2016 Section 5 Green Book

TABLE I. Definition of the CRS Subclasses.

CRS Subclass

History

Atopy

Asthma

6 1 1 2 2 2 6

1 6 1 1 1 2 6

AERD

Positive aspirin sensitivity

AFS

Positive fungal stain in eosinophilic mucin

AScA

Positive pulmonary function test and allergy test (in vitro or in vivo)

ASsA

Positive pulmonary function test and negative history or allergy test

NAScA

No history of asthma and positive allergy (in vitro or in vivo)

NASsA

No history of asthma or allergy

CF

Positive sweat test or gene test

AERD 5 aspirin exacerbated respiratory disease also known as aspirin triad; AFS 5 allergic fungal sinusitis; AScA 5 asthmatic sinusitis with allergy; ASsA- asthmatic sinusitis without allergy; CF 5 cystic fibrosis; CRS 5 chronic rhinosinusitis; NAScA 5 nonasthmatic sinusitis with allergy; NASsA 5 nonasthmatic sinusitis without allergy.

to the macrolides. 4 These two research study findings are consistent. Macrolides do not affect T helper 2 (Th2)- mediated inflammation seen in patients with allergic asthma or high serum IgE. Rather, macrolides target Th1 inflammation by decreasing interleukin (IL)6 and IL8 production. 5 Therefore, patients with an infection- based inflammation are more likely to have a response to macrolides, because these patients are more likely to have a Th1-mediated inflammation. By definition, all CRS cases have sinonasal inflam- mation. The question is what type of inflammation is it? Currently, CRS is divided into CRS with polyp and CRS without polyp. In general, CRS with polyp is thought to be a Th2-mediated process, whereas CRS without polyp is mediated by Th1 process. However, this division of CRS is too simplistic and does not account for any possi- ble difference that may exist for CRS with polyp. Also, the definition of CRS with polyp is not clearly defined. What criteria determine the definition of a nasal polyp in CRS? In other words, when does nasal mucosal swel- ling become a polyp? There is no clearly delineated size of a nasal mucosal engorgement defining a nasal polyp. Two factors that have enormous impact on the devel- opment of CRS, especially in CRS with polyp, are allergy and asthma. 6 Therefore, using asthma and allergy, CRS was divided into different categories. The objectives of this study were to characterize the phenotype and the nasal polyp and understand the inflammatory pathway for each CRS subclass that has been defined. By charac- terizing the phenotype and pathway of nasal polyps formation for the various types of CRS, well-characterized and distinct groups of CRS can be described. By dividing CRS into specific distinguished entities, targeted medical and surgical treatment can be developed for each CRS subclass to improve efficacy of treatment. Also by delin- eating specific CRS entities, bench and clinical research results and outcomes may become more coherent.

The study groups for CRS were aspirin triad or aspirin exacer- bated respiratory disease (AERD), asthmatic sinusitis with allergy (AScA), asthmatic sinusitis without allergy (ASsA), non- asthmatic sinusitis with allergy (NAScA), nonasthmatic sinusitis without allergy (NASsA), allergic fungal sinusitis (AFS), and cystic fibrosis (CF). Both AScA and ASsA will be defined as asthmatic sinusitis. Both NAScA and NASsA will be defined as nonasthmatic sinusitis. The CRS study group defini- tion is described in Table I. The control group did not have any clinical, endoscopic, or radiographic evidence of CRS and pre- sented for cerebrospinal fluid (CSF) leakage. Phenotype During the initial office visit, CRS patients completed two quality-of-life (QoL) questionnaires: the Rhinosinusitis Disabil- ity Index (RSDI) and the Chronic Sinusitis Survey (CSS). Demographic data, nasal endoscopy (NE), and computed tomog- raphy (CT) findings during the initial visits were documented. NE findings were recorded and scored according to a nasal NE score sheet (Fig. 1). The CT scans during the initial visit were scored based on the Lund-Mackay scoring system. Data were collected and organized into the database. Fisher exact probability test was used to evaluate gender differ- ences between CRS subclasses. Using SAS Statistical Software

MATERIALS AND METHODS Study Group

Institutional review board approval was obtained for this prospective case-control study evaluating CRS. A total of seven subclasses of CRS and a control group were used in the study.

Fig. 1. The Nasal Endoscopy Findings Scoring system rates posi- tive findings on nasal endoscopy. A total score is calculated on a scale of 0 to 8 possible points.

Laryngoscope 123: March 2013

Han: Subclassification of Chronic Sinusitis

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