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Orlandi et al.

TABLE VIII-2 Evidence for establishing the diagnosis of RARS Study Year LOE Study Design Study Groups

Clinical Endpoint Establishing correct diagnosis of RARS

Conclusions

Rudmik 206

2019 4

Expert panel establishing appropriateness criteria

RARS

To establish the diagnosis of RARS, need 4 or more episodes of ABRS per year, with at least 1 of those episodes confirmed by CT or nasal endoscopy. Patients self-identifying as having RARS, with normal CT scans between episodes, rarely have positive CT scans during an exacerbation of symptoms. CT imaging can be used to help establish the diagnosis of RARS. CT imaging can be used to help establish the diagnosis of RARS.

Barham 205

2017 4

Prospective case series

Patients

Abnormalities on sinus CT confirming sinonasal disease

self-identified as having RARS

Kirsch 483

2017 4

Expert panel establishing appropriateness criteria

RARS

Establishing correct diagnosis of RARS

Setzen 311

2012 4

Expert panel establishing appropriateness criteria

RARS

Establishing correct diagnosis of RARS

Using Endoscopy and Imaging to Establish the Diagnosis of RARS Aggregate Grade of Evidence: D (Level 4: 4 studies; Table VIII-2). Benefit: Distinguish RARS from non-RS condi tions. Harm: Although most point of care CT scanners are low-dose radiation, there is still a dose deliv ered to the patient; there may be delay in treat ment as the patient waits for visit and endoscopy or CT scan; there may be discomfort associated with nasal endoscopy. Cost: Cost of either nasal endoscopy or CT scan or both. Benefits-Harm Assessment: Benefit very likely to outweigh harm. Value Judgments: Importance of avoiding inap propriate treatment, importance of decreasing delay to appropriate treatment. Policy Level: Option. Intervention: Nasal endoscopy and/or CT imag ing are an option during at least 1 episode of sus pected RARS to appropriately confirm and diag nose RARS, and distinguish it from other diag noses such as allergy exacerbation or primary headache syndromes. While there are consider able advantages in this approach, a policy level of “recommendation” cannot be made due to the level of the evidence.

VIII.B.2 Differential Diagnosis of RARS The differentiation of RARS from CRS remains diffi cult. Persistent RS lasting more than 12 weeks, with or without acute exacerbations, meets criteria for CRS. On a histopathological level, chronic changes including remodeling of the mucosa (basement membrane thick ening, fibrosis, squamous metaplasia) are seen in CRS, as opposed to normal sinus anatomy seen in RARS in between episodes. 490 Recent research, however, suggests the symptom burden and health care costs of RARS and CRS are similar. 232,247,248 The distinction of ABRS from AVRS is made based on the constellation and duration of symptoms indicative of a bacterial etiology. 31,88 ABRS lasts 10 or more days or is often associated with a double worsening of symptoms, com pared to AVRS. Misdiagnosis has been reported based on the perceived association of discolored or purulent secre tions alone with ABRS. 205 Recent research by Beswick et al. calls into question alternative or concomitant diagnoses during diagnosis of RARS. 204 In patients meeting diagnostic criteria for RARS, one-half had a negative endoscopy during an acute exacerbation, indicating they may have been suffering from a different condition. Additionally, over one-third of patients had nasal inflammation seen in-between episodes, suggesting alternative or concomitant disease such as asthma or allergy. In patients with RARS, consid eration should be given to potential predisposing factors, including asthma, cystic fibrosis, immunocompromised