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Orlandi et al.

VIII Recurrent Acute Rhinosinusitis (RARS) VIII.A Incidence and Prevalence of RARS It is difficult to accurately determine the true incidence of recurrent acute rhinosinusitis (RARS) as these patients often do not present to an otolaryngologist. The EPOS2020 document requires at least 1 diagnosis of post-viral ARS to be confirmed by objective evidence of paranasal sinus involvement through either nasal endoscopy and/or CT scan before considering the diagnosis of RARS. 26 However, RARS patients present mainly to their general practitioner or emergency room, most not undergoing nasal endoscopy or CT. An attempt had been made to identify RARS preva lence by studying medical claims data from 2003-2008 in the United States, and sub-analyzing the number of claims made for 4 or more episodes of documented ARS where the patient was prescribed antibiotics during all occasions. 232 An incidence of 0.035% was identified using this method ology with approximately 1 in 3000 adults affected per year. However, this number is likely an underestimate, as patients treated with watchful waiting, surgery or those who never filled their prescriptions remained unaccounted for. 206 Recent evidence suggests that RARS patients have an impairment in their QoL during exacerbations but this does not always correlate well with positive findings on nasal endoscopy. 204 VIII.B Diagnosis of RARS There is significant heterogeneity and ambiguity in the diagnostic criteria for RARS (Table VIII-1), with the recent EPOS2020 and ICAR-RS-2016 documents having differing criteria. While ICAR-RS-2016 required at least 4 episodes of ARS in a 12-month period, EPOS2020 also requires the patient to present with at least 4 episodes of documented acute bacterial or post-viral rhinosinusitis in a 12-month period, with relative normalcy in the intervening peri ods. The EPOS2020 steering group recommended at least 1 diagnosis of post-viral ARS to be confirmed by objec tive evidence of paranasal sinus involvement through nasal endoscopy and/or CT scan before considering the diagno sis of RARS. 26 Post Viral RS is defined as an increase in symptoms after 5 days or persistence of symptoms after 10 days of onset of ARS with a total duration of less than 12 weeks. 31 Assigning 4 attacks of ABRS as a required crite rion was arbitrarily chosen and primarily based on the fact that on average an individual would have 1.4 to 2.3 bouts of viral rhinosinusitis per year. 201 The diagnosis may be

Complications involving the orbit have traditionally been classified as described by Chandler et al. This system includes group I – preseptal cellulitis, group II – orbital cel lulitis, group III – subperiosteal abscess, and group IV – orbital abscess. 462 A fifth group, cavernous sinus thrombo sis, will be described as an intracranial complication. The most frequent orbital pathogens include common respi ratory pathogens. Concomitant infection with Streptococ cus anginosus group and oral anerobes are also frequently seen, possibly indicating pathogenic synergy. 463 The vast majority of orbital complications from ARS present in the pediatric population. In the adult population, orbital com plications are much rarer. In adults it is frequently seen in patients with a history of CRS who have previously under gone surgical intervention and have structural abnormali ties of the lamina papyracea, for example, dehiscence due to mucocele. 464 Intracranial complications may present at any age, with greatest prevalence in the second and third decades of life. 465 Patients typically present with fever, headache, and mental status changes. Intracranial involvement may develop as a discrete collection of purulence (epidural abscess, subdural empyema, or brain abscess) or with out suppuration (cerebritis or meningitis). These com plications are most often secondary to frontal sinusitis, though ethmoid sinusitis has also been implicated. 465,466 Cavernous sinus thrombosis, however, is typically sec ondary to sphenoid sinusitis and presents with ophthalmo plegia, vision change, papilledema, and/or other cranial neuropathies. 466 The Pott’s puffy tumor, osteomyelitis and subperiosteal abscess of the frontal bone, makes up the osseous com plication of ARS. With the advent of antibiotic therapy this has become much less common though head trauma remains a risk factor. 466 These patients, typically adoles cents, are at risk for concurrent orbital as well as intracra nial complications. 466–468 The hallmarks of management are swift diagnosis, rapid initiation of broad-spectrum intravenous antibiotics, and in many cases surgical intervention. 464–466,468 CT is typi cally the first-line imaging modality in diagnosing com plicated ARS. Magnetic resonance imaging (MRI) pro vides soft tissue visualization and is useful when there is concern for intracranial involvement. Magnetic reso nance venography may be useful for evaluation of CSS and other vasculature. Endoscopic sinus surgery is typi cally recommended in patients with these complications. While ESS is usually a sufficient approach for address ing orbital complications, open neurosurgical interven tion is often required for even sub-centimeter intracranial abscess. 469