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are associated with or predispose patients to RARS. 207,208 Despite the growing literature, RARS is still an under examined entity and has been identified as one of the top priorities for rhinology-specific quality improvement in the future. 209

is growing, additional research is needed to create a precise consensus definition of AECRS.

Definition of Acute Exacerbation of Chronic Rhinosinusitis An acute worsening of preexisting CRS symp toms, with subsequent return to baseline symp toms spontaneously or following treatment.

Definition of Recurrent Acute Rhinosinusitis Four or more episodes of ARS per year with distinct symptom-free periods between acute episodes.

The definition of pediatric disease is discussed in section V.G.

Definition of Acute Exacerbation of Chronic Rhinosinusitis Aggregate Grade of Evidence: D (Level 3: 1 study; level 4: 2 studies; Table V-6).

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

V.E Subacute Rhinosinusitis Subacute RS is a term that has been used to describe clini cal presentations of sinonasal disease that fall between the timeframe of ARS and CRS (symptoms of 4 to 12 weeks duration). 1,143 There continue to be few clinical reports on which to delineate these patients as a distinct clinical entity and those that do define the process based on consensus. The previous iteration of ICAR:RS included subacute RS, which has been largely absent from consensus statements and guidelines for several years. 1 It is thought that patients who fall into this group either have slow to resolve ARS or an early presentation of evolving CRS. In some arti cles, subacute RS is defined in part as resolving completely following treatment. 143 However, it is possible that these poorly defined patients may be experiencing the onset of CRS and may go on to develop persistent symptoms. Of note, in the European Position Paper on Rhinosinusi tis and Nasal Polyps 2012, the term subacute RS was elimi nated as the number of patients who fell into this category was extremely small, and were thought to represent other disease processes. 31 Of the few studies that have set out to examine subacute RS in the recent literature, the duration of patient symp toms is unclear, as are the patient outcomes. 213,214 Unfor tunately, there is no additional clarity on the definition or classification of subacute RS in these studies. Use of this definition or classification should be limited until a better understanding of this condition is achieved.

V.D Acute Exacerbation of Chronic Rhinosinusitis An acute exacerbation of chronic rhinosinusitis (AECRS) is described as an acute worsening of preexisting CRS symptoms, with subsequent return to baseline symptoms spontaneously or following treatment. 1 In the previous ICAR:RS, a definition of AECRS was proposed which included worsening nasal blockage, congestion or stuffi ness, nasal discharge or postnasal drip, facial pain, pres sure or headache, and reduction in sense of smell. This may be accompanied by endoscopic evidence of puru lence, crusting, edema or polyps supporting the diagno sis of AECRS in a patient previously diagnosed with CRS. 1 Since these criteria were introduced, there has been lim ited work on AECRS. There have been 3 studies utilizing the suggested definition from the 2016 ICAR document, including 1 literature review and 2 cohort studies which used but did not assess the definition. 29,210,211 One additional study examined 3 different definitions of AECRS. 212 Of these, the most sensitive definition was a worsening in sinonasal symptoms ≥ 1 week in duration. The definition with the highest positive predictive value was a worsening in sinonasal symptoms ≥ 1 week and green/yellow discharge. 212 While the literature on AECRS