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International consensus statement on rhinosinusitis

The definition of pediatric disease is discussed in sec tionV.G.

After the recommendation of the Task Force, many guidelines involving multidisciplinary specialties have rec ognized and adopted the term rhinosinusitis. 31,149,151 How ever, there are still some critiques on the universal use of rhinosinusitis for all types of sinusitis. 219 The main criti cism is that rhinitis and sinusitis are just 2 different dis eases which coexist in most cases, but do not necessarily reflect the same pathophysiological process. In the clinical practice, there is a wide range of clin ical presentations regarding rhinitis leading to sinusitis and vice-versa. It is a fact that "rhinosinusitis" reflects the majority of cases because it shows the coexistence and a continuum of the inflammatory process affecting the paranasal sinuses and the nose. Nevertheless, it is impor tant to recognize that the term “sinusitis” still may be the most appropriate for some conditions, such as fungus ball, odontogenic sinusitis, or mucopyocele. V.G Definition Differences for Pediatric Rhinosinusitis Pediatric ARS (PARS) is defined as the new onset of 2 or more of the following symptoms in children that occur for less than 12 weeks: nasal obstruction, discolored nasal discharge, and cough. 31 In bacterial PARS, the most com monly isolated pathogens are similar to adult ARS ( S.pneu moniae, H. influenzae , and M. catarrhalis) . Isolation of S. aureus occurs in adults but is rare in children. 88 Pediatric CRS (PCRS) is defined as 2 or more of the following symptoms that are present in children for 12 or more weeks: nasal obstruction, nasal discharge, facial pain/pressure, and cough. Further, the diagnosis of PCRS requires either nasal obstruction or nasal discharge to be present as well as endoscopic or radiologic confirmation of sinonasal inflammation. 31 Nasal polyps in children are diagnosed similarly to adults. 31,88 Subacute RS in the pediatric population had been pre viously defined as RS lasting from 4-12 weeks, 220,221 how ever EPOS and AAO-HNS guidelines note that this clas sification is no longer required and RS lasting up to 12 weeks in children is classified as PARS. 31,88 RARS has been described in children but is not a commonly employed classification. 222 Diagnoses of PARS and PCRS rely more heavily on cough than in the adult population. In a study of 154 pedi atric patients with RS, cough was the most common princi pal symptom, noted by 54% of subjects with PARS and 45% of subjects with PCRS. 223 Another study of 50 patients with PCRS found that 40% had nocturnal or daytime cough, with other symptoms being more common. 224 Prior evi dence also suggests that cough is among the 4 most com mon symptoms in children with rhinosinusitis. 225

Definition of Subacute Rhinosinusitis Aggregate Grade of Evidence: D (Level 2: 1 study against; level 3: 1 study; level 4: 3 studies; Table V-7).

V.F Coexistence of Rhinitis with Sinusitis: What Evidence Supports Using the Term “Rhinosinusitis”? Historically, there has been a broad debate on the best ter minology to represent the inflammatory conditions that may afflict the paranasal sinuses. Since 1996, the Task Force on Rhinosinusitis (sponsored by the AAO-HNS) has suggested the replacement of the term “sinusitis” by “rhinosinusitis.” 215 The main argument is that the majority of inflammatory diseases affect both the paranasal mucosa and the nose, in variable degrees of pathological involve ment and clinical presentation. However, the evidence to support the terminology “rhi nosinusitis” instead of “sinusitis” is still scant in the litera ture. Gwaltney et al. 216 evaluated 31 self-diagnosed patients with common cold using computed tomography (CT). They demonstrated that within 96 hours after onset of clin ical manifestation, most patients presented sinus mucosal alteration (eg, 77% of cases with thickening of the ethmoid infundibulum) and nasal mucosal lining involvement (42% of cases with nasal lateral wall thickening, 22% with infe rior turbinate engorgement). This study was the first to demonstrate that in patients with common cold, there is a frequent simultaneous involvement of the nose and sinus mucosa. Another piece of evidence was introduced by Bhattacharrya, 217 who compared the density of inflam matory cells in the ethmoidal mucosa with the nasal sep tum mucosa in patients with CRS. Bhattacharya showed that the density of eosinophils in the ethmoid correlates with the number of cells in the nasal septum, but not with other inflammatory cells or the total number of cells. Finally, Van Crombruggen et al. 218 studied the levels of inflammatory markers in the inferior turbinate mucosa plus the mucosa of the ethmoid sinus and nasal polyps from the same individual diagnosed with CRS, comparing results with healthy controls. CRS patients demonstrated increased inflammatory mediators in both sinus and infe rior turbinate mucosa in relation to controls.