xRead - Nasal Obstruction (September 2024) Full Articles

20426984, 2021, 3, Downloaded from https://onlinelibrary.wiley.com/doi/10.1002/alr.22741 by Stanford University, Wiley Online Library on [01/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License

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Orlandi et al.

in an effort to help guide future research efforts toward the subjects most in need of continued investigation.

I.A Introduction The 5 years since the publication of the first International Consensus Statement on Allergy and Rhinology: Rhinos inusitis (ICAR-RS) 1 has witnessed foundational progress in our understanding and treatment of rhinologic disease. These advances are reflected within the more than 40 new topics covered within the ICAR-RS-2021 document includ ing an emphasis on diagnostic algorithms, quality met rics, cost-effectiveness, and novel therapeutics. Further more, the structured methodology used to update each of the original 140 topics coupled with the contributions of a global network of experts has served to produce a truly comprehensive evidence-based compendium of our cur rent body of knowledge regarding RS. ICAR-RS-2021 provides a critical review of the diagno sis, pathophysiology, management, and complications of Acute RS (ARS), Recurrent ARS, Chronic RS (CRS) with and without nasal polyps (CRSwNP and CRSsNP), Acute Exacerbation of CRS (AECRS), and Pediatric RS. While the most up-to-date evidence has been incorporated into each of these areas, the novel application of biologic therapies for CRSwNP has emerged as perhaps the most informa tive. The precise immunopathologic underpinning of RS subtypes remains an evolving area of active investigation and has therefore been excluded from this summary. How ever, recent clinical data using biologic agents has not only validated that an elaboration of RS immunopathology can yield effective therapeutic targets but has also provided a standard for the execution of double-blind, randomized, clinical trials against which all future therapies are likely to be compared. It is also of historical interest that the ICAR-RS 2021 document was actively assembled amidst the emer gence of COVID-19 and includes a section on rhinologic considerations with regard to this unprecedented pan demic. While many of the upper airway manifestations of this viral syndrome became clear early on including high nasal/nasopharyngeal viral loads 2 and widespread acute chemosensory dysfunction, 3 other sequelae may yet become evident in the years to come. It should be noted that within the first 2 months of the pandemic the rhino logic community produced the largest number of COVID 19 related manuscripts (n = 41) among the Otolaryngology Head and Neck Surgery sub-specialties (n = 235), which themselves produced the most scholarly work of any sur gical field (n = 773). While these numbers speak directly to the maturation of our field with regard to the pursuit of evidence-based care, ICAR-RS-2021 also acknowledges that there remain significant gaps in our understanding and treatment of RS. These topics have been detailed at the end of the document

I.B Methods Each of 183 topics in RS was assigned to 1 of 85 rhi nology experts worldwide. The amount of evidence in any given topic varied such that 34 were assigned as literature reviews. The remaining topics that had sub stantial evidence were assigned as evidence-based reviews with recommendations (EBRRs) or as evidence-based reviews (EBRs) only, 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 4 was followed for each of these sections. Briefly, a systematic review was performed with grading of all evidence. An initial author drafted a summary of the evidence, with an aggregate evidence grade and, where applicable, a structured rec ommendation. A multistage online semi-blinded iterative review process then refined each section. Following this thorough EBR and EBRR development and review with 3 to 4 rhinologists for each topic, the section manuscripts were then combined into a cohesive single document. The entire manuscript was then reviewed by all authors for consensus. Definitions and Diagnostic Algorithms RS is divided and defined based on the temporal course of its manifestation. Diagnosis of CRS requires confirmation of both subjective and objective criteria. I.C.2 Incidence, Prevalence, and Endotype ARS is one of the most commonly diagnosed diseases in the outpatient setting, accounting for 2% to 10% of pri mary care and otolaryngology visits (Table I-1 and Figure I-1). 5,6 The estimated incidence of ARS ranges from 1.39% to 9% annually depending on the study methodology and population. 7–9 The incidence of acute bacterial RS (ABRS) is unknown, however it is thought to account for 0.5% to 2.0% of all viral infections. 10 While CRS is thought to be common, the true prevalence is difficult to measure given the need for objective confir mation of the diagnosis (Table I-2 and Figure I-1). National surveys in the U.S. assessing for symptoms alone have estimated a prevalence ranging from 2.1% to 13.8%. 9,11–13 I.C Results I.C.1