xRead - Nasal Obstruction (September 2024) Full Articles

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Orlandi et al.

IX.B Diagnosis of CRSsNP CRS is defined by greater than or equal to 12 weeks of a combination of subjective and objective metrics (Fig ure IX-1). Diagnostically, CRSsNP and CRSwNP differ only in the objective finding of nasal polyposis. The cardinal symptoms of CRS are mucopurulent drainage (rhinor rhea or post-nasal drip), nasal obstruction, hyposmia and facial pressure/pain. 146 Additional regional and systemic symptoms associated with CRS include oropharyngeal dis comfort, otalgia, halitosis, dental pain, cough, malaise, headache, and fatigue. 146 These symptoms are highly sen sitive individually but not specific. 513,514 Objective con firmation of inflammation by endoscopy or imaging is required (Figure IX-1). The most common symptom of CRS is nasal obstruction/congestion. 31,149 Different study popula tions have shown variability in the relative prevalence of the other symptoms. 31,201 Evidence has shown combining 2 or more symptoms together with objective findings of disease (imaging, endoscopy) substantially increases diag nostic specificity and positive predictive value. 146,201,480 The 1997 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) guideline used major and minor criteria for the diagnosis of CRS. 147 More recent guidelines from EPOS 2012 and AAO-HNS 2015 evolved to focus on the 4 most sensitive symptoms of CRS listed in Section V.B. The other regional and sys temic symptoms may be present and related to CRS but are not included in the definition. Both the EPOS 2012 and AAO-HNS 2015 guidelines require at least 2 of these 4 symptoms to be present to make the diagnosis of CRS. Although these criteria are widely adopted for research purposes and clinical care, there remain opportunities to refine the diagnostic criteria. In order to improve speci ficity, EPOS 2012 stipulates that either nasal obstruc tion or discharge must be present to make the diag nosis of CRS. This strategy was validated in a Euro pean cohort by the Global Allergy and Asthma Euro pean Network of Excellence (GA 2 LEN). 515 In an Amer ican cohort, Bhattacharyya found that more complex heuristics are required to improve upon equally weight ing the 4 symptoms. 516 Recent studies conclude that facial pain is the least specific symptom of CRS and suggest it could be removed from the diagnostic criteria with out adversely reducing sensitivity. 517,518 In addition, as understanding of CRS evolves, it is becoming increasingly clear that CRS is a broad definition encompassing multi ple endotypes. Expanded diagnostic criteria may be pos sible as clarification of these subtypes emerges. At the time of this writing, however, there remains no consen

sus regarding altering the diagnostic criteria. Therefore, the ICAR-RS diagnostic criteria mirror the AAO-HNS 2015 criteria. Differences in treatment responses and recurrence rates also supports separating the CRS into categories as CRSsNP shows improved outcomes and decreases in recur rence rates. 519 Endotype-driven diagnostic techniques are an emerging modality that may inform treatment strate gies including candidacy for novel therapeutics. 55,520,521 Establishing the Diagnosis of CRS Because of limited data, CRSsNP and CRSwNP are com bined in this analysis. The definition of CRS in adults is based on guidelines that have remained consistent over the last 3 decades. The diagnosis of CRS entails sinonasal inflammation for at least 12 consecutive weeks with the presence of at least 2 major symptoms and at least 1 documented objective finding. 143,522,523 The major symptoms include: 1) nasal obstruction or congestion, 2) nasal discharge (anterior or posterior), 3) facial pain or pressure, or 4) loss of smell. 479,524 While hyposmia is a positive predictor of CRS, 516,525 it is important to note many studies prior to 2008 did not distinguish between CRSsNP and CRSwNP. The diagnosis must be confirmed by one of the fol lowing objective measures: 1) sinus inflammation and/or purulence on nasal endoscopy or (2) sinus inflamma tion on CT. 88,480,526 Reliance on symptoms alone for the diagnosis of CRS has a high false positive rate. 516 Self reported CRS symptoms have a sensitivity of 84% to 87% and a lower, more variable specificity of 12.3% to 82%. 480,527 The addition of an objective measure improves the diag nostic accuracy. 88,480,522 While interrater variability on endoscopy for CRS exists, 528 the diagnostic accuracy of nasal endoscopy increases for patients with Lund-Kennedy scores ≥ 2. 253,529 The addition of nasal endoscopy does not improve the diagnosis of CRS in patients who fail to meet the symptom guidelines (Table IX-1 and X-1). 516 IX.B.1 Establishing the Diagnosis of CRS Aggregate grade of evidence: B (Level 1: 5 studies; level 2: 4 studies; level 3: 5 studies; level 4: 1 study; Table IX-1). Benefit: Prompt identification of patients with CRS allows for treatment and reduced costs/loss of productivity. Harm: Increased cost associated with diagnostic testing. Nasal endoscopy may cause discomfort