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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International consensus statement on rhinosinusitis

Benefit: Avoid unnecessary radiation dose to patients, avoid cost of unnecessary test, avoid delay in diagnosis from waiting for results of unneces sary test, avoid incidental radiographic findings leading to patient concern and further testing which may or may not be warranted. Harm: Risk of delayed diagnosis if alternative underlying condition exists. Cost: Minimal. Benefits-Harm Assessment: Benefit very likely to outweigh harm. Value Judgments: Importance of avoiding unnec essary radiation and cost in diagnosis of ARS. Policy Level: Recommendation against obtaining imaging. Intervention: Do not use radiographic imaging studies in the diagnosis of uncomplicated ARS, instead use history and physical exam and estab lished clinical criteria. VII.B.2 Differentiating Viral from Bacterial ARS Distinguishing between bacterial and viral ARS can be challenging as the symptoms associated with these con ditions greatly overlap. 145,314 Duration is thought to be a key factor differentiating ABRS from a common cold, with persistence of symptoms beyond 10 days or worsening of symptoms after 5 days being indicators of development of post-viral ABRS. 88,314–316 Unfortunately, little evidence exists to support this widely held belief. Clinical factors associated with ABRS include purulent discharge, 88 localized unilateral pain, 317 and a period of worsening after an initial milder phase of illness. 309,318,319 Nasopharyngeal or sinus cultures are not necessary for ABRS diagnosis, but may help with antibiotic guidance in the primary care setting (Table VII-4). 320 Some groups recommend assuming bacterial ARS is present if diagnostic criteria for ARS are met along with 2 additional findings such as timing of the disease, severe pain over the teeth and maxilla, purulent secretions on rhinoscopy, and fever > 38˚C; whereas others suggest there is no data to support symptom severity or purulence as dif ferentiators and suggest relying on the disease time course. Unfortunately, the data supporting these various positions are low in both quality and quantity. CRP is elevated in bacterial infection and therefore, advocated as a marker of bacterial respiratory tract infec tion to limit unnecessary antibiotic use. 321 CRP levels are significantly correlated with changes on CT scans, 322 a

raised CRP is predictive of a positive bacterial culture on sinus puncture or lavage 307,323 and CRP-guided treatment has been associated with a reduction in antibiotic use with out any impairment of outcomes. 304 Similarly, procalcitonin has been advocated as a poten tial biomarker for more severe bacterial infection. A review of 2 RCTs using procalcitonin as a marker showed reduced antibiotic prescribing without detrimental effects on outcomes. 324 Markers of inflammation such as ESR are also raised in ABRS. ESR levels correlate with CT changes in ARS with an ESR of > 10 predictive of sinus fluid levels or sinus opacity on CT scans. 307 Another anal ysis of laboratory indices indicated they have poor speci ficity and questionable sensitivity in ABRS, limiting their utility. 325 In summary, differentiating between bacterial and viral ARS can be challenging even in the setting of endoscopy and cultures. Close follow-up of patient symptomology can often help in making the diagnosis, especially for patients that do not improve with supportive care. The evidence related to differentiating acute viral from acute bacterial RS is variable and is summarized in Table VII-4.

Differentiating Viral from Bacterial ARS Aggregate Grade of Evidence: B (Level 1: 1 study, level 2: 5 studies, level 3: 4 studies; Table VII-4).

VII.C Pathophysiology of ARS VII.C.1 Contributing Factors for ARS: Anatomic Variants and Septal Deviation Evidence that anatomical variants are associated with the development of ARS is lacking. This is due in large part to the fact that radiographic imaging is not indicated in the diagnosis of uncomplicated ARS making retrospective studies difficult. Instead, inferences have been made from studies of complex cases including RARS, complications of ARS, AECRS, or collective cases of undefined RS. There is mixed evidence supporting the association of ARS (definition based on clinical suspicion and mucosal thickening on imaging) and anatomical variants specific to concha bullosa, 305,329–331 nasal septal deviation, 305,329,331,332 infraorbital ethmoid cell, 305,329–331,333 infundibulum stenosis, 305,329,330,333 or agger nasi cell. 329,331 There is also limited evidence of association with radiographic mucosal thickening and findings of intralamellar cells, 329