Integrated Approach Key to Evaluating Recalcitrant Rhinosinusitis Patients

Cystic fibrosis, Dr. Batra said, although it may be a soft indication, is certainly something to consider as well when evaluating CRS patients.

A study out of France from a couple of years ago looked at 44 patients with atypical chronic sinusitis. In these patients, at least one CFTR [cystic fibrosis transmembrane regulator] mutation was noted in 38 percent and one out of six had a positive sweat chloride test, he noted. So, you should consider CF testing in children with nasal polyposis and adults with a history of chronic rhinosinusitis that has been present all their lives.

When evaluating the CRS patient, Dr. Batra said it’s also important to think about asthma, which is a very common problem in this population.

You need to make sure they are on an appropriate regimen of inhaled steroids, leukotriene modifiers, and they should always have an rescue inhaler, he said. If you don’t want to manage their asthma, make sure they have a pulmonologist who is actively involved in their care. And think about chronic steroid use; many of these patients have been on steroids for years, so you should obtain a bone density study and make sure the patients are taking calcium and vitamin D. That’s a critical issue.

The bottom line, according to Dr. Batra, is that the effective evaluation and treatment of CRS truly requires a multidisciplinary approach.

We can drive it as otolaryngologists, but we need to incorporate other specialists into the mix when appropriately indicated, he said.

Microbiologic Issues

Is rhinosinusitis an infectious disease? That was the question posed by Peter H. Hwang, MD, of the Stanford Sinus Center at the Stanford University School of Medicine, who discussed cultures and the issue of identification of pathogens.

Clearly, we’re aware of inflammatory issues in chronic sinusitis; however, I think the infectious issues are still srelevant, but the relationship between these two is not clear, Dr. Hwang said.

The role of antimicrobial therapy is being reassessed, he said, citing a recent survey of the membership of the American Rhinologic Society.

It was almost unanimous that antibiotic therapy was considered to be part of maximal medical therapy in the treatment of chronic rhinosinusitis, Dr. Hwang said. So, if we do choose to use antimicrobial therapy for treating rhinosinusitis, then knowledge about the pathogen and its resistance profile is certainly relevant and it influences antimicrobial choices.

That highlights the importance of obtaining cultures, he said, noting that there are a number of technical factors that can influence success rate in obtaining a yield for traditional bacterial and fungal culture.