2018 Section 5 - Rhinology and Allergic Disorders

Orlandi et al.

It is our hope that this summary of the evidence in RS will point out where additional research efforts can be directed.

TABLE III-1. Definitions and diagnostic criteria for rhinosinusitis

Condition

Definition and diagnostic criteria

II. Methods Each of 144 topics in RS was assigned to 1 of 76 rhinol- ogy experts worldwide. The amount of evidence in any given topic varied such that a few were assigned as litera- ture reviews. The remaining topics that had substantial evi- dence were assigned as EBRRs or as evidence-based reviews only (EBRs), if they did not lend themselves to providing a recommendation, such as those addressing diagnosis and pathogenesis. For EBRs and EBRRs, the methodology of Rudmik and Smith 2 was followed for each of these sections. Briefly, a systematic review was performed with grading of all ev- idence. An initial author drafted a summary of the evi- dence, with an aggregate evidence grade and, where appli- cable, a structured recommendation. A multistage online semi-blinded iterative review process then refined each sec- tion. Following this thorough EBR and EBRR development and review with 3 to 4 rhinologists for each topic, the sec- tion manuscripts were then combined into a cohesive single document. The entire manuscript was then reviewed by all authors for consensus. III. Results The resulting ICAR:RS document addresses a number of significant areas, including: 1. Definitions and diagnostic criteria for the various forms of RS. 2. Presentation of the burden of RS, both at the societal and individual level. 3. A thorough review of the potential pathophysiologic mechanisms for the various forms of RS. 4. Recommendations for diagnosis and treatment of the various manifestations of RS, including cost-effective evaluation of the CRS patient. The structured recom- mendations are listed below. 5. Evaluation of the efficacy of endoscopic sinus surgery (ESS) in improving quality of life in CRS patients. An evidence-based regimen for appropriate medical ther- apy prior to considering surgery is provided. Structured recommendations regarding preoperative and postoper- ative care as well as intraoperative technique are listed below. III.A. Results: Definitions and Diagnostic Criteria RS in adults is divided and defined based on the temporal course of its manifestation (Table III-1). Subacute RS is a term used to describe RS when it lasts greater than 4 weeks but less than 12 weeks. Its clinical features fall somewhere between ARS and CRS. Use of this classification should be limited until a better understanding of this condition is achieved.

Sinonasal inflammation lasting less than 4 weeks associated with the sudden onset of symptoms. Symptoms must include both: nasal blockage/obstruction/congestion OR nasal discharge (anterior/posterior) AND facial pain/pressure OR reduction/loss of smell. Radiology and endoscopy are not required for diagnosis. Sinonasal inflammation persisting for more than 12 weeks. Symptoms must include at least 2 of the following: nasal blockage/obstruction/congestion nasal discharge (anterior/posterior) facial pain/pressure reduction/loss of smell Additionally, the diagnosis must be confirmed by: Evidence of inflammation on paranasal sinus examination or computed tomography (CT) Evidence of purulence coming from paranasal sinuses or ostiomeatal complex CRS is divided into CRSwNP or CRSsNP based on the presence or absence of nasal polyps. Four or more episodes of ARS per year with distinct symptom-free intervals between episodes. Each episode must meet the above criteria for ARS Sudden worsening of CRS symptoms with a return to baseline symptoms following treatment

Acute rhinosinusitis (ARS)

Chronic rhinosinusitis (CRS)

Recurrent acute

rhinosinusitis (RARS)

Acute exacerbation of chronic rhinosinusitis (AECRS)

CRSsNP = CRS without nasal polyps; CRSwNP = CRS with nasal polyps.

III.B. Results: The Burden of RS We increasingly understand the significant burden of RS, both at a societal and at an individual level. The ICAR:RS document thoroughly reviews this literature, including direct and indirect costs as well as the substantial effect on individual well-being. Notable findings are an individual direct cost of US$770 to US$1220 per patient-year for CRS and a RS-related work productivity cost that approaches US$4 billion in the United States annually. At the individ- ual level, the impact is also found to be substantial. Overall CRS quality of life is worse than that of individuals with congestive heart failure, chronic obstructive pulmonary

International Forum of Allergy & Rhinology, Vol. 6, No. S1, February 2016

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