xRead - Nasal Obstruction (September 2024) Full Articles

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International consensus statement on rhinosinusitis

and irritation while computed tomography yields low dose radiation. Cost: Associated costs of in-office procedures and imaging. Benefits-Harm Assessment: There is a significant benefit over harm in combining subjective symp toms and objective parameters in diagnosing CRS as well as ruling out other diagnoses which may otherwise be treated as CRS. Value Judgement: Patients with possible CRS are often referred to otolaryngologists for further eval uation. Patients with symptoms similar to those of CRS that are referred to otolaryngologists whose objective examination does not show CRS, will be saved from the harm of incorrect and often repeti tive antibiotic administration and be directed more rapidly along the correct pathway to alternate diag nosis. Policy Level: Recommendation. Intervention: An algorithm can be used to diag nose CRS. Aside from the presence of 2 cardi nal symptoms for ≥ 12 weeks, the addition of 1 objective finding on CT or nasal endoscopy greatly increases diagnostic accuracy. IX.B.2 Differential Diagnosis of CRSsNP Because of the broad differential for CRSsNP, it is fre quently difficult to differentiate it from other diseases with out diagnostic modalities including nasal endoscopy and radiologic examination. 516,531 AR is a hypersensitivity of the nasal mucosa to foreign substances mediated through IgE antibodies. 532 In most cases, sneezing and itching are clues to distinguish AR from CRS, though not in all cases. 533 Another symptomatic mimic of CRSsNP is non AR, which includes non-AR with eosinophilia syndrome (NARES), hormonal rhinitis, drug-induced rhinitis, irri tant rhinitis, atrophic rhinitis and idiopathic rhinitis. 534,535 Although only a small proportion of patients with purulent CRS without coexisting chest disease complain of cough, CRS should be differentiated from gastroesophageal reflux and asthma by physical examination. In the case of CRS with recurrent acute facial pain and pressure episodes, it is not easy to differentiate it from pri mary headache disorders, such as migraine and tension type headache, because they are commonly accompa nied by sinus-related symptoms like rhinorrhea and nasal congestion. 536–538 To rule out the primary headache and similar disorders, such as myofascial pain and temporo

mandibular joint pain, an accurate history and physi cal exam are needed. Chronic dental infection, foreign body, and both benign and malignant sinonasal neoplasia must be included in the differential diagnosis of unilateral CRS. 539S1 Most of these conditions can be eliminated by a thorough physical exam including nasal endoscopy along with appropriate imaging (CT or MRI). If nasal discharge is unilateral and clear, clinicians should rule out cerebrospinal fluid (CSF) rhinorrhea. 540 History of trauma and surgery, and salty taste of discharge may be important clues for diagnosis. 541 Detection of β 2 transferrin in nasal secretions confirms CSF. 542 Patients with obstructive sleep apnea often have similar symptoms as CRS patients, especially as facial pressure and nasal obstruction are common symptoms in both types of patients, so differential diagnosis is necessary. 543 IX.B.3 Cost Effective Work Up of CRS Because of limited data, CRSsNP and CRSwNP are com bined in this analysis and recommendations. There are few evidence-based reviews which directly address recommendations for the cost-effective diagnosis of adult CRS. Since any discussion of the cost effective ness of CRS is dependent on disease definitions in use, the transition from a symptom-combination definition to more recent consensus statements requiring appropriate symptoms combined with objective signs of inflammation in the form of CT imaging or endoscopy has had significant implications on the costs of CRS diagnosis. 1,31,88,146,147,151 Although relative consensus exists for the inclusion of objective findings within the diagnostic criteria of CRS there are scarce studies that address the optimal timing and sequence of such testing for use in validation of a CRS diagnosis. Published algorithms recommend estab lishing a symptom-based definition of CRS through the patient history, followed by nasal endoscopy. 544–546 Diag nostic imaging, especially CT imaging, is strongly rec ommended for evaluation for pre-operative planning for sinus surgery, and complications for CRS, 547 but also is critical for evaluating patients with unilateral CRS given the high prevalence of alternate pathology (eg, odonto genic, fungal or neoplastic). It is also helpful with the symptomatic patient with equivocal or normal findings on endoscopy where treatment with oral antibiotics or cor ticosteroids is being considered. 1,548,549 Furthermore, dis cussion of the cost efficiency of CRS diagnosis is highly dependent on healthcare system-specific direct costs and availability of professionals, diagnostic modalities, and therapeutic regimens for CRS. Indirect costs, including radiation exposure, time lost from work, societal costs from engendering antibiotic resistance, cost of incidental