest isključiti otogenu ili faringolaringogenu otalgiju, a potom se diferencijalno dijagnostički uključuje obrada u smjeru cervikogene otalgije (radiološka obrada vratne kralježnice), artralgije temporomandibularnog zgloba (radiološka obrada zgloba, konzultacija stomatologa) ili odontogene otalgije (konzultacija stomatologa). U tome su smislu u obradu uključeni radiolog, stomatolog, reumatolog i neurolog

Prognostička vrijednost IL-5 u sinusnom ispirku kod bolesnika s kroničnim maksilarnim sinusitisom

The aim of the study was to evaluate subjective outcomes in patients with chronic rhinosinusitis after steroid/antibiotic endosinusal treatment and to test the hypothesis that pretreatment levels of the cytokine interleukin-5 in sinus fluid could predict response to endosinusal steroid/antibiotic treatment. Twenty-four patients with symptoms of chronic rhinosinusitis were recruited for the study. Inclusion criteria were sinusitis symptoms persisting for more than three months and maxillary sinus mucosa thickening by >6 mm, considered as maxillary sinusitis. Patients with asthma, polyposis, recent infection, systemic steroid therapy or previous sinus surgery were excluded. Patients were treated endosinusally with 2 mg dexamethasone and 40 mg gentamicin per maxillary sinus daily for 5 days. Patients rated nasal/chronic rhinosinusitis disease-specific symptoms and completed a self-administered questionnaire concerning sinusitis symptoms at inclusion and after 30 days. Sinus lavage collected at inclusion was analyzed for interleukin-5 concentration. Endonasal treatment led to improvement with symptom alleviation in ten (52.6%) patients (responders), whereas unchanged or worsened condition was recorded in nine (47.4%) patients (nonresponders). Significant improvement was noted for overall sinusitis symptom score (p=0.02), and for obstruction, postnasal drip, headache, sneezing and cough (p<0.05) in the study group as a whole. There was a positive correlation of baseline interleukin-5 level in sinus lavage with the improvement rate of overall sinusitis symptom score (p<0.01) and improvement rate of nasal secretion score (p<0.01). Results indicated the increased interleukin-5 levels in sinus fluid to predict good response to endosinusal steroid/antibiotic treatment.Cilj studije bio je procijeniti subjektivne ishode u bolesnika s kroničnim rinosinusitisom nakon endosinusne steroidne/ antibiotske terapije, te ispitati pretpostavku prema kojoj bi se iz prijeterapijske razine citokina interleukina-5 u sinusnoj tekućini mogao predvidjeti odgovor na ovu vrst liječenja. U studiju je bilo uključeno 24 bolesnika sa simptomima kroničnog rinosinusitisa. Kriteriji za uključivanje u studiju bili su trajanje simptoma sinusitisa duže od tri mjeseca i zadebljanje sluznice maksilarnih sinusa za više od 6 mm, tj. maksilarni sinusitis. Bolesnici s astmom, polipozom, nedavnom infekcijom, sistemskom uporabom steroida ili prethodnom operacijom sinusa bili su isključeni. Bolesnici su endosinusno primali 2 mg deksametazona i 40 mg gentamicina po maksilarnom sinusu kroz 5 dana. Bolesnici su ocjenjivali nosne simptome i simptome specifične za kronični rinosinusitis, i sami ispunili anketni obrazac o simptomima sinusitisa na početku i 30 dana nakon ispitivanja. Koncentracija interleukina-5 analizirana je u sinusnom ispirku uzetom na početku studije. U desetoro (52,6%) bolesnika je nakon endonazalne terapije nastupilo poboljšanje s ublaženjem simptoma (bolesnici s terapijskim odgovorom), dok je u devetoro (47,4%) bolesnika stanje ostalo nepromijenjeno ili se je pogoršalo (bolesnici bez terapijskog odgovora). Značajno je poboljšanje zabilježeno za ukupni zbroj simptoma sinusitisa (p=0,02), te za opstrukciju, postnazalni drip, glavobolju, kihanje i kašalj (p<0,05) u cijeloj skupini. Nađena je pozitivna korelacija između bazalne razine interleukina-5 u sinusnom ispirku i stope poboljšanja sveukupnog zbroja simptoma sinusitisa (p<0,01), kao i stope poboljšanja zbroja za nazalnu sekreciju (p<0,01). Rezultati su pokazali kako povišene razine interleukina-5 u sinusnoj tekućini predskazuju dobar odgovor na endosinusnu steroidnu/antibiotsku terapiju

