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Wise et al.

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rhinosinusitis is debatable. 1 Identifying comorbid rhinosinusitis is essential to ensure the appropriate management of both conditions. Of note, these conditions are not mutually exclusive and there may be an association between rhinosinusitis and AR. It is possible to have concurrent AR and rhinosinusitis, and this possibility should be considered when patients meet diagnostic criteria for both independently and when patient symptomatology or response to treatment does not fit with a single diagnosis. 1 A high degree of clinical suspicion is required; however, careful consideration of these factors may help guide clinicians to the correct diagnosis or diagnoses. Rhinosinusitis is a broad term that includes the diagnoses of acute rhinosinusitis (ARS), RARS, and CRS, demarcated as CRSwNP or CRS without nasal polyposis (CRSsNP). Symptomatically, these conditions are characterized by nasal obstruction, nasal congestion, facial pressure or pain, anterior or posterior nasal discharge, and anosmia/hyposmia for varying durations of time. 1,138 AR shares several overlapping symptoms, namely rhinorrhea and nasal congestion, which may be confused with the subtypes of rhinosinusitis. 264,265 Conversely, rhinosinusitis may be mistaken for AR due to the similar symptomatology. 1 Understanding the diagnostic criteria for the subtypes of rhinosinusitis will aid clinicians in solidifying the correct diagnosis, as well as identifying comorbid conditions. ARS is defined as the sudden onset of sinonasal symptoms with associated sinonasal inflammation that lasts less than 4 weeks. 1,137,138,266,267 Symptoms include nasal congestion, nasal obstruction or nasal discharge, and facial pressure or pain, or anosmia/ hyposmia. Nasal discharge is often purulent and may be discolored, with a tendency to be unilateral although may be bilateral. 1,138 Facial pressure and pain is described as moderate to severe. 137 ARS may be viral or bacterial. In general, viral ARS is present for less than 10 days. A longer duration of illness suggests bacterial ARS. 137,138 Progressive worsening over a short period of time (ie, 5 days) is also suggestive of bacterial ARS. 137,138 In the European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) statement, fever and elevated serum markers of inflammation (C-reactive protein or erythrocyte sedimentation rate) are also included as diagnostic criteria. 138 Fever is not included in other guidelines, due to its low specificity and sensitivity. 137 RARS is defined as at least 4 episodes of ARS per year, with disease-free intervals between episodes. 1,137,138,266,268 CRS is an inflammatory condition of the sinonasal cavity persisting for more than 12 weeks with at least 2 symptoms of nasal obstruction and congestion, mucopurulent nasal drainage (anterior or posterior), facial pressure or pain, and anosmia/hyposmia. 1,137,138,266,267 In addition, patients must have objective evidence of sinonasal inflammation on either nasal endoscopy (polyps, edema, mucopurulent rhinorrhea) or on CT scans of the sinuses. 137,138,266,267 CRS is divided into 2 main phenotypic groups: CRSwNP and CRSsNP. Comparatively, AR is characterized by nasal obstruction, nasal congestion, clear watery rhinorrhea (anterior or posterior), and allergic symptoms. 264,265 The presence of these symptoms should raise suspicions of AR as either a primary or comorbid diagnosis. Conversely, AR is typically not associated with purulent or unilateral nasal discharge. Moderate to severe facial pain and/or fever would also be atypical for isolated AR and may indicate the presence of an episode of ARS or an acute exacerbation of CRS, differentiated

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Int Forum Allergy Rhinol . Author manuscript; available in PMC 2020 June 10.