xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

TABLE VIII-1 Summary of evidence for diagnosis of RARS Items Explanation Aggregate Grade of Evidence B Endoscopy :

Level 1: 1 study; level 2: 2 studies; level 4: 1 study Culture : Level 1: 1 study; level 2: 1 study; level 4: 1 study Imaging : Level 2: 4 studies; level 3: 2 studies; level 4: 4 studies; level 5: 1 study Additional testing : Level 2: 3 studies

easily missed, due to the possibility of the patient present ing to different healthcare providers such as the family practitioner, emergency room, allergy specialist etc. 470 Endoscopy . According to a meta-analysis of 17 studies, the single most important clinical finding in an acute patient is the presence of colored discharge in the middle meatus, along with clinical features of ARS. 297 However, according to Bhattacharya et al. only 2.4% of patients with RARS receive a nasal endoscopy at the end of 1 year. 232 RARS patients have significant impairment in their QoL scores during exacerbations, although this does not corre late well with positive findings on nasal endoscopy. 204,208 Endoscopy is recommended in this cohort of patients to visualize contributing factors, confirm the presence of mucopus in the middle meatus and for getting access to a culture specimen. 88 Culture . The presence of mucopurulent discharge is mandatory for the diagnosis of RARS but doesn’t always correlate with the presence of a bacterial infection. 297,471 Some studies have shown that the mucopurulence could be secondary to neutrophil influx into the sinuses which supports a bacterial as opposed to a viral etiology. 317,472–476 It is important to note that the growth of a pathogen or presence of neutrophils is not necessary for the diagnosis ofRARS. Imaging . With the exception of EPOS2020, imaging is not primarily recommended by any of the guidelines for RARS in uncomplicated cases. 151,205,232,296,319,477–486 Imaging may be useful to study the anatomy of the sinuses prior to surgery, but there is mixed data on the presence of anatomical variances in patients with RARS when compared to CRS or normal patients. Of the 3 retrospec tive studies correlating anatomical variations with RARS incidence, 2 of them suggest a positive correlation whereas one did not find any correlation. 88,451,487 Most researchers however agree, that if need be, the scan should be done in-between acute episodes. 26,232,488 Additional Testing. Testing for immunoglobulin defi ciencies as well as for environmental allergens has been recommended by 2 separate guidelines for RARS. 232,475 A study of 94 children with RARS showed that 78.7% of these

patients had IgG deficiency and 35.1% of these patients had AR. 489

VIII.B.1 Establishing the Diagnosis of RARS Establishing the diagnosis of RARS can be difficult, as often a provider will not see the patient exactly when they are at the height of their symptoms, and thus the exam and current symptomatology may be completely normal at the time of visit. An expert consensus has established appropriateness criteria for intervention for RARS based on properly establishing the diagnosis. 206 These criteria suggest that to confirm RARS, at least 1 episode should be confirmed by either CT or presence of mucopurulence on nasal endoscopy. The primary reason for this objective val idation is that a majority of patients self-reporting ABRS do not actually show signs of this on a CT, and in 1 par ticular study, instead were given final diagnoses including rhinitis, migraine and facial pain disorder. 205 This approach indicates the importance of instructing patients to come in to clinic to be evaluated using nasal endoscopy when they feel they are at the height of their symptoms before utilizing any treatment, and the need to fit them in during this time for evaluation. This also indicates that if nasal endoscopy does not show purulent drainage in spite of active symptomatology, then CT to fully evaluate the paranasal sinuses would be indicated. This can be helpful not only in proving sinonasal inflammation or infection, but also can disprove a sinus source of symp toms and allow the patient to pivot to another diagnostic pathway, such as primary headache workup and manage ment. In line with the above mentioned panel on appropriate ness criteria for intervention in RARS, both otolaryngolo gists and radiologists have established expert panels to sug gest appropriateness criteria for CT imaging in different forms of RS, and both groups agree that CT is indicated to completely evaluate RARS, although these expert opinions and consensus are not based on studies of very high level of evidence. 311,483