Prognostička vrijednost IL-5 u sinusnom ispirku kod bolesnika s kroničnim maksilarnim sinusitisom

The aim of the study was to evaluate subjective outcomes in patients with chronic rhinosinusitis after steroid/antibiotic endosinusal treatment and to test the hypothesis that pretreatment levels of the cytokine interleukin-5 in sinus fluid could predict response to endosinusal steroid/antibiotic treatment. Twenty-four patients with symptoms of chronic rhinosinusitis were recruited for the study. Inclusion criteria were sinusitis symptoms persisting for more than three months and maxillary sinus mucosa thickening by >6 mm, considered as maxillary sinusitis. Patients with asthma, polyposis, recent infection, systemic steroid therapy or previous sinus surgery were excluded. Patients were treated endosinusally with 2 mg dexamethasone and 40 mg gentamicin per maxillary sinus daily for 5 days. Patients rated nasal/chronic rhinosinusitis disease-specific symptoms and completed a self-administered questionnaire concerning sinusitis symptoms at inclusion and after 30 days. Sinus lavage collected at inclusion was analyzed for interleukin-5 concentration. Endonasal treatment led to improvement with symptom alleviation in ten (52.6%) patients (responders), whereas unchanged or worsened condition was recorded in nine (47.4%) patients (nonresponders). Significant improvement was noted for overall sinusitis symptom score (p=0.02), and for obstruction, postnasal drip, headache, sneezing and cough (p<0.05) in the study group as a whole. There was a positive correlation of baseline interleukin-5 level in sinus lavage with the improvement rate of overall sinusitis symptom score (p<0.01) and improvement rate of nasal secretion score (p<0.01). Results indicated the increased interleukin-5 levels in sinus fluid to predict good response to endosinusal steroid/antibiotic treatment.Cilj studije bio je procijeniti subjektivne ishode u bolesnika s kroničnim rinosinusitisom nakon endosinusne steroidne/ antibiotske terapije, te ispitati pretpostavku prema kojoj bi se iz prijeterapijske razine citokina interleukina-5 u sinusnoj tekućini mogao predvidjeti odgovor na ovu vrst liječenja. U studiju je bilo uključeno 24 bolesnika sa simptomima kroničnog rinosinusitisa. Kriteriji za uključivanje u studiju bili su trajanje simptoma sinusitisa duže od tri mjeseca i zadebljanje sluznice maksilarnih sinusa za više od 6 mm, tj. maksilarni sinusitis. Bolesnici s astmom, polipozom, nedavnom infekcijom, sistemskom uporabom steroida ili prethodnom operacijom sinusa bili su isključeni. Bolesnici su endosinusno primali 2 mg deksametazona i 40 mg gentamicina po maksilarnom sinusu kroz 5 dana. Bolesnici su ocjenjivali nosne simptome i simptome specifične za kronični rinosinusitis, i sami ispunili anketni obrazac o simptomima sinusitisa na početku i 30 dana nakon ispitivanja. Koncentracija interleukina-5 analizirana je u sinusnom ispirku uzetom na početku studije. U desetoro (52,6%) bolesnika je nakon endonazalne terapije nastupilo poboljšanje s ublaženjem simptoma (bolesnici s terapijskim odgovorom), dok je u devetoro (47,4%) bolesnika stanje ostalo nepromijenjeno ili se je pogoršalo (bolesnici bez terapijskog odgovora). Značajno je poboljšanje zabilježeno za ukupni zbroj simptoma sinusitisa (p=0,02), te za opstrukciju, postnazalni drip, glavobolju, kihanje i kašalj (p<0,05) u cijeloj skupini. Nađena je pozitivna korelacija između bazalne razine interleukina-5 u sinusnom ispirku i stope poboljšanja sveukupnog zbroja simptoma sinusitisa (p<0,01), kao i stope poboljšanja zbroja za nazalnu sekreciju (p<0,01). Rezultati su pokazali kako povišene razine interleukina-5 u sinusnoj tekućini predskazuju dobar odgovor na endosinusnu steroidnu/antibiotsku terapiju

