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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blockage, drainage or postnasal drainage (PND), and facial pressure/pain. 297,299–303 ARS may also be associated with regional upper airway symptoms such as sore throat, hoarseness, and cough, as well as non-specific systemic complaints such as malaise, fatigue, and fever. 297,303 Objec tive evidence of ARS on nasal endoscopy, antral puncture, or radiographic imaging (X-ray, ultrasonography, or CT) is not required for the diagnosis in uncomplicated cases. 304,305 In patients with suspected ARS based on symptoms, the prevalence of confirmed ARS through imaging, culture, or antral puncture is around 50% in adults. 297,304 Anterior rhinoscopy is recommended and may reveal evidence of inflammation, mucosal edema, and discharge. 306 Clinical decision models have been devel oped to diagnose ARS but lack prospective validation. 297 ESR and CRP are inflammatory markers found to be elevated during ARS, but they are not routinely used for diagnosis because of their limited specificity (Table VII-1). 301,304,307

sensus groups. Nasal endoscopy is not necessary for diag nosis, but anterior rhinoscopy is indicated to evaluate for the nasal drainage, and other findings on rhinoscopy may include mucosal inflammation and edema. 300 It is important to note here that nasal obstruction on its own without purulent nasal drainage is not enough for this diagnosis, and facial pain or pressure on its own without purulent nasal drainage is also not enough for diagnosis. Inquiry should also be made about typical allergy symp toms such as itchy and watery eyes and nose to distinguish ARS from an allergy flare and about other syndromes such as primary headache etiologies that can cause facial pres sure and pain (Table VII-2). Use of Clinical History and Physical Examina tion to Establish the Diagnosis of ARS Aggregate Grade of Evidence: C (Level 2: 2 studies; level 3: 3 studies; level 4: 6 studies; Table VII-2). Benefit: Distinguish non-RS (especially non infectious) conditions from ARS. Harm: Risk of misclassifying ARS as something else. Cost: Minimal. Benefits-Harm Assessment: Benefit very likely to outweigh harm. Value Judgments: Importance of avoiding inap propriate treatment, importance of decreasing Intervention: Use clinical history and physical exam to appropriately diagnose ARS, and distin guish infectious RS from other diagnoses such as allergy or primary headache syndromes. Finally, radiographic imaging is not indicated for the diagnosis of ARS, unless evaluating for a complication or searching for alternative diagnosis. There are mul tiple studies, including a meta-analysis, demonstrating that clinical criteria had similar diagnostic accuracy, and that radiographic imaging is not cost-effective (Table VII-3). 311–313 Figure VII-1 depicts a diagnostic algorithm for suspected ARS. delay to appropriate treatment. Policy Level: Recommendation.

Diagnosis of Acute Rhinosinusitis Aggregate Grade of Evidence: C (Level 2: 3 studies; level 3: 2 studies; level 4: 4 studies; Table VII-1).

VII.B.1 Establishing the Diagnosis of ARS ARS as a general entity is both underdiagnosed and overly treated, which can lead to missed opportunities in both providing patients with validation of their symptoms as well as non-antibiotic supportive sinus treatment. Thus, correctly diagnosing patients with ARS is the first and most important step in correctly treating them. The diagnosis is a clinical one, based on history and examina tion. There are many symptoms and signs potentially asso ciated with ARS, including sneezing, malaise, fever, cough, nasal discharge, nasal obstruction, cough, sore throat and headache, however many of these are nonspecific and can also be seen in isolated nasal infection or inflam mation as well as with allergy flares. 299,301,303,307–309 The 3 cardinal symptoms and signs that otolaryngology, rhi nology, and infectious disease experts have agreed upon to diagnose ARS are: up to 4 weeks of purulent nasal drainage, accompanied by nasal obstruction, or facial pain/pressure/fullness, or both. 26,31,88,146,310 These cardinal symptoms and signs do not have high level of evidence backing them up but instead have been agreed upon mul tiple times over many years by various task forces and con

Using Radiographic Imaging to Establish the Diagnosis of ARS Aggregate Grade of Evidence: B (Level 2: 1 study; level 3: 1 study; level 4: 2 studies; Table VII-3).