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International consensus statement on rhinosinusitis

The distinction between viral ARS and bacterial ARS (ABRS) is largely based on illness pattern and duration, with viral illnesses lasting fewer than 10 days. 31,88,142 The American Academy of Otolaryngology – Head and Neck Surgery defines ABRS as: a) symptoms/signs of ARS with out evidence of improvement for at least 10 days beyond the onset of symptoms, or b) symptoms/ signs of ARS that worsen within 10 days after an initial improvement (dou ble worsening). 88 The European Position Paper on Rhinos inusitis and Nasal Polyposis (EPOS) also recognizes acute post-viral rhinosinusitis, defined as worsening symptoms after 5 days, or persistent symptoms after 10 days. 31 Fever, elevated erythrocyte sedimentation rate (ESR) and/or C reactive protein (CRP) are also included in their diagnostic criteria. 31 The Canadian guidelines define ABRS as symp toms persisting beyond 7 days. 88,142 The definition of pediatric disease is discussed in sec tionV.G. Definition of Acute Rhinosinusitis Sinonasal inflammation lasting less than 4 weeks associated with sudden onset of symptoms. Symp toms must include: – purulent nasal drainage (anterior/posterior) and – nasal blockage/obstruction/congestion or facial pain/pressure or both

CPODS: facial Congestion/fullness, facial Pain/pressure, nasal Obstruction/blockage, nasal Drainage, and Smell dysfunction (hyposmia/anosmia). 151 Symptoms alone have high sensitivity but low specificity, which is why the symptoms must be accompanied by objec tive evidence of disease. Objective evidence is defined either by radiographic evidence of sinonasal inflamma tion or by mucopurulent mucus, edema or polyps on examination. 1,31,88,143,146,149,150 Phenotypic subgroups, including CRSwNP and CRSsNP, are well-recognized clinical entities, as are allergic fungal rhinosinusitis (AFRS), aspirin exacerbated respiratory disease (AERD), and cystic fibrosis. Odonto genic sinusitis is an increasingly recognized variant of CRS. Additionally, our understanding of classification by endotype is emerging, with some research suggesting 10 or more inflammatory subtypes may exist. 49 While the global definition of CRS remains stable, it is important to recognize the significant variability present within this condition. Refer to section V.G for pediatric disease definition. Definition of Chronic Rhinosinusitis Sinonasal inflammation persisting for more than 12 weeks, with a combination of at least 2 of the following symptoms and confirmed by endoscopic or radiographic findings: – nasal obstruction/congestion/blockage. – anterior or posterior (mucopurulent) nasal drainage.

– loss or decreased sense of smell. – facial pressure/pain/fullness.

Definition of Acute Rhinosinusitis Aggregate Grade of Evidence: B (Level 2: 2 studies; level 3: 5 studies; level 4: 2 studies; Table V-1).

Definition of Chronic Rhinosinusitis Aggregate Grade of Evidence: B (Level 1: 1 studies; level 2: 4 studies; level 3: 2 studies; Table V-2).

V.B Chronic Rhinosinusitis (CRS) Chronic rhinosinusitis (CRS) is defined as sinonasal inflammation persisting for more than 12 weeks. 1,31,88,143,146,149,150 The diagnosis is based on global consensus and has been consistent for the last 3 decades. Diagnosis requires a combination of subjective and objec tive findings. Recognized symptoms of CRS are nasal obstruction/congestion/blockage, anterior or posterior (mucopurulent) nasal drainage, loss or decreased sense of smell, and facial pressure/pain/fullness. 1,31,88,143,146,149,150 These are sometimes referred to using the mnemonic

V.B.1 CRS: Disease or Syndrome? In view of different clinical phenotypes and inflammatory endotypes, CRS can be considered an umbrella term cov ering several inflammatory disease states of the sinonasal