Na dokazima zasnovano liječenje kroničnog rinosinusitisa

Although chronic rhinosinusitis is one of the most common chronic disorders, and major advances in minimally invasive surgery and potent antimicrobial and anti-inflammatory conservative treatment have been accomplished in the past decade, evidence for the most effective treatment of chronic rhinosinusitis is still lacking. Randomized controlled trials, which provide the best possible evidence in terms of testing the efficacy of chronic rhinosinusitis treatment, are too few. Those that have been done so far, have proven advantages of endoscopic sinus surgery over classic radical surgery in terms of providing better health related quality of life. Case controlled studies of endoscopic sinus surgery have shown a 91% (73.0%-97.5%) improvement with a major complication rate of 1.6%. Still, at long-term follow up, improvement rate drops to 50% in revision cases and in patients with systemic disease (allergy, asthma). Further improvement in surgical failures can be achieved with long-term topical steroid and low-dose macrolide treatment. Conservative treatment, which includes aggressive long-term steroid and antibiotic therapy, with permanent nasal saline douches and short-term decongestants, has proved successful in half of the treated patients, yet with a shorter follow up. However, only few of clinical trials are randomized controlled trials, and placebo-controlled studies have not recognized significant advantage of any conservative treatment. The level of evidence for the treatment for pediatric sinusitis is satisfactory, and meta-analysis of conservative treatment has been cited in the Cochrane Library Database. Meta-analysis of surgical treatment for pediatric sinusitis yields a success rate of 88% with a mean follow up of 3.7 years and major complication rate of 0.6%.Iako je kronični rinosinusitis jedna od najčešćih kroničnih bolesti, a u prošlom su desetljeću postignuti veći pomaci u minimalno invazivnoj kirurgiji, kao i u pojačanoj antimikrobnoj i protuupalnoj konzervativnoj terapiji, još uvijek nedostaju dokazi o najdjelotvornijem liječenju kroničnog rinosinusitisa. Premalo je randomiziranih kontroliranih studija koje pružaju najbolje moguće dokaze u smislu ispitivanja učinkovitosti liječenja kroničnog rinosinusitisa. Dosad provedene studije dokazale su prednosti endoskopske operacije sinusa pred klasičnog radikalnom kirurgijom, jer osigurava bolju zdravstvenu kvalitetu života. Kontrolirane studije endoskopske kirurgije sinusa pokazale su 91.%-tno (73,0%-97,5%) poboljšanje sa stopom većih komplikacija od 1,6%. Međutim, uz dugotrajnije praćenje stopa poboljšanja opada na 50% kod ponovno ispitanih slučajeva i u bolesnika sa sistemskim bolestima (alergija, astma). U slučajevima gdje operacija zakaže daljnje poboljšanje može se postići dugotrajnim liječenjem topičnim steroidima i niskim dozama makrolida. Konzervativno liječenje, koje uključuje agresivnu dugotrajnu terapiju steroidima i antibioticima uz trajnu primjenu nazalnom ispiranja fiziološkom otopinom i kratkoročno sredstvima za dekongestiju, pokazalo se je uspješnim u polovice tako liječenih bolesnika, no uz kraće vrijeme praćenja. Međutim, tek je nekoliko randomiziranih kontroliranih kliničkih studija, dok placebom kontrolirane studije nisu dokazale nikakvu značajnu prednost bilo koje konzervativne terapije. Razina dokaza za liječenje sinusitisa u djece je zadovoljavajuća, a meta-analiza konzervativnog liječenja navedena je u Cochrane Library Database. Meta-analiza kirurškog liječenja sinusitisa u djece pokazuje stopu uspješnosti od 88% uz prosječeno vrijeme praćenja od 3,7 godina i stopu ozbiljnijih komplikacija od 0,6%