xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

nasal septal deviation, and there continues to be a lack of data associating ARS with other anatomical variants (Table VII-5). Non-osteomeatal complex related causes of ARS include oro-antral fistula and odontogenic sinusitis. One retro spective case series showed that patients with a periapi cal abscess of a maxillary tooth are 9.75 times ( p < 0.001) more likely to have substantial reactive maxillary sinus mucosal thickening on cone beam CT. 335 Additionally, another study demonstrated that periodontal disease with tooth roots emerging into the antrum and oro-antral fistu las can cause the symptoms and signs of ARS. 336 However, Hirshoren et al. noted that intrusion of healthy teeth into the maxillary sinus is a common finding and not associ ated with ARS. 331 More recently, a series assessed unilat eral symptoms in ARS patients and found that an odon togenic origin was suspected in 15% of patients, with sig nificant association of oral microbial findings in maxillary sinus cultures, indicating that odontogenic sinusitis is a source of ARS. 337 In summary, the evidence for association between ARS and anatomic variants is conflicting and limited and largely inferred from a small number of studies.

opment of ARS or modification of disease course. Regard ing the latter, Holzmann et al. reported an increased preva lence of AR in children with orbital complications of ARS and that these complications were seen more commonly during pollinating seasons. 354 Conversely, a 2014 system atic review found no evidence to support a prolonged course of ARS in the setting of AR. 355 Furthermore, a ran domized controlled trial of the effect of loratadine as an adjunct to antibiotic and corticosteroid therapy in patients with comorbid AR and ARS demonstrated improvement in individual symptoms of sneezing, nasal obstruction, and cough, as well as total symptom scores; ARS cure rate was not assessed. 356 Only 1 prospective study exists examining AR as a risk factor for ARS, and this study was performed in a pedi atric population. Leo et al. followed a group of 242 children with grass pollen induced AR and 65 normal controls for 3 months during the grass pollen season and found no signif icant difference in the incidence of ARS between groups. 357 Several pathologic mechanisms have been proposed to facilitate an interaction between AR and ARS including increased inflammation and narrowing of sinus ostia. To this end, allergen stimulation of nasal mucosa in allergic individuals was shown to generate increased eosinophils in the maxillary sinus 358 and a study of subjects with ragweed-sensitive AR found 60% had sinus mucosal abnor malities on CT imaging during ragweed season. 359 The exact contribution of allergic inflammation to ARS is not clear as the mucosal abnormalities persisted in the CT scans after the ragweed season despite symptomatic improvement. A murine model was also employed to study the rela tionship of AR and ARS. Allergen-sensitized mice that were induced with ARS and exposed to intranasal allergen demonstrated increased mucosal inflammation mediated by Th2 cells. 360,361 These studies suggest that local allergic inflammation may play a role in the expression of ARS. In summary, population-based studies seem to sup port an association between AR and ARS. Addition ally, a murine model demonstrates comorbid AR and ARS leads to Th2-driven increased mucosal inflamma tion. In human subjects, allergic individuals demonstrate increased mucosal inflammation during peak allergy sea son, but this has not been shown to lead to increased inci dence of ARS in a prospective study of pediatric patients. While there is some evidence that AR may increase the incidence of orbital complications in children with ARS, there is no evidence to support a prolonged course of ARS in patients with AR. In the treatment of comorbid AR and ARS, loratadine decreases symptoms of cough, sneez ing, nasal obstruction and overall symptom scores. While INCS or intranasal corticosteroids (INCS) have clear bene fit forAR, 135 no studies have investigated the utility of these

Anatomic Variants as a Contributing Factor forARS Aggregate Grade of Evidence: C (Level 2: 1 study; level 4: 15 studies; Table VII-5).

VII.C.2 Contributing Factors for ARS: Allergy Some studies demonstrate an association between allergic rhinitis (AR) and ARS, though this is a not a uniform find ing. An early investigation by Savolainen 350 identified a 25% prevalence of allergy in a group of 224 patients with acute maxillary sinusitis vs 16% in the disease-free control group. More recently, in a nationwide survey of the Nether lands citizenship, the risk of ARS was increased in respon dents with a physician’s diagnosis of AR 351 and a cross sectional study of the Finnish population demonstrated increased risk for RS in patients with atopic disease. 352 Increased risk for ARS was also found in pediatric patients with AR in a nationwide cohort study of Taiwanese chil dren (Table VII-6). 353 The pathophysiology of ARS is not well-characterized, with studies investigating AR’s contribution to the